Mortality rates among adult critical care patients with unusual or extreme values of vital signs and other physiological parameters: a retrospective study

BACKGROUND

We evaluated relationships of vital signs and laboratory-tested physiological parameters with in-hospital mortality, focusing on values that are unusual or extreme even in critical care settings.

METHODS

We retrospectively studied Philips Healthcare-MIT eICU data (207 U.S. hospitals, 20142015), including 166,959 adult-patient critical care admissions. Analyzing most-deranged (worst) value measured in the first admission day, we investigated vital signs (body temperature, heart rate, mean arterial pressure, and respiratory rate) as well as albumin, bilirubin, blood pH via arterial blood gas (ABG), blood urea nitrogen, creatinine, FiO2 ABG, glucose, hematocrit, PaO2 ABG, PaCO2 ABG, sodium, 24-hour urine output, and white blood cell count (WBC).

RESULTS

In-hospital mortality was ≥50% at extremes of low blood pH, low and high body temperature, low albumin, low glucose, and low heart rate. Near extremes of blood pH, temperature, glucose, heart rate, PaO2 , and WBC, relatively. Small changes in measured values correlated with several-fold mortality rate increases. However, high mortality rates and abrupt mortality increases were often hidden by the common practice of thresholding or binning physiological parameters. The best predictors of in-hospital mortality were blood pH, temperature, and FiO2 (scaled Brier scores: 0.084, 0.063, and 0.049, respectively).

CONCLUSIONS

In-hospital mortality is high and sharply increasing at extremes of blood pH, body temperature, and other parameters. Common-practice thresholding obscures these associations. In practice, vital signs are sometimes treated more casually than laboratory-tested parameters. Yet, vitals are easier to obtain and we found they are often the best mortality predictors, supporting perspectives that vitals are undervalued.

Assessing Changes in Stethoscope Hygiene During COVID-19: A Multicentre Cross-Sectional Study

Background

The COVID-19 (SARS-CoV-2) pandemic has increased infection control vigilance across several modes of patient contact. However, it is unknown whether hygiene pertaining to stethoscopes, which carry the potential for pathogenic contamination, has also shifted accordingly.

Aim

To characterize pandemic-related changes in stethoscope hygiene.

Methods

We surveyed healthcare providers at three major medical centres. Questions quantitatively (Likert scale and frequency) assessed stethoscope hygiene beliefs and practices with two components: before and during COVID-19. Participants were grouped based on performance of optimal stethoscope hygiene (after every patient) before and during COVID-19. Groups were compared using χ² and analysis of variance (ANOVA).

Findings

Of the 515 (10%) who completed the survey, 55 were excluded (N = 460). Optimal hygiene increased from 27.4% to 55.0% (P < 0.001). There were significant increases in Likert scores for all questions pertaining to knowledge of stethoscope contamination (P < 0.001). Belief in stethoscope contamination increased (P < 0.001) despite no change in perceived hygiene education. Resident physicians were less likely compared with attending physicians and nurses to have adopted optimal hygiene during COVID-19 (P < 0.001).

Conclusion

Despite a positive shift in stethoscope hygiene during COVID-19, optimal hygiene was still only performed by around half of providers. Educational interventions, particularly targeting early-career providers, are encouraged.

646 A Review of The Urodynamic Referral Pathway and The Accuracy of Urodynamic Study Requests

Aim

Urodynamic studies (UDS) are physiological measurements of voiding and storage function of the lower urinary tract that are commonly performed in clinical practice to investigate bothersome lower urinary tract symptoms. Despite considerable efforts to improve UDS, standardisation of the practice remains to be challenging. This audit thus, presents a review the current UDS referral process and analysis of the clinical details included on urodynamic requests.

Method

This audit included retrospective data from 112 patients between March and Oct 2020, 98 of which had UDS performed. Patient electronic records, referral forms and clinic letters were all used for data collection.

Results

Data shows that 47% of patients were females with average age of 56 years, range (16-86) years. The reason of UDS was clearly stated in 8 referrals only and the clinical examination findings were clearly mentioned in 31% only. More than three quarters of patients (i.e., 77%) had assessment of post void residual prior to UDS, but half of the proportion had no history of relevant medications. In 98 patients who had UDS done, the main findings showed that 4 patients had normal studies, 3 with dysfunctional voiding, 7 had bladder outflow obstruction, 32 patients were diagnosed with detrusor overactivity, 12 had stress incontinence and 7 showed detrusor underactivity.

