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Background: There is conflicting evidence on the association between afterhours discharge from the intensive care unit (ICU) and hospital mortality. We examined the effects of afterhours discharge, including the potential effect of residual organ dysfunction, on hospital mortality in a large integrated health region. Methods: We performed a multi-center retrospective cohort study of 10,463 adults discharged from 9 mixed medical/surgical ICUs in Alberta from June 2012 to December 2014. We applied a 2-stage modeling strategy to investigate the association between afterhours discharge (19:00h to 07:59h) and post-ICU hospital mortality. We applied mixed-effect multi-variable linear regression to assess the relationship between discharge organ dysfunction and afterhours discharge. We then applied mixed-effect multi-variable logistic regression to evaluate the direct, indirect and integrated associations of afterhours discharge on hospital mortality and hospitalization duration. Results: Of 10,463 patients, 23.7% (n = 2,480) were discharged afterhours, of which 27.4% occurred on a holiday or weekend. This varied significantly by ICU size, type, and site. Patients discharged afterhours were more likely medical admissions, had greater multi-morbidity and illness acuity. A greater average SOFA score in the 72 hours prior to ICU discharge was not associated with afterhours discharge. However, a greater average SOFA score was associated with hospital mortality (adjusted-odds ratio [OR], 1.23; 95% CI, 1.18-1.28). Afterhours discharge was associated with higher hospital mortality (adjusted-OR, 1.19; 95% CI, 1.01-1.39), increased hospital stay (adjusted-risk ratio [RR], 1.10; 95% CI, 1.09-1.11) and increased post-ICU stay (adjusted-RR, 1.16; 95% CI, 1.14-1.17) when compared with workhours discharge. Conclusions: Afterhours discharge is common, occurring in 1 in 4 discharges, and is widely variable across ICUs. Patients discharged afterhours have greater risk of hospital mortality and prolonged hospitalization. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Triage is crucial for patient's management and estimation of the required intensive care unit (ICU) beds is fundamental for health systems during the COVID-19 pandemic. We assessed whether chest computed tomography (CT) of COVID-19 pneumonia has an incremental role in predicting patient's admission to ICU. We performed volumetric and texture analysis of the areas of the affected lung in CT of 115 outpatients with COVID-19 infection presenting to the emergency room with dyspnea and unresponsive hypoxyemia. Admission blood laboratory including lymphocyte count, serum lactate dehydrogenase, D-dimer and C-reactive protein and the ratio between the arterial partial pressure of oxygen and inspired oxygen were collected. By calculating the areas under the receiver-operating characteristic curves (AUC), we compared the performance of blood laboratory-arterial gas analyses features alone and combined with the CT features in two hybrid models (Hybrid radiological and Hybrid radiomics)for predicting ICU admission. Following a machine learning approach, 63 patients were allocated to the training and 52 to the validation set. Twenty-nine (25%) of patients were admitted to ICU. The Hybrid radiological model comprising the lung %consolidation performed significantly (p = 0.04) better in predicting ICU admission in the validation (AUC = 0.82; 95% confidence interval 0.73–0.97) set than the blood laboratory-arterial gas analyses features alone (AUC = 0.71; 95% confidence interval 0.56–0.86). A risk calculator for ICU admission was derived and is available at: https://github.com/cgplab/covidapp. The volume of the consolidated lung in CT of patients with COVID-19 pneumonia has a mild but significant incremental value in predicting ICU admission. [ABSTRACT FROM AUTHOR]

Textbook outcome is a composite quality measurement of short-term outcomes for evaluating complex surgical procedures. We compared textbook outcome and survival of robotic total gastrectomy (RTG) with those of laparoscopic total gastrectomy (LTG). We retrospectively reviewed 395 patients (RTG, n = 74; LTG, n = 321) who underwent curative total gastrectomy for gastric cancer via minimally invasive approaches from 2009 to 2018. We performed propensity score matched analysis to adjust for potential selection bias. Textbook outcome included a negative resection margin, no intraoperative complication, retrieved lymph nodes > 15, no severe complication, no reintervention, no unplanned intensive care unit admission, hospitalization ≤ 21 days, no readmission after discharge, and no postoperative mortality. Survival outcomes included 3-year overall and relapse-free survival rates. After matching, 74 patients in each group were selected. Textbook outcome was similar in the RTG and LTG groups (70.3% and 75.7%, respectively), although RTG required a longer operative time. The quality metric least often achieved was the presence of severe complications in both groups (77.0% in both groups). There were no differences in the 3-year overall survival rate (98.6% and 89.7%, respectively; log-rank P = 0.144) and relapse-free survival rate between the RTG and LTG groups (97.3% and 87.0%, respectively; log-rank P = 0.167). Textbook outcome and survival outcome of RTG were similar to those of LTG for gastric cancer. [ABSTRACT FROM AUTHOR]

Basic research suggests some contributing mechanisms underlying asthma might at the same time benefit patients with asthma against sepsis, while the potential protective effect of comorbid asthma on prognosis of sepsis has not been well studied in clinical research. The study aimed to assess the association between comorbid asthma and prognosis in a cohort of patients admitted to intensive care unit (ICU) with severe sepsis. Patients with severe sepsis admitted to ICUs were included from the MIMIC-III Critical Care Database, and categorized as patients without asthma, patients with stable asthma, and patients with acute exacerbation asthma. The primary study outcome was 28-day mortality since ICU admission. Difference in survival distributions among groups were evaluated by Kaplan–Meier estimator. Multivariable Cox regression was employed to examine the association between comorbid asthma and prognosis. A total of 2469 patients with severe sepsis were included, of which 2327 (94.25%) were without asthma, 125 (5.06%) with stable asthma, and 17 (0.69%) with acute exacerbation asthma. Compared with patients without asthma, patients with asthma (either stable or not) had a slightly younger age (66.73 ± 16.32 versus 64.77 ± 14.81 years), a lower proportion of male sex (56.81% versus 40.14%), and a lower median SAPS II score (46 versus 43). Patients with acute exacerbation asthma saw the highest 28-day mortality rate (35.29%), but patients with stable asthma had the lowest 28-day mortality rate (21.60%) when compared to that (34.42%) in patients without asthma. Consistent results were observed in Kaplan–Meier curves with a p-value for log-rank test of 0.016. After adjusting for potential confounding, compared to being without asthma, being with stable asthma was associated with a reduced risk of 28-day mortality (hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.44–0.97, p = 0.0335), but being with acute exacerbation asthma was toward an increased risk of 28-day mortality (HR 1.82, 95% 0.80–4.10, p = 0.1513). E-value analysis suggested robustness to unmeasured confounding. These findings suggest comorbid stable asthma is associated with a better prognosis in critically ill patients with severe sepsis, while acute exacerbation asthma is associated with worse prognosis. [ABSTRACT FROM AUTHOR]

Many Intensive Care (ICU) survivors experience long lasting impairments in physical and psychological health as well as social functioning. The objective of our study was to evaluate these effects up to 10 years after ICU discharge. We performed a long-term prospective cohort study in patients admitted for longer than 48 h in a medical-surgical ICU. We evaluated health-related quality of life (HRQOL) before ICU admission using the Short-form-36 (SF-36), at ICU discharge, at hospital discharge and at 1, 2, 5 and 10 years follow up (all by patients). Changes in HRQOL were assessed based on linear mixed modeling. We included a total of 749 patients (from 2000 to 2008). During 10 years 475 (63.4%) patients had died, 125 (16.7%) patients were lost to follow up and 149 (19.9%) patients could be evaluated. The mean scores of four HRQOL dimensions (i.e., physical functioning (p < 0.001; mean 54, SD 32, effect size 0.77, 95% CI [0.54–1.0]), role-physical (p < 0.001; mean 44, SD 47, effect size 0.65, 95% CI [0.41–0.68] general health (p < 0.001; mean 52, SD 27, effect size 0.48; 95% CI 0.25–0.71) and social functioning (p < 0.001; mean 72, SD 32, effect size 0.41, 95% CI [0.19–0.64]) were still lower 10 years after ICU discharge compared with pre-admission levels (n = 149) and with an age reference population. Almost all SF-36 dimensions changed significantly over time from ICU discharge up to 10 years after ICU discharge. Over the 10 year follow up physical functioning of medical-surgical ICU survivors remains impaired compared with their pre-admission values and an age reference population. However, effect sizes showed no significant differences suggesting that surviving patients largely regained their age-specific HRQOL at 10 years. [ABSTRACT FROM AUTHOR]

Sepsis is the main cause of death in the intensive care units (ICU) and increasing incidences of ICU admissions for sepsis are reported. Identification of patients at risk for sepsis and poor outcome is therefore of outmost importance. We performed a nation-wide case–control study aiming at identifying and quantifying the association between co-morbidity and socio-economic factors with intensive care admission for community-acquired sepsis. We also explored 30-day mortality. All adult patients (n = 10,072) with sepsis admitted from an emergency department to an intensive care unit in Sweden between 2008 and 2017 and a control population (n = 50,322), matched on age, sex and county were included. In the sepsis group, 69% had a co-morbid condition at ICU admission, compared to 31% in the control group. Multivariable conditional logistic regression analysis was performed and there was a large variation in the influence of different risk factors associated with ICU-admission, renal disease, liver disease, metastatic malignancy, substance abuse, and congestive heart failure showed the strongest associations. Low income and low education level were more common in sepsis patients compared to controls. The adjusted OR for 30-day mortality for sepsis patients was 132 (95% CI 110–159) compared to controls. [ABSTRACT FROM AUTHOR]

Preliminary data have produced conflicting results regarding whether initial vitamin C levels in patients with severe sepsis correlate with mortality outcomes. We hypothesized that low plasma ascorbic acid or thiamine levels in severe sepsis patients admitted from the Emergency Department (ED) to the Intensive Care Unit (ICU) would be associated with increased mortality and an increased incidence of shock. Retrospective analysis of a prospective database of severe sepsis patients admitted to the ICU at an urban, academic medical center. Ascorbic acid and thiamine levels were analyzed in relation to survivors vs. non-survivors and shock vs. non-shock patients. 235 patients were included; mean age, 59.4 years ± 16.8 years; male, 128 (54.5%); in-hospital mortality, 16.6% (39/235); mean APACHE3 score, 61.8 ± 22.8; mean ascorbic acid level (reference range 0.40–2.10 mg/dL), 0.23 mg/dL (95% CI 0.07–4.02); and the mean thiamine level (reference range 14.6–29.5 nmol/L), 6.0 nmol/L (95% CI 4.0–9.5). When survivors were compared to non-survivors, survivors were more likely to be male (57.7% [113/196] vs. 38.5% [15/39]) and have lower APACHE3 scores (58.2 ± 22.6 vs. 79.9 ± 16.0). For the total cohort of 235 patients, there was no statistically significant relationship between a patient's initial ascorbic acid or thiamine level and either survival or development of shock. In this analysis of early plasma samples from patients with severe sepsis admitted from the ED to the ICU, we found that mean ascorbic acid and thiamine levels were lower than normal range but that there was no relationship between these levels and outcomes, including 28 day mortality and development of shock. [ABSTRACT FROM AUTHOR]

Limited information exists regarding the effect of off-hour admission among critically ill children. To evaluate whether children admitted to intensive care units (ICUs) in off-hour have worse outcomes, we conducted a cohort study in 2013–2018 in a multicenter registry in Japan. Pediatric (age < 16 years) unplanned ICU admissions were divided into regular-hour (daytime on business days) or off-hour (others). Mortality and changes in the functional score at discharge from the unit were compared between the two groups. We established multivariate logistic regression models to examine the independent association between off-hour admission and outcomes. Due to the small number of outcomes, two different models were used. There were 2512 admissions, including 757 for regular-hour and 1745 for off-hour. Mortality rates were 2.4% (18/757) and 1.9% (34/1745) in regular-hour and off-hour admissions, respectively. There was no significant association between off-hour admission and mortality both in model 1 adjusting for age, sex, and Pediatric Index of Mortality 2 (adjusted odds ratio [aOR] 0.89, 95% confidence interval [CI] 0.46–1.72) and in model 2 adjusting for propensity score predicting off-hour admission (aOR 1.05, 95% CI 0.57–1.91). In addition, off-hour admission did not show an independent association with deterioration of functional score. [ABSTRACT FROM AUTHOR]

Obstetric hemorrhage is one of the leading preventable causes of maternal mortality in the United States. Although hemorrhage risk-prediction models exist, there remains a gap in literature describing if these risk-prediction tools can identify composite maternal morbidity. We investigate how well an established obstetric hemorrhage risk-assessment tool predicts composite hemorrhage-associated morbidity. We conducted a retrospective cohort analysis of a multicenter database including women admitted to Labor and Delivery from 2016 to 2018, at centers implementing the Association of Women's Health, Obstetric, and Neonatal Nurses risk assessment tool on admission. A composite morbidity score incorporated factors including obstetric hemorrhage (estimated blood loss ≥ 1000 mL), blood transfusion, or ICU admission. Out of 56,903 women, 14,803 (26%) were categorized as low-risk, 26,163 (46%) as medium-risk and 15,937 (28%) as high-risk for obstetric hemorrhage. Composite morbidity occurred at a rate of 2.2%, 8.0% and 11.9% within these groups, respectively. Medium- and high-risk groups had an increased combined risk of composite morbidity (diagnostic OR 4.58; 4.09–5.13) compared to the low-risk group. This established hemorrhage risk-assessment tool predicts clinically-relevant composite morbidity. Future randomized trials in obstetric hemorrhage can incorporate these tools for screening patients at highest risk for composite morbidity. [ABSTRACT FROM AUTHOR]

Background: There is a lack of nationwide studies on critically ill patients' health disparity under the National Health Insurance (NHI) system. We evaluated health disparities in intensive care unit (ICU) admission, outcomes, and readmission in impoverished children.Methods: We conducted a retrospective cohort study using a national database from the Korean NHI and Medical Aid Program (MAP). MAP supports the population whose household income is lower than 40% of the median Korean household income. We defined poverty as being a MAP beneficiary and compared the poverty and non-poverty groups. Patients between 28 days and 18 years old who were admitted to the ICU were included. Hospital mortality and readmission were analyzed with adjustment for patient characteristics, hospital type, and management procedures.Results: Out of 17,893 patients, 1153 (6.4%) patients were in poverty. The age-standardized ICU admission rate was higher in the poverty group (126.9 vs. 80.2 per 100,000 person-years). There was more age-standardized mortality in the poverty group (11.8 vs. 4.3 per 100,000 person-years). Patients in the poverty group did not have a statistically different risk of adjusted in-hospital mortality to those in the non-poverty group (odds ratio: 1.15, confidence interval [CI]: 0.84-1.55) but had a higher readmission rate (hazard ratio 1.25, CI 1.09-1.42).Conclusion: Under the NHI system, the disparity in pediatric critical care outcomes according to poverty is not definite, but the healthcare disparity in pre- and post-hospital care is a concern. Further studies are required to improve pre- and post-hospital healthcare quality of impoverished children. [ABSTRACT FROM AUTHOR]

The ideal method of identifying frailty is uncertain, and data on long-term outcomes is relatively limited. We examined frailty indices derived from population-scale linked data on Intensive Care Unit (ICU) and hospitalised non-ICU patients with pneumonia to elucidate the influence of frailty on mortality. Longitudinal cohort study between 2010–2018 using population-scale anonymised data linkage of healthcare records for adults admitted to hospital with pneumonia in Wales. Primary outcome was in-patient mortality. Odds Ratios (ORs [95% confidence interval]) for age, hospital frailty risk score (HFRS), electronic frailty index (eFI), Charlson comorbidity index (CCI), and social deprivation index were estimated using multivariate logistic regression models. The area under the receiver operating characteristic curve (AUC) was estimated to determine the best fitting models. Of the 107,188 patients, mean (SD) age was 72.6 (16.6) years, 50% were men. The models adjusted for the two frailty indices and the comorbidity index had an increased odds of in-patient mortality for individuals with an ICU admission (ORs for ICU admission in the eFI model 2.67 [2.55, 2.79], HFRS model 2.30 [2.20, 2.41], CCI model 2.62 [2.51, 2.75]). Models indicated advancing age, increased frailty and comorbidity were also associated with an increased odds of in-patient mortality (eFI, baseline fit, ORs: mild 1.09 [1.04, 1.13], moderate 1.13 [1.08, 1.18], severe 1.17 [1.10, 1.23]. HFRS, baseline low, ORs: intermediate 2.65 [2.55, 2.75], high 3.31 [3.17, 3.45]). CCI, baseline < 1, ORs: '1–10′ 1.15 [1.11, 1.20], > 10 2.50 [2.41, 2.60]). For predicting inpatient deaths, the CCI and HFRS based models were similar, however for longer term outcomes the CCI based model was superior. Frailty and comorbidity are significant risk factors for patients admitted to hospital with pneumonia. Frailty and comorbidity scores based on administrative data have only moderate ability to predict outcome. [ABSTRACT FROM AUTHOR]

The aim was to assess the ability of nasopharyngeal SARS-CoV-2 viral load at first patient's hospital evaluation to predict unfavorable outcomes. We conducted a prospective cohort study including 321 adult patients with confirmed COVID-19 through RT-PCR in nasopharyngeal swabs. Quantitative Synthetic SARS-CoV-2 RNA cycle threshold values were used to calculate the viral load in log10 copies/mL. Disease severity at the end of follow up was categorized into mild, moderate, and severe. Primary endpoint was a composite of intensive care unit (ICU) admission and/or death (n = 85, 26.4%). Univariable and multivariable logistic regression analyses were performed. Nasopharyngeal SARS-CoV-2 viral load over the second quartile (≥ 7.35 log10 copies/mL, p = 0.003) and second tertile (≥ 8.27 log10 copies/mL, p = 0.01) were associated to unfavorable outcome in the unadjusted logistic regression analysis. However, in the final multivariable analysis, viral load was not independently associated with an unfavorable outcome. Five predictors were independently associated with increased odds of ICU admission and/or death: age ≥ 70 years, SpO2, neutrophils > 7.5 × 103/µL, lactate dehydrogenase ≥ 300 U/L, and C-reactive protein ≥ 100 mg/L. In summary, nasopharyngeal SARS-CoV-2 viral load on admission is generally high in patients with COVID-19, regardless of illness severity, but it cannot be used as an independent predictor of unfavorable clinical outcome. [ABSTRACT FROM AUTHOR]

Background: Subsequent epidemic waves have already emerged in many countries and in the absence of highly effective preventive and curative options, the role of patient characteristics on the development of outcomes needs to be thoroughly examined, especially in middle-east countries where such epidemiological studies are lacking. There is a huge pressure on the hospital services and in particular, on the Intensive Care Units (ICU). Describing the need for critical care as well as the chance of being discharged from hospital according to patient characteristics, is essential for a more efficient hospital management. The objective of this study is to describe the probabilities of admission to the ICU and the probabilities of hospital discharge among positive COVID-19 patients according to demographics and comorbidities recorded at hospital admission.Methods: A prospective cohort study of all patients with COVID-19 found in the Electronic Medical Records of Jaber Al-Ahmad Al-Sabah Hospital in Kuwait was conducted. The study included 3995 individuals (symptomatic and asymptomatic) of all ages who tested positive from February 24th to May 27th, 2020, out of which 315 were treated in the ICU and 3619 were discharged including those who were transferred to a different healthcare unit without having previously entered the ICU. A competing risk analysis considering two events, namely, ICU admission and hospital discharge using flexible hazard models was performed to describe the association between event-specific probabilities and patient characteristics.Results: Results showed that being male, increasing age and comorbidities such as chronic kidney disease (CKD), asthma or chronic obstructive pulmonary disease and weakened immune system increased the risk of ICU admission within 10 days of entering the hospital. CKD and weakened immune system decreased the probabilities of discharge in both females and males however, the age-related pattern differed by gender. Diabetes, which was the most prevalent comorbid condition, had only a moderate impact on both probabilities (18% overall) in contrast to CKD which had the largest effect, but presented only in 7% of those admitted to ICU and in 1% of those who got discharged. For instance, within 5 days a 50-year-old male had 19% (95% C.I.: [15,23]) probability of entering the ICU if he had none of these comorbidities, yet this risk jumped to 31% (95% C.I.: [20,46]) if he had also CKD, and to 27% in the presence of asthma/COPD (95% C.I.: [19,36]) or of weakened immune system (95% C.I.: [16,42]).Conclusions: This study provides useful insight in describing the probabilities of ICU admission and hospital discharge according to age, gender, and comorbidities among confirmed COVID-19 cases in Kuwait. A web-tool is also provided to allow the user to estimate these probabilities for any combination of these covariates. These probabilities enable deeper understanding of the hospital demand according to patient characteristics which is essential to hospital management and useful for developing a vaccination strategy. [ABSTRACT FROM AUTHOR]

To identify the risk factors of mortality for the coronavirus disease 19 (COVID-19) patients admitted to intensive care units (ICUs) through a retrospective analysis. The demographic, clinical, laboratory, and chest imaging data of patients admitted to the ICU of Huoshenshan Hospital from February 10 to April 10, 2020 were retrospectively analyzed. Student's t-test and Chi-square test were used to compare the continuous and categorical variables, respectively. The logistic regression model was employed to ascertain the risk factors of mortality. This retrospective study involved 123 patients, including 64 dead and 59 survivors. Among them, 57 people were tested for interleukin-6 (IL-6) (20 died and 37 survived). In all included patients, the oxygenation index (PaO2/FiO2) was identified as an independent risk factor (odd ratio [OR] = 0.96, 95% confidence interval [CI]: 0.928–0.994, p = 0.021). The area under the curve (AUC) was 0.895 (95% CI: 0.826–0.943, p < 0.0001). Among the patients tested for IL-6, the PaO2/FiO2 (OR = 0.955, 95%CI: 0.915–0.996, p = 0.032) and IL-6 (OR = 1.013, 95%CI: 1.001–1.025, p = 0.028) were identified as independent risk factors. The AUC was 0.9 (95% CI: 0.791–0.964, p < 0.0001) for IL-6 and 0.865 (95% CI: 0.748–0.941, p < 0.0001) for PaO2/FiO2. PaO2/FiO2 and IL-6 could potentially serve as independent risk factors for predicting death in COVID-19 patients requiring intensive care. [ABSTRACT FROM AUTHOR]

Early admission to the neurosciences intensive care unit (NSICU) is associated with improved patient outcomes. Natural language processing offers new possibilities for mining free text in electronic health record data. We sought to develop a machine learning model using both tabular and free text data to identify patients requiring NSICU admission shortly after arrival to the emergency department (ED). We conducted a single-center, retrospective cohort study of adult patients at the Mount Sinai Hospital, an academic medical center in New York City. All patients presenting to our institutional ED between January 2014 and December 2018 were included. Structured (tabular) demographic, clinical, bed movement record data, and free text data from triage notes were extracted from our institutional data warehouse. A machine learning model was trained to predict likelihood of NSICU admission at 30 min from arrival to the ED. We identified 412,858 patients presenting to the ED over the study period, of whom 1900 (0.5%) were admitted to the NSICU. The daily median number of ED presentations was 231 (IQR 200–256) and the median time from ED presentation to the decision for NSICU admission was 169 min (IQR 80–324). A model trained only with text data had an area under the receiver-operating curve (AUC) of 0.90 (95% confidence interval (CI) 0.87–0.91). A structured data-only model had an AUC of 0.92 (95% CI 0.91–0.94). A combined model trained on structured and text data had an AUC of 0.93 (95% CI 0.92–0.95). At a false positive rate of 1:100 (99% specificity), the combined model was 58% sensitive for identifying NSICU admission. A machine learning model using structured and free text data can predict NSICU admission soon after ED arrival. This may potentially improve ED and NSICU resource allocation. Further studies should validate our findings. [ABSTRACT FROM AUTHOR]

Investigation of physician-related causes of unscheduled revisits to the emergency department (ED) within 72 h with subsequent admission to the intensive care unit (ICU) is an important parameter of emergency care quality. Between 2012 and 2017, medical records of all adult patients who visited the ED and returned within 72 h with subsequent ICU admission were retrospectively reviewed by three experienced emergency physicians. Study parameters were categorized into "input" (Patient characteristics), "throughput" (Time spent on first ED visit and seniority of emergency physicians, and "output" (Charlson Comorbidity Index). Of the 147 patients reviewed for the causes of ICU admission, 35 were physician-related (23.8%). Eight belonged to more urgent categories, whereas the majority (n = 27) were less urgent. Patients who spent less time on their first ED visits before discharge (< 2 h) were significantly associated with physician-related causes of ICU admission, whereas there was no significant difference in other "input," "throughput," and "output" parameters between the "physician-related" and "non-physician-related" groups. Short initial management time was associated with physician-related causes of ICU admission in patients with initial less urgent presentations, highlighting failure of the conventional triage system to identify potentially life-threatening conditions and possibility of misjudgement because of the patients' apparently minor initial presentations. [ABSTRACT FROM AUTHOR]

Objective: To determine key demographic and intrapartum antecedents predisposing to severe adverse neonatal outcome at term.Methods: This was a retrospective cohort study of severe adverse neonatal outcomes of nonanomalous singleton term births at an Australian tertiary maternity unit between January 2007 and April 2017. Serious neonatal outcome (SNO) was defined as any of the following: Apgar score ≤3 at 5 min, severe respiratory distress syndrome, severe acidosis, admission into neonatal intensive care unit (NICU), stillbirth, or neonatal death. Multivariable generalized estimating equations were used to identify key demographic and intrapartum risk factors predisposing to poor neonatal outcomes.Results: There were 77 888 births with SNO occurring in 7247 (9.3%) cases. Young maternal age, raised BMI, indigenous ethnicity, nulliparity, smoking, illicit drug use, and diabetes mellitus were more common in the SANO cohort. Instrumental birth (aOR 3.24, 95%CI 3.02-3.47, p < .001), emergency cesarean section (aOR 1.61, 95%CI 1.49-1.73, p < .001), emergency cesarean for nonreassuring fetal status (aOR 3.45, 95%CI 3.04-3.92, p < .001), cord accidents (aOR 4.98, 95%CI 2.81-8.83, p < .001) and intrapartum hemorrhage (aOR 1.42, 95%CI 1.08-1.87, p = .01) were major antecedents. Induction of labor (aOR 1.08, 95%CI 1.01-1.15, p = .03), prolonged second stage (aOR 1.76, 95%CI 1.55-2.00, p < .001) and use of intramuscular opioids/narcotics (aOR 1.41, 95%CI 1.30-1.52, p < .001) were also associated with adverse neonatal outcome. Low birth weight (< 5th and <10th centiles) and macrosomia (> 90th and >95th centiles) and delivery at 37 weeks and >41 weeks were additional risk factors.Conclusion: There are multiple maternal and intrapartum risk factors which can predispose to severe outcomes in the neonate. [ABSTRACT FROM AUTHOR]

Objectives: Birth order is one of the main factors that influences the neonatal outcome of twins. However, there is little prior data regarding the effect of birth order under different clinical circumstances. This study investigates the effect of birth order on the neonatal outcomes of twins delivered during early-preterm, late-preterm and term gestations according to chorionicity, delivery mode and indication for delivery.Methods: This is a retrospective cohort study of women with twin pregnancies delivered at 24-40 weeks of gestation between 1995 and 2014. We excluded twin pregnancies with the following complications: twin-to-twin transfusion syndrome, monoamnionic twins, delayed interval delivery and fetal death, chromosomal anomalies or major congenital malformation in one or more of the twins. The neonatal outcomes, including death, admission to neonatal intensive care unit (NICU), mechanical ventilator support, and respiratory distress syndrome (RDS) was compared between the first and second twin born at early-preterm (24-33 weeks of gestation), late-preterm (34-36 weeks of gestation) and term (≥37 weeks of gestation) gestations. These outcomes were further analyzed according to chorionicity, mode of delivery and indication for delivery by multivariable analysis (after adjusting for sex, presentation, and birth weight).Results: Among a total of 1,614 women with twin pregnancies who met the selection criteria, 423, 674 and 517 women delivered at early-preterm, late-preterm and term gestation, respectively. Overall, the second-born twins were lighter and had higher rates of NICU admission, mechanical ventilator support, and RDS than did first-born twins. Second twins born at early-preterm gestation had higher rates of RDS and mechanical ventilator support than did first twins. Second twins born at late-preterm gestation had higher rates of NICU admission and mechanical ventilator support than did first twins. Second twins born at term gestation also had a higher NICU admission rate than did first twins. However, in the multivariable analysis of the subgroups, the rates of NICU admission, mechanical ventilator support and RDS were not significantly different between most twin pairs. However, there were several significant differences. There was a higher risk of RDS in the second twins in the early-preterm premature rupture of membranes (PROM) subgroup, and a higher risk of mechanical ventilator support in the late-preterm PROM subgroup. Low birth weight was the only significant factor independently associated with a higher risk of adverse neonatal outcome in the second twins compared with the first twins in all subgroups.Conclusions: Second twins born at early-preterm, late-preterm and term were at higher risk of adverse neonatal outcome than were their respective first twins. However, this finding was mainly represented lower birth weight of the second twin. Still, second twins delivered due to early-preterm and late-preterm PROM had a higher risk of RDS and mechanical ventilator support, respectively, than did the first twin after adjusting for birth weight. [ABSTRACT FROM AUTHOR]

Normal vaginal delivery is not replaced by caesarean section over the period of last century in spite of being safer in terms of maternal and neonatal morbidity, mortality and even cost. The trend of caesarean section increasing day by day, which is being a huge concern in many parts of the world. Objectives: To assess the frequency of maternal and neonatal morbidity associated with second stage caesarean section. Study Design: Descriptive case series. Study Setting: Gynecology and Obstetrics unit 3, Civil Hospital Karachi. Period: June to November 2015. Material & Methods: A total of 123 pregnant women undergoing second stage caesarean section were included in this study. Data regarding demographic characteristics and complications during caesarean section were identified and noted. Neonatal outcome records were also collected on predesign pro-forma. Results: Primary postpartum hemorrhage was 14.6% cases; extension of a transverse uterine incision 7.3% and need of blood transfusions 17.1% cases as well as 30.1% of the women had a hospital stay of three to five days. There were 86.2% alive babies, 7.3% still births and 13% early neonatal deaths. 13% neonates required admission to the neonatal intensive care unit. Conclusion: Overall, maternal and neonatal morbidities during second stage caesarean sections were not very high. [ABSTRACT FROM AUTHOR]

Aim: To critically analyse the management of status dystonicus and prestatus dystonicus in children and adolescents, in order to examine clinical features, acute management, and risk of relapse in a paediatric cohort.Method: Clinical, demographic, and therapeutic features were analysed according to disease severity. Risk of subsequent relapse was estimated through Kaplan-Meier curves.Results: Thirty-four patients (eight females, 26 males) experiencing 63 episodes of acute dystonia exacerbations at a tertiary referral Italian hospital were identified. Mean age at status dystonicus presentation was 9 years 11 months (11y at inclusion in the study). Onset of dystonia dated back to infancy in most cases. Fourteen patients experienced two or more episodes. Infections were the most common trigger (48%). Benzodiazepines were the most commonly used drugs for acute management. Stereotactic pallidotomy was performed in six cases during status dystonicus, and in two additional patients it was electively performed after medical management. The probability of survival free from status dystonicus relapses was 78% after 4 months and 61% after 27 months.Interpretation: Dystonia exacerbations are potentially life-threating emergencies, with a considerable risk of relapse. Nevertheless, no obvious factors for relapse risk stratification exist. Pallidotomy is a feasible option in medical refractory status dystonicus for patients with limited deep brain stimulation applicability, but the risk of recurrence is elevated.What This Paper Adds: Acute exacerbations may affect up to 10% of children with dystonia. Infections are the most common precipitant factor. In about 30% of the cases, intensive care unit admission is needed. Subsequent relapses are common, reaching 25% risk at 1 year. Pallidotomy can be considered in medical-refractory cases with no deep brain stimulation applicability. [ABSTRACT FROM AUTHOR]

Objective: Some studies have suggested that the fetal cerebroplacental ratio (CPR) is an independent predictor of intrapartum fetal compromise and admission to the neonatal intensive care unit (NICU) at term particularly in small for gestational age (SGA) compared to appropriate for gestational age (AGA) infants. The aim of this study was to evaluate the association between the CPR and emergency caesarean for intrapartum fetal compromise (CS IFC) and NICU admission at term after adjusting for estimated fetal weight (EFW) and other confounding factors.Methods: This was a retrospective study of women who birthed at the Mater Mother's Hospital in Brisbane, Australia between for women who birthed between January 2000 and April 2017. The CPR was measured within 2 weeks of birth in women that delivered at term and assessed for correlation with CS IFC and admission to NICU. The study cohort was also stratified into four categories according to EFW and CPR thresholds. Appropriate for gestational age (EFW ≥10th centile) and normal CPR (≥10th centile), AGA and low CPR (<10th centile), SGA (EFW <10th centile) and normal CPR and SGA and low CPR.Results: Both CPR <10th centile (adjusted odds ratio (aOR) 2.60, 95% CI 1.82-3.71, p < .001) and EFW <10th centile (aOR 2.63, 95% CI 1.85-3.74, p < .001) demonstrated significant associations with CS IFC. EFW <10th centile (aOR 2.23, 95% CI 1.61-3.09, p < .001) but not CPR <10th centile (aOR 1.41, 95% CI 0.99-2.01, p = .06) was predictive of NICU admission. When stratified according to EFW and CPR thresholds, SGA had significant odds ratios for CS IFC and NICU admission regardless of CPR status. However, the AGA and low CPR cohort was only at increased risk of CS IFC (aOR 2.09, 95% CI 1.30-3.34, p = .002) but not of admission to NICU.Conclusions: At term, the CPR is an independent risk factor for CS IFC regardless of fetal weight. However, the CPR was only predictive of NICU admission in an SGA cohort. Overall, our findings suggest that fetal size is a more important variable for both CS IFC and NICU admission. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether meconium-stained amniotic fluid (MSAF) encountered in pregnancies complicated by preterm premature rupture of membranes (PPROM) is associated with adverse maternal and perinatal outcome.Methods: A retrospective cohort study of all singleton pregnancies with PPROM and MSAF who delivered in a tertiary hospital at 24 + 0-36 + 6 weeks of gestation between 2007 and 2017. Women with PPROM-MSAF (study group) were compared to women with PPROM and clear amniotic fluid (control group). Controls were matched to cases according to age, gravidity, parity and gestational age at delivery in a 3:1 ratio. Primary outcome was defined as neonatal intensive care unit admission. Secondary outcomes were neonatal adverse outcomes, chorioamnionitis and placental abruption diagnosed clinically or by placental cultures and histology.Results: Seventy-five women comprised the study group and were matched to 225 women representing the control group. A significantly higher rate of neonatal intensive care unit admissions was noted in the study group compared to controls (61.3% vs. 45.7%, p = 0.03). Multivariate analysis demonstrated that MSAF is an independent risk factor for neonatal intensive care unit admission (adjusted OR = 2.82, 95% CI 1.39-5.75, p = 0.004). MSAF was found to be associated to higher rates of cesarean and operative vaginal deliveries (30.7% vs. 24.4% and 5.3% vs. 2.7%, p = 0.057, respectively) as well as to chorioamnionitis and placental abruption (33.3% vs. 19.3%, p = 0.034 and 16.0% vs. 7.7%, p = 0.021, respectively).Conclusion: MSAF is associated with higher frequencies of adverse perinatal outcome when compared to clear amniotic fluid in pregnancies complicated by PPROM. [ABSTRACT FROM AUTHOR]

Background: While many patients with lower limb ischemia also have severe infections, few studies have investigated whether the presence of preoperative sepsis affects patient prognosis following lower limb amputation (LLA). Therefore, we investigated the factors (including sepsis as defined in SEPSIS-3) that contribute to the acute mortality rate in patients who underwent LLA due to arteriosclerosis obliterans (ASO) or diabetes mellitus (DM).Methods: In this retrospective, single-center, 10-year chart review study, 122 adult patients who underwent LLA due to ASO and/or DM were identified from 56,438 surgery cases. Patient characteristics, including co-morbidities, surgical conditions, the presence/absence of sepsis, and acute physiological condition after surgery, were investigated in patients who died within 30 days of LLA and those who survived. Univariate analysis between groups was performed using the chi-square test. Comparisons of age and American Society of Anesthesiologists-Physical Status classification between groups were performed using the Mann-Whitney U test. Risk factors for 30-day mortality after LLA were examined using stepwise logistic regression (backward elimination). Statistical results were considered significant at P < 0.05.Results: Eight cases of mortality (6.6%) were found; we identified the causes as sepsis, myocardial infarction, fatal arrhythmia, and mesenteric artery occlusive disease in 5 (62.5%), 1 (12.5%), 1 (12.5%), and 1 (12.5%) cases, respectively. Using univariate analysis, we identified that age (≥74), delirium, sepsis, intensive care unit admission, non-DM (ASO only), hemodialysis, and acute kidney injury were significantly higher in the mortality group. In logistic regression analysis, non-DM (odds ratio [OR]: 35.2, 95% confidence interval [CI]: 2.8-432) and sepsis (OR: 80.7, 95% CI: 6.7-959) were potential risk factors for 30-day mortality.Conclusions: This study suggests that cases resulting in amputation due to ASO pathology alone might have poor prognosis and that preoperative sepsis can increase perioperative mortality; hence, the decision to amputate must be considered before the development of sepsis. [ABSTRACT FROM AUTHOR]

Objective: To investigate the predictive ability for adverse perinatal outcome of abnormal third-trimester uterine artery Doppler in late small-for-gestational-age (SGA) fetuses.Methods: A systematic search was performed to identify relevant observational studies and randomized controlled trials evaluating the performance of abnormal third-trimester uterine artery Doppler for the prediction of adverse perinatal outcome in suspected SGA fetuses and SGA neonates. Abnormal uterine artery Doppler was defined as uterine artery pulsatility index > 95th percentile or ≥ 2 SD above the mean, or bilateral uterine artery notching. Hierarchical summary receiver-operating-characteristics (ROC) curves were constructed using random-effects modeling. Bayesian analysis was used to calculate the posterior probability of adverse perinatal outcome following an abnormal or normal uterine artery Doppler assessment.Results: Seventeen observational studies (including 7552 fetuses either diagnosed with suspected SGA (n = 3461) or later diagnosed as a SGA neonate (n = 4091)) met the inclusion criteria; no randomized-controlled trials met the inclusion criteria. Summary ROC curves showed that, among suspected SGA fetuses, the best predictive accuracy of abnormal third-trimester uterine artery Doppler was for perinatal mortality and the worst was for composite adverse perinatal outcome, with areas under the summary ROC curves of 0.90 and 0.66, respectively. The corresponding positive and negative likelihood ratios were 16.5 and 0.6 for perinatal mortality and 2.82 and 0.65 for composite adverse perinatal outcome, respectively. Following an abnormal vs normal uterine artery Doppler assessment, the posterior risks for composite adverse perinatal outcome, admission to the neonatal intensive care unit, Cesarean section for intrapartum fetal compromise, 5-min Apgar score < 7, neonatal acidosis and perinatal death were: 52.3% vs 20.2%, 48.6% vs 18.7%, 23.1% vs 15.2%, 3.59% vs 1.32%, 9.15% vs 5.12% and 31.4% vs 1.64%, respectively.Conclusion: Abnormal uterine artery Doppler in the third trimester appears to be moderately useful in predicting perinatal death in pregnancies with suspected SGA. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Objective: To describe maternal and perinatal outcomes for women with chronic hypertension, comparing those with superimposed pre-eclampsia (SPE) with those without pre-eclampsia (NPE).Methods: In a retrospective cohort study in a tertiary hospital in Brazil, the records of women with chronic hypertension were reviewed between January 1, 2012, and May 31, 2017, in order to compare maternal and perinatal outcomes among those with and without SPE. Poisson regression was performed to investigate factors independently associated with severe pre-eclampsia.Results: Of 385 women with chronic hypertension included in the study, 167 were in the SPE group and 218 in the NPE group. The majority were white, overweight (body mass index ≥30 kg/m2 ), with mean age around 31 years. Adverse neonatal outcomes were significantly more prevalent among women with SPE, including small for gestational age (SPE 17.46% vs NPE 9.63%, P=0.01), low birth weight (SPE 2577 g ± 938 vs NPE 3128 g ± 723, P=0.003), neonatal intensive care unit admission (SPE 44.91% vs NPE 18.34%, P=0.08), and incidence of cesarean delivery (SPE 79.64% vs NPE 62.38%, P=0.003). Fetal growth restriction (PR [prevalence ratio] 2.62, 95% confidence interval [CI] 1.39-4.94) and previous pre-eclampsia (PR 1.96, 95% CI 1.17-3.28) were associated with severe pre-eclampsia.Conclusion: SPE is associated with prematurity and higher rates of admission to neonatal intensive care unit. Fetal growth restriction and previous pre-eclampsia are factors associated with severe complications of pre-eclampsia. [ABSTRACT FROM AUTHOR]

Guidelines for management of intracranial hemorrhage do not account for bleed location. We hypothesize that parafalcine subdural hematoma (SDH), as compared to convexity SDH, is a distinct clinical entity and these patients do not benefit from critical care monitoring or repeat imaging. We identified patients presenting to a single level I trauma center with isolated head injuries from February 2016 to August 2017. We identified 88 patients with isolated blunt traumatic parafalcine SDH and 228 with convexity SDH. Demographics, comorbidities, and use of antiplatelet and anticoagulant agents were similar between the groups. As compared to patients with convexity SDH, patients with parafalcine SDH had a significantly lower incidence of radiographic progression, and had no cases of neurologic deterioration, neurosurgical intervention, or mortality (all P < 0.005). Compared to patients admitted to the intensive care unit, patients with parafalcine SDH admitted to the floor had a shorter length of stay (2.0 ± 1.6 versus 3.8 ± 2.9 d, P < 0.005) with no difference in outcomes. Patients presenting with a parafalcine SDH are a distinct and relatively benign clinical entity as compared to convexity SDH and do not benefit from repeat imaging or intensive care unit admission. [ABSTRACT FROM AUTHOR]

Background: Estimating the global burden of influenza hospitalizations is required to allocate resources and assess interventions that aim to prevent severe influenza. In France, the current routine influenza surveillance system does not fully measure the burden of severe influenza cases. The objective was to describe the characteristics and severity of influenza hospitalizations by age‐group and by season between 2012 and 2017. Methods: All hospitalizations with a diagnosis of influenza in metropolitan France between July 2012 and June 2017 were extracted from the French national hospital discharge database (PMSI). For each season, the total number of influenza hospitalizations, admissions to intensive care units (ICU), proportion of deaths, lengths of stay, and distribution in diagnosis‐related groups were described by age‐group. Results: Over the five seasons, 91 255 hospitalizations with a diagnosis of influenza were identified. The average influenza hospitalization rate varied from 13/100 000 in 2013‐2014 to 46/100 000 in 2016‐2017. A high rate was observed in elderlies during the 2014‐2015 and 2016‐2017 seasons, dominated by A(H3N2) virus. The youngest were impacted in 2015‐2016, dominated by B/Victoria virus. The proportion of influenza hospitalizations with ICU admission was 10%, and was higher in age‐group 40‐79 years. The proportion of deaths and length of stay increased with age. Conclusions: The description of influenza hospitalizations recorded in the PMSI give key information on the burden of severe influenza in France. Analyses of these data annually is valuable in order to document the severity of influenza hospitalizations by age‐group and according to the circulating influenza viruses. [ABSTRACT FROM AUTHOR]

Objective: Worldwide controversy exists regarding the best approach and criteria for gestational diabetes mellitus (GDM) screening and diagnosis. The aim of this systematic review and meta-analysis of randomized trials was to assess the incidence of maternal and neonatal outcomes comparing the one step with the two step approach for the diagnosis of GDM.Methods: Electronic databases were searched from their inception until June 2018. We included all the randomized trials comparing the one step versus the two step method for screening and diagnosis of GDM. The primary outcome was the incidence of large for gestational age (LGA), defined as birth weight >90th percentile. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI).Results: Four randomized clinical trials (RCTs) (n = 2582 participants) were identified as relevant and included in the meta-analysis. Women screened with the one step approach had a significantly lower risk of adverse perinatal outcomes, including LGA (RR 0.46, 95% CI 0.25-0.83), admission to neonatal intensive care unit (NICU) (RR 0.49, 95% CI 0.29-0.84) and neonatal hypoglycemia (RR 0.52, 95% CI 0.28-0.95), compared to those randomized to the screening with the two step approach. The one step approach was also associated with lower mean birth weight (mean difference -112.91 grams, 95% CI -190.48 to -35.33). No significant difference in the incidence of GDM was found comparing the one step versus the two step approach (8.3 versus 4.4%; RR 1.60, 95% CI 0.93-2.75).Conclusions: This study provides high quality evidence that the diagnosis of GDM by the one step approach is associated with better perinatal outcomes, including lower incidences of LGA, NICU admission and neonatal hypoglycemia, compared to the two step approach. Based on these findings, we recommend screening of GDM using the one-step approach. [ABSTRACT FROM AUTHOR]

Febrile neutropenia (FN) is a critical complication of chemotherapy associated with increased in‐hospital mortality. However, associations with increased mortality and intensive care unit (ICU) admissions during longer follow‐up are not established. Patients treated with standard first‐line chemotherapy for solid cancers at Rigshospitalet, Denmark in 2010‐2016 were included. Incidence rate ratios (IRR) of all‐cause, infectious and cardiovascular mortality, and ICU admissions after FN were analyzed by Poisson regression. Risk factors at the time of FN were analyzed in the subpopulation of patients with FN; all‐cause mortality was further stratified by the time periods 0‐30, 31‐365, and 366+ days after FN. We included 9018 patients with gastric (14.4%) and breast (13.1%) cancer being the most common, 51.2% had locally advanced or disseminated disease and the patients had a median Charlson Comorbidity Index score of 0 (interquartile range, 0‐0). During follow‐up, 845 (9.4%) experienced FN and 4483 (49.7%) died during 18 775 person‐years of follow‐up. After adjustment, FN was associated with increased risk of all‐cause mortality, infectious mortality, and ICU admissions with IRRs of 1.39 (95% CI, 1.24‐1.56), 1.94 (95% CI, 1.43‐2.62), and 2.28 (95% CI, 1.60‐3.24). Among those with FN, having a positive blood culture and low lymphocytes were associated with excess risk of death and ICU admissions (predominantly the first 30 days after FN), while elevated C‐reactive protein and low hemoglobin predicted mortality the first year after FN. The risk of death varied according to the time since FN; adjusted IRR per additional risk factor present for the time periods 0‐30, 31‐365, and 366+ days after FN were 2.00 (95% CI, 1.45‐2.75), 1.36 (95% CI, 1.17‐1.57), and 1.17 (95% CI, 0.98‐1.41). FN was associated with increased mortality and risk of ICU admissions. An objectively identifiable subgroup of patients among those with FN carried this excess risk. [ABSTRACT FROM AUTHOR]

Background: It is well known that low platelet count on admission to intensive care units (ICU) is associated with increased mortality. However, it is unknown whether prothrombin time (PT-INR) and activated partial thromboplastin time (APTT) on admission correlate with mortality and organ failure. Therefore, the aim of this study was to investigate whether PT-INR and APTT at admission can predict outcome in the critically ill patient after adjusting for severity of illness measured with Simplified Acute Physiology Score 3 (SAPS 3).Materials and Methods: Data were retrospectively collected. APTT and PT-INR taken on admission and SAPS 3 score were independent variables in all regression analyses. Survival analysis was done with Cox regression. Organ failure was reported as days alive and free (DAF) of vasopressors and invasive ventilation, need of continuous renal replacement therapy (CRRT) and Acute Kidney Injury Network creatinine score (AKIN-crea).Results: A total of 3585 ICU patients were included. Prolonged APTT correlated with mortality with 95% confidence interval (CI) of hazard ratio 1.001-1.010. Prolonged APTT also correlated with DAF vasopressor, CRRT and AKIN-crea with 95% CI of odds ratio (OR) 1.009-1.034, 1.016-1.037 and 1.009-1.028, respectively. Increased PT-INR correlated with DAF vasopressor and DAF ventilator with 95% CI of OR 1.112-2.014 and 1.135-1.847, respectively.Conclusions: Activated partial thromboplastin time prolongation was associated with mortality and all morbidity outcomes except the DAF ventilator. PT-INR increase at admission was associated with DAF vasopressor and DAF ventilator. APTT and PT-INR at admission correlate with morbidity, which is not accounted for in the SAPS 3 model. [ABSTRACT FROM AUTHOR]

BACKGROUND Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients. METHODS We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. RESULTS The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radio-graphic or CT abnormality was found in 157 of 877 patients (17.9%) with non-severe disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission. CONCLUSIONS During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.) [ABSTRACT FROM AUTHOR]

Background: The increasing incidence of allergies and allergic reactions among children and adults has become a major public health concern. The etiology of allergic reactions can often be confirmed based on a detailed history and supportive testing. However, there are cases where the underlying factors are more complex and difficult to identify.Case Presentation: Here we present the case report of a 14-year-old Caucasian  girl with weight loss and a 3-year history of reported angioedema culminating in five intensive care unit admissions over the course of 2.5 months. Her initial clinical presentation included hypotension, dyspnea, and reported facial edema, but allergy and immunological workup were negative. A psychiatric workup identified an eating disorder with food restriction, comorbid major depression, obsessive compulsive disorder, and posttraumatic stress disorder. A close collaboration between Adolescent Medicine, Allergy and Immunology, and Psychiatry helped disentangle medical from psychiatric problems, including fluoxetine medication effects, as well as develop a treatment plan that was acceptable to the family. The angioedema was ultimately diagnosed as factitious disorder.Conclusions: This patient's treatment highlights the importance of a multidisciplinary team approach, a multifactorial etiology that needed to be addressed by multiple specialists, and the importance of long-term treatment and support. [ABSTRACT FROM AUTHOR]

Objective: Hypertension in pregnancy is associated with adverse maternal and neonatal outcomes. Previous studies have demonstrated disparities in the risk of preeclampsia based on race, educational attainment, census tract income level and household income. Yet, data on the association of insurance type, classification of hypertension in pregnancy and outcomes have not been well described. We sought to compare outcomes in women with hypertensive disorders of pregnancy, by private versus public insurance.Study design: This was a retrospective cohort study of subjects with a hypertensive disorder of pregnancy that delivered ≥23-week gestation at Oregon Health & Science University (October 2013-December 2017). The cohort began with the 2013 American College of Obstetricians and Gynecologists Executive Summary on Hypertension in Pregnancy, which advised surveillance for severe features of disease in women with hypertension. Utilizing ICD-9 and ICD-10 discharge codes, followed by individual chart review, subjects were stratified into two groups by insurance status: Medicaid (public insurance), or individual or group health insurance (private insurance). As primary outcomes, we assessed severe features of preeclampsia, adverse maternal or neonatal outcomes (composite), and final hypertensive diagnosis: (i) chronic hypertension; (ii) gestational hypertension; (iii) preeclampsia without severe features and, (iv) preeclampsia with severe features. Differences in demographic and outcome data were analyzed by chi-square, t-test, and logistic regression.Results: Among 10 132 deliveries, 1335 (13.2%) were delivered with a hypertensive disorder of pregnancy. Medicaid covered 54.1% (722) of these deliveries; 44.1% (589) were covered by private insurance, and 1.8% (24) had unknown insurance. There was a similar percentage of subjects with Medicaid or private insurance in each hypertensive group (p = .08). However, compared to subjects with private insurance, those with Medicaid had more severe blood pressure (BP) elevations (systolic BP ≥160 mmHg, p = .001) and more cases of eclampsia (p = .04), while neonates of subjects with Medicaid had more intensive care unit admissions (p = .02), and preterm births (p < .001). The association between Medicaid insurance and severe BP elevation, or adverse neonatal outcomes, persisted after multivariable adjustment.Conclusion: Medicaid was not associated with a particular hypertensive disorder in pregnancy, yet those with Medicaid experienced more severe BP elevations and higher rates of adverse neonatal outcomes. More research is needed to understand potential risk factors and ways to improve outcomes for those with publicly funded insurance. [ABSTRACT FROM AUTHOR]

Purpose: Vitamin D plays an important role in the modulation of the immune system and anti-autoimmune activities. Autoimmune thyroid diseases related to endocrine disorders are associated with poor obstetric outcomes in pregnancy. Herein, we aimed to investigate the contribution of vitamin D hypovitaminosis to poor pregnancy outcomes in pregnant women with the positive autoimmune antibody.Materials and methods: This was a prospective case-control study that enrolled pregnant women at their first trimester. The pregnant women were divided based on thyroid antibody (TA) status (TA-positive pregnant group (TAs (+)) and negative group (TAs (-)). Vitamin D status was categorized as sufficient, insufficient, and deficient (severe and moderate).Results: A total of 283 pregnant women were enrolled in this study. A total of 219 pregnant women were assigned to the TAs (-) group and 64 to the TAs (+) group. The rate of vitamin D insufficiency was 8.7, and 7.8% in the pregnant with TAs (-), and the pregnant with TAs (+) groups, respectively. Vitamin D deficiency was highly prevalent in all groups. Specifically, the prevalence rate was 91 and 92% in the pregnant with TAs (-) and the pregnant with TAs (+) groups, respectively. Admission to the neonatal intensive care unit (NICU) was more prevalent in the pregnant with TAs (+) group than in the pregnant with TAs (-) group (40.6 versus 25%; p = .0187; effect size (ES) = 0.134). The rate of gestational diabetes mellitus (GDM) was significantly higher in the pregnant women with TAs (+) group than that in the pregnant women with TAs (-) group (12.5 versus 4.1%; p = .03; ES =0.13). The rate of NICU admission and GDM was significantly higher in the severe vitamin D-deficient pregnant group with TAs (+) than that in the severe vitamin D-deficient pregnant group with TAs (-) (47 versus 23%; p = .007; ES =0.207 and 19.4% versus 4.1%; p = .006; ES =0.214, respectively).Conclusions: Severe vitamin D deficiency may contribute to increase the prevalence of GDM and need for NICU admission in pregnant women with positive TA. [ABSTRACT FROM AUTHOR]

Background: Renal failure is common in patients seeking help in medical emergency departments. Decreased renal function is associated with increased mortality in patients with heart failure or sepsis. In this study, the association between renal function (reflected by estimated glomerular filtration rate (eGFR) at the time of admission) and clinical outcome was evaluated. Methods/Objectives: Data was used from a prospective, multi-national, observational cohort of patients treated in three medical emergency departments of tertiary care centers. The eGFR was calculated from the creatinine at the time of admission (using the Chronic Kidney Disease-Epidemiology Collaboration equation,CKD-EPI). Uni- and multivariate regression models were used for eGFR and 30-day mortality, in hospital mortality, length of stay and intensive care unit admission rate. Results: 6983 patients were included. The 30-day mortality was 1.8%, 3.5%, 6.9%, 11.1%, 13.6%, and 14.2% in patients with eGFR of above 90, 60–89, 45–59, 30–44, 15–29, and <15 ml/min/1.73m2, respectively. Using multivariate regression, the adjusted odds ratio (OR) was 2.31 (for 15–29 ml/min/1.73m2, 95% confidence interval 1.36 to 3.90, p = 0.002) and 3.73 (for eGFR <15ml/min/1.73m2 as compared to >90 ml/min/1.73m2, 95% CI 2.04 to 6.84, p<0.001). For 10 ml/min/1.73m2 decrease in eGFR the OR for the 30-day mortality was 1.15 (95% CI1.09 to 1.22, p<0.001).The eGFR was also significantly associated with in-hospital mortality, the percentage of ICU-admissions, and with a longer hospital stay. No association was found with hospital readmission within 30 days. As limitations, only eGFR at admission was available and the number of patients on hemodialysis was unknown. Conclusion: Reduced eGFR at the time of admission is a strong and independent predictor for adverse outcome in this large population of patients admitted to medical emergency departments. [ABSTRACT FROM AUTHOR]

Background: The aim of the study was to detect differences in the conjunctival microcirculation between septic patients and healthy subjects and to evaluate the course of conjunctival and retinal microvasculature in survivors and non-survivors over a 24-h period of time. Methods: This single-center prospective observational study was performed in mixed ICU in a tertiary teaching hospital. We included patients with sepsis or septic shock within the first 24 h after ICU admission. Conjunctival imaging, using an IDF video microscope, and retinal imaging, using portable digital fundus camera, as well as systemic hemodynamic measurements, were performed at three time points: at baseline, 6 h and 24 h. Baseline conjunctival microcirculatory parameters were compared with healthy controls. Results: A total of 48 patients were included in the final assessment and analysis. Median APACHE II and SOFA scores were 16[12–21] and 10[7–12], respectively. Forty-four (92%) patients were in septic shock, 48 (100%) required mechanical ventilation. 19 (40%) patients were discharged alive from the intensive care unit. We found significant reductions in all microcirculatory parameters in the conjunctiva when comparing septic and healthy subjects. In addition, we observed a significant lower microvascular flow index (MFI) of small conjunctival vessels during all three time points in non-survivors compared with survivors. However, retinal arteriolar vessels were not different between survivors and non-survivors. Conclusions: Conjunctival microvascular blood flow was altered in septic patients. In the 24-h observation period conjunctival small vessels had a significantly higher MFI, but no difference in retinal arteriolar diameter in survivors in comparison with non-survivors. Trial registration NCT04214743, https://www.clinicaltrials.gov. Date of registration: 31 December 2019 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04214743 [ABSTRACT FROM AUTHOR]

Aim: While the incidence and aetiology of serious bacterial infections among febrile infants younger than 90 days old are well studied, those concerning viral infection are not. There are severe life-threatening viral infections requiring immediate intense therapy. The objective of the study is to describe the incidence and aetiology of serious viral infections (SVI) among young febrile infants.Methods: A retrospective audit was performed covering all the febrile infants younger than 90 days old admitted to a paediatric emergency department in Japan from 2011 to 2013. SVI was defined as a viral illness that may result in permanent organ dysfunctions or life-threatening complications. Diagnostic investigation consisted of urine and blood culture for all infants, cerebrospinal fluid cultures for infants who do not fulfil the low-risk criteria, rapid antigen tests for several viruses in infants with specific symptoms and blood and/or cerebrospinal fluid polymerase chain reaction of possible viruses for infants with fever without a localising source.Results: Of 275 cases, 32 and 45 cases were diagnosed as serious viral and bacterial infections, respectively. Intensive care unit admission occurred for three viral and four bacterial infections. Viral aetiology consisted of respiratory syncytial virus (11 cases), aseptic meningitis (9 cases), enterovirus (6 cases), influenza virus (3 cases), rotavirus (2 cases) and herpes simplex virus-1 (1 case). Respiratory (14 cases), central nervous (12 cases) and circulatory (6 cases) systems were affected.Conclusion: SVI was observed in 11.6% of febrile young infants in a paediatric emergency department. [ABSTRACT FROM AUTHOR]

Objective  Streptococcal toxic shock syndrome (STSS) is a very rare and severe entity from among the invasive diseases caused by Streptococcus pyogenes , whose characteristics, treatment, morbidity, and mortality are little known in pediatrics. The aim of this study was to determine its prevalence and the characteristics of its presentation in the emergency department (ED) in Spain. Methods  This is a descriptive and observational study. Patients from 1 month to 18 years of age, admitted to the ED with a final diagnosis of STSS between 2009 and 2014, were included. Patients whose parents or guardians did not allow informed consent were excluded. Results  Nine cases were diagnosed (1/100,000 consultations); the median average age was 2 years, and five were girls. No patient had a significant medical history. The most frequent reason for consultation was fever (9/9), followed by respiratory symptoms (6/9). Six presented in the ED with shock. Seven were diagnosed with pleuropneumonia, one with meningitis, and one with necrotizing fasciitis. All patients required admission at the pediatric intensive care unit, mechanical ventilation, and inotropic support. All had a complete recovery. Conclusion  STSS is a rare entity in the ED affecting healthy patients who presented respiratory or otorhinolaryngology disease. In our patients, nonspecific clinical manifestations and its rapid progression to shock are shown, meaning the importance of bearing this entity in mind in the emergency room. Understanding the epidemiology and clinical manifestations of this syndrome in our work area helps pediatricians to recognize it and to initiate the appropriate treatment at an early stage, which helps engender a quick and effective approach, essential for a favorable prognosis. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of publicly reporting a statewide fetal growth restriction (FGR) performance indicator.Design: Retrospective cohort study from 2000 to 2017.Setting: All maternity services in Victoria, Australia.Population: A total of 1 231 415 singleton births at ≥32 weeks of gestation.Methods: We performed an interrupted time-series analysis to assess the impact of publicly reporting an FGR performance indicator on the rate of detection for severe cases of small for gestational age (SGA). Rates of perinatal mortality and morbidity and obstetric intervention were assessed for severe SGA pregnancies and pregnancies delivered for suspected SGA.Main Outcome Measures: Gestation at delivery, obstetric management and perinatal outcome.Results: The public reporting of a statewide FGR performance indicator was associated with a steeper reduction per quarter in the percentage of severe SGA undelivered by 40 weeks of gestation, from 0.13 to 0.51% (P = 0.001), and a decrease in the stillbirth rate by 3.3 per 1000 births among those babies (P = 0.01). Of babies delivered for suspected SGA, the percentage with birthweights ≥ 10th centile increased from 41.4% (n = 307) in 2000 to 53.3% (n = 1597) in 2017 (P < 0.001). Admissions to a neonatal intensive care unit for babies delivered for suspected SGA but with a birthweight ≥ 10th centile increased from 0.8 to 2.0% (P < 0.001).Conclusions: The public reporting of an FGR performance indicator has been associated with the improved detection of severe SGA and a decrease in the rate of stillbirth among those babies, but with an increase in the rate of iatrogenic birth for babies with normal growth.Tweetable Abstract: The public reporting of hospital performance is associated with a reduction in stillbirth, but also with unintended interventions. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the hypothesis that the Modified Early Warning Score (MEWS) at the time of intensive care unit discharge is associated with readmission and to identify the MEWS that most reliably predicts intensive care unit readmission within 48 hours of discharge. Methods: This was a retrospective observational study of the MEWSs of discharged patients from the intensive care unit. We compared the demographics, severity scores, critical illness characteristics, and MEWSs of readmitted and non-readmitted patients, identified factors associated with readmission in a logistic regression model, constructed a Receiver Operating Characteristic (ROC) curve of the MEWS in predicting the probability of readmission, and presented the optimum criterion with the highest sensitivity and specificity. Results: The readmission rate was 2.6%, and the MEWS was a significant predictor of readmission, along with intensive care unit length of stay > 10 days and tracheostomy. The ROC curve of the MEWS in predicting the readmission probability had an AUC of 0.82, and a MEWS > 6 carried a sensitivity of 0.78 (95%CI 0.66 - 0.9) and specificity of 0.9 (95%CI 0.87 - 0.93). Conclusion: The MEWS is associated with intensive care unit readmission, and a score > 6 has excellent accuracy as a prognostic predictor. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the functional status of pediatric patients undergoing congenital heart surgery after discharge from the intensive care unit, and to evaluate the correlations among clinical variables, functional status and surgical risk. Methods: Cross-sectional study including patients aged 1 month to less than 18 years undergoing congenital heart surgery between October 2017 and May 2018. Functional outcome was assessed by the Functional Status Scale, surgical risk classification was determined using the Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1), and clinical variables were collected from electronic medical records. Results: The sample comprised 57 patients with a median age of 7 months (2 - 17); 54.4% were male, and 75.5% showed dysfunction, which was moderate in 45.6% of the cases. RACHS-1 category > 3 was observed in 47% of the sample, indicating higher surgical risk. There was a correlation between functional deficit and younger age, longer duration of invasive mechanical ventilation and longer intensive care unit stay. Moreover, greater functional deficit was observed among patients classified as RACHS-1 category > 3. Conclusion: The prevalence of functional deficit was high among children and adolescents with congenital heart disease after cardiac surgery. Higher surgical risk, longer duration of invasive mechanical ventilation, longer intensive care unit stay and younger age were correlated with worse functional status. [ABSTRACT FROM AUTHOR]

Aim: Older colorectal cancer (CRC) patients are at increased risk of postoperative morbidity and mortality. Routine postoperative overnight intensive care unit (ICU) admission might reduce this risk. This study aimed to examine the effect of routine overnight ICU admission after CRC surgery on postoperative adverse outcomes and costs in patients aged 80 years or older. Methods: Patients aged 80 years or older who underwent CRC surgery in our centre were included in this observational cohort study. All patients in the period 2014–2017 with routine overnight ICU admission were assigned to the ICU cohort; all patients in the period 2009–2013 were assigned to the non‐ICU cohort. Multivariable logistic regression was performed to compare the primary composite end‐point (30‐day mortality, serious complications and readmission) between the groups. Cost data from the literature were used to perform a cost analysis. Results: A total of 242 patients were included, 125 in the ICU cohort and 117 in the non‐ICU cohort. Routine overnight ICU admission was associated with a reduced risk of the composite end‐point (OR 0.44, 95% CI 0.22–0.87, P = 0.02) after adjusting for important confounders. In the ICU cohort 28% of patients experienced ICU events requiring intervention; this was not associated with postoperative morbidity or mortality. The 9% reduction in the incidence of serious complications in the ICU cohort is sufficient to offset the additional costs of routine overnight ICU admission. Conclusion: Routine overnight ICU admission after CRC surgery in patients aged 80 years and older is associated with reduced risk of postoperative mortality and morbidity and seems to be cost‐effective. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness of a 12-hour versus 24-hour intravenous maintenance dose of magnesium sulfate (MgSO4 ) in women with pre-eclampsia, and the maternal and fetal outcomes.Methods: This was a randomized controlled trial conducted at the labor ward complex of University College Hospital, Ibadan, Nigeria between May and August 2014. Pregnant women with severe pre-eclampsia were randomized to receive a 12-hour versus 24-hour maintenance dose of MgSO4 . Study outcomes were occurrence of seizures, adverse maternal effects, neonatal survival, and admission to the intensive care unit. Data analysis involved descriptive statistics and bivariate analysis using Statistical Package for Social Science (SPSS) version 20.Results: There were 80 patients randomized to the 12-hour (n=40) and 24-hour (n=40) groups. The participants in the two groups had comparable demographic features. There was no significant difference (P>0.999) between the satisfactory maternal outcome following the 12-hour maintenance dose and the standard 24-hour regimen (95.0% vs 97.5%). Similarly, there was no significant difference (P=0.276) in perinatal mortality in the 12-hour versus 24-hour arm (17.5% vs 12.5%, respectively). No case of eclampsia and maternal death was recorded.Conclusion: A 12-hour maintenance dose of intravenous MgSO4 in the management of severe pre-eclampsia is effective and safe when compared with the 24-hour maintenance dose. [ABSTRACT FROM AUTHOR]

Early extubation, also known as fast track, is desirable after intracranial hematoma surgery to avoid ventilator-associated complications associated with admission to an intensive care unit (ICU). The objective of the present study was to determine whether ICU stay and ventilator-associated complications are reduced in patients who received surgery for intracranial hematoma if they are extubated early. A total of 17 patients were randomly assigned to two groups: In Group 1, patients were extubated early or using the fast track method, while those in Group 2 were conventionally extubated at a later stage and were managed at the ICU. Patients from both groups were assessed on admission to the operating room per the established standards and after the selection criteria had been confirmed, general anesthesia was applied. Extubation time and hemodynamic stability (number of anesthetic adjustments required to maintain hemodynamic parameters within 20% of the predicted values) were assessed post-operatively. Patients in the conventional group (n=10) were transferred to the ICU and extubated at 8 h post-operatively; hemodynamic stability and the presence of complications were evaluated. The fast track group had no complications associated with ventilation or any other parameter. All patients extubated in a conventional manner and who were transferred to the ICU presented with complications, including seizures, aspiration, atelectasis or failed extubation. In the future, fast track should be regarded as a routine technique in patients who meet the required criteria, so that they may be discharged quickly and with fewer complications. The present study was authorized by the ethics committee of the hospital and the research sub-directorate with the number AN14-003; it was submitted to and approved by the ISRCTN registry for clinical trials (ID, ISRCTN16924441). [ABSTRACT FROM AUTHOR]

Acute post-operative pain following sternotomy in cardiac surgery should be adequately managed so as to avoid adverse hemodynamic consequences and pulmonary complications. In the era of fast tracking, adequate and efficient technique of post-operative analgesia enables early extubation, mobilization and discharge from intensive care unit. Due to increasing expertise in ultrasound guided blocks there is a recent surge in trial of bilateral nerve blocks for pain relief following sternotomy. The aim of this article was to review non-neuraxial regional blocks for analgesia following sternotomy in cardiac surgery. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. A total of 17 articles were found to be directly related to the performance of non-neuraxial regional nerve blocks across all study designs. Due to scarcity of literature, comments cannot be made on the superiority of these blocks over each other. However, most of the reviewed techniques were found to be equally efficacious or better than conventional and established techniques. [ABSTRACT FROM AUTHOR]

Summary: Background: Epidermal necrolysis (EN) is a rare and life‐threatening condition. Objectives: To assess whether admitting hospital characteristics and interhospital transfer are associated with mortality due to EN. Methods: We studied the French nationwide hospital discharge database (retrospective national cohort). All patients admitted during 2012–2016 with a code for EN in the International Classification of Diseases, 10th Revision, were eligible. We extracted data on the patients (age, sex, intensive care unit admission, comorbidities) and hospitals (private proprietary vs. public, nonteaching or teaching; and number of admissions for EN as a proxy for experience). Multivariable analysis was used to identify independent predictors of in‐hospital mortality with mixed logistic regression. Results: We identified 991 patients (467 male; mean age 52·7 ± 23 years). They were admitted to 300 different hospitals, including teaching hospitals (25% of hospitals) for around half of the patients. Overall, 597 patients (60%) had a diagnosis of Stevens–Johnson syndrome (SJS), 171 (17%) had SJS/toxic epidermal necrolysis (TEN) overlap and 223 (23%) had TEN. In total, 109 (11%) patients died: nine (2%) with SJS, 26 (15%) with SJS/TEN overlap and 74 (33%) with TEN. The in‐hospital mortality rate was lower in centres with vs. without substantial EN experience – odds ratio for one supplemental EN admission in a department 0·5 (95% confidence interval 0·3–1·0); P = 0·05 – even after adjusting for potentially relevant individual risk factors. We found no significant association between mortality and interhospital transfer. Conclusions: Our findings highlight increased survival of patients with EN in centres with a high volume of EN procedures. If confirmed in other settings, these findings reinforce the importance of expertise in early diagnosis and management of this condition. What's already known about this topic? Epidermal necrolysis (EN) is a rare and life‐threatening condition.At the individual level, risk factors for in‐hospital mortality have been identified.Few studies have examined the association between hospital characteristics and EN mortality, with special attention to referral hospitals. What does this study add? Short‐term mortality rates were lower for patients in centres with EN experience than in centres without EN experience, after adjusting for known risk factors.We found no association between interhospital transfer and survival.If confirmed in other settings, these findings support the early transfer of patients with suspected or diagnosed EN to centres with experience, where a multidisciplinary approach can be implemented by experienced healthcare professionals, to maximize short‐term survival. Respond to this article Plain language summary available online [ABSTRACT FROM AUTHOR]

Background: Both the thrombo-inflammatory prognostic score (TIPS) and the quick sequential (sepsis-related) organ failure assessment (qSOFA) are quick prognostic scores for sepsis during the early phase, while either of two scores has limited prognostic value for sepsis patients. This study aimed to evaluate whether TIPS adds more information of sepsis risk stratification for qSOFA. Methods: This was a retrospective cohort study of patients with sepsis in the emergency department (ED). We performed a receiver-operating characteristic curve, integrated discrimination improvement (IDI), net reclassification improvement (NRI) and decision-curve analysis (DCA) analyses to investigate whether TIPS can improve qSOFA for risk prediction in patients with sepsis. The primary endpoint was mortality and the secondary endpoints were mechanical ventilation and admission to the intensive care unit (ICU) during the 28-day follow-up. Results: We identified 821 patients with sepsis. We randomly assigned the patients' data to a derivation group (n = 498; n = 112 died during the 28-days follow-up) or to a validation group (n = 323; n = 61). The addition of TIPS to qSOFA (T-qSOFA) improved the area under the curve (AUC) from 0.724 to 0.824 (p < 0.001) for predicting 28-day mortality. The discrimination improvement was confirmed by an IDI of 0.092 (p < 0.001). Addition of TIPS to the qSOFA resulted in a NRI of 0.247 (p < 0.001). The DCA showed that the net benefit of T-qSOFA was higher than that of TIPS or qSOFA for any threshold probabilities. Conclusions: The prognostic value of qSOFA for patients with sepsis was enhanced by adding the TIPS score on admission for risk prediction in patients with sepsis during early phases in the ED. [ABSTRACT FROM AUTHOR]

Objective: To assess if delayed amniotomy during labor induction is associated with adverse delivery outcomes.Study Design: Retrospective cohort study of women with a viable, singleton gestation who underwent labor induction at a tertiary-care hospital (4/2014-3/2017). Women were excluded if oxytocin was not used or if spontaneous rupture of membranes (ROM) occurred ≤8 h after oxytocin initiation. The primary outcome was cesarean delivery, and secondary outcomes included postpartum hemorrhage, maternal infectious morbidity, neonatal 5-min Apgar score <7, and neonatal intensive care unit admission. Women were compared by timing of amniotomy: delayed (ROM > 8 h after oxytocin initiation) versus not delayed. Multivariable logistic regression was used to estimate the association between delayed amniotomy and study outcomes.Results: Of 2081 women who met inclusion criteria, 1125 (before 54%) had delayed amniotomy. Women with delayed amniotomy had ROM 12.7 h (IQR 10.0, 17.9) after oxytocin versus 5.0 h (IQR 3.7, 6.5) without delayed amniotomy. In multivariable regression, delayed amniotomy was associated with increasingly higher odds of cesarean as maternal obesity severity increased (aOR 1.58, 95 %CI 1.24-2.03 at BMI 30 kg/m2; aOR 2.15, 95 %CI 1.45-3.21 at BMI 40 kg/m2; aOR 2.93, 95 %CI 1.54-5.57 at BMI 50 kg/m2).Conclusion: Delayed amniotomy >8 h after starting oxytocin for labor induction was associated with higher odds of cesarean delivery. Significant delay in ROM should be avoided during labor induction. [ABSTRACT FROM AUTHOR]

Background: Numerous patients experience long-term impairments after discharge from the intensive care unit (ICU), including physical, psychological and cognitive deficiencies. This study aims to investigate the knowledge and handling of post-intensive care impairments among Danish doctors and nurses in the medical and surgical wards.Methods: An electronic questionnaire survey was distributed to consultants and development nurses, head nurses and assistant head nurses at departments of abdominal surgery and internal medicine of hospitals with an ICU in the Region Zealand of Denmark.Results: We invited 350 employees to participate, 48% responded. Most participants, 82.8% nurses and 86.6% doctors, reported their knowledge of in-hospital needs of the ICU patients to be average or higher. Sixty per cent of doctors reported having average or higher knowledge of the patients' post-discharge needs. More than half the doctors (60.2%) reported that they "Rarely" or "Never" addressed possible ICU-related impairments in the discharge summary. During hospital admission, 22.9% replied "No screening performed" for physical impairment, while the rates for psychological and cognitive impairments were 70.7% and 57.3%, respectively. Most respondents believed that doctors (92.8%) and nurses (92.1%) in the ward and ICU doctors (89.4%) play an important role in detecting ICU-related impairments; 63.8% felt that general practitioners play a key role.Conclusion: Doctors and nurses generally reported having average or higher knowledge of ICU patients' in-hospital needs, but few screened systematically for ICU-related impairments. Most respondents believed that detecting these problems is a shared responsibility between professionals in the primary and, especially, the secondary healthcare sector. [ABSTRACT FROM AUTHOR]