Conclusions

Finding of this audit clearly suggest a level of unclarity in the great majority of referrals. Evidently, key history of relevant medication is overlooked in half of the referrals. Improvements to the current pathway to UDS is therefore pivotal.

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

Fever Incidence Is Much Lower in the Morning than the Evening: Boston and US National Triage Data

INTRODUCTION

In this observational study, we evaluated time-of-day variation in the incidence of fever that is seen at triage. The observed incidence of fever could change greatly over the day because body temperatures generally rise and fall in a daily cycle, yet fever is identified using a temperature threshold that is unchanging, such as ≥38.0° Celsius (C) (≥100.4° Fahrenheit [F]).

METHODS

We analyzed 93,225 triage temperature measurements from a Boston emergency department (ED) (2009-2012) and 264,617 triage temperature measurements from the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2002-2010), making this the largest study of body temperature since the mid-1800s. Boston data were investigated exploratorily, while NHAMCS was used to corroborate Boston findings and check whether they generalized. NHAMCS results are nationally representative of United States EDs. Analyses focused on adults.

RESULTS

In the Boston ED, the proportion of patients with triage temperatures in the fever range (≥38.0°C, ≥100.4°F) increased 2.5-fold from morning to evening (7:00-8:59 PM vs 7:00-8:59 AM: risk ratio [RR] 2.5, 95% confidence interval [CI], 2.0-3.3). Similar time-of-day changes were observed when investigating alternative definitions of fever: temperatures ≥39.0°C (≥102.2°F) and ≥40.0°C (≥104.0°F) increased 2.4- and 3.6-fold from morning to evening (7:00-8:59 PM vs 7:00-8:59 AM: RRs [95% CIs] 2.4 [1.5-4.3] and 3.6 [1.5-17.7], respectively). Analyses of adult NHAMCS patients provided confirmation, showing mostly similar increases for the same fever definitions and times of day (RRs [95% CIs] 1.8 [1.6-2.1], 1.9 [1.4-2.5], and 2.8 [0.8-9.3], respectively), including after adjusting for 12 potential confounders using multivariable regression (adjusted RRs [95% CIs] 1.8 [1.5-2.1], 1.8 [1.3-2.4], and 2.7 [0.8-9.2], respectively), in age-group analyses (18-64 vs 65+ years), and in several sensitivity analyses. The patterns observed for fever mirror the circadian rhythm of body temperature, which reaches its highest and lowest points at similar times.

CONCLUSION

Fever incidence is lower at morning triages than at evening triages. High fevers are especially rare at morning triage and may warrant special consideration for this reason. Studies should examine whether fever-causing diseases are missed or underappreciated during mornings, especially for sepsis cases and during screenings for infectious disease outbreaks. The daily cycling of fever incidence may result from the circadian rhythm.

The daily, weekly, and seasonal cycles of body temperature analyzed at large scale

We performed large-scale analyses of circadian and infradian cycles of human body temperature, focusing on changes over the day, week, and year. Temperatures (n= 93,225) were collected using temporal artery thermometers from a Boston emergency department during 2009-2012 and were statistically analyzed using regression with cyclic splines. The overall mean body temperature was 36.7°C (98.1°F), with a 95% confidence interval of 36.7-36.7°C (98.1-98.1°F) and a standard deviation of 0.6°C (1.1°F). Over the day, mean body temperature followed a steady cycle, reaching its minimum at 6:00-8:00 and its maximum at 18:00-20:00. Across days of the week, this diurnal cycle was essentially unchanged, even though activities and sleeping hours change substantially during the weekly cycles of human behavior. Over the year, body temperatures were slightly colder in winter than summer (~0.2°C difference), consistent with most prior studies. We propose these seasonal differences might be due to ambient effects on body temperature that are not eliminated because they fall within the tolerance range of the thermoregulatory system. Over the year, bathyphase (daily time of minimum temperature) appeared to parallel sunrise times, as expected from sunrise's zeitgeber role in circadian rhythms. However, orthophase (daily time of maximum temperature) and sunset times followed opposite seasonal patterns, with orthophase preceding nightfall in summer and following nightfall in winter. Throughout the year, bathyphase and orthophase remained separated by approximately 12 h, suggesting this interval might be conserved. Finally, although 37.0°C (98.6°F) is widely recognized as the mean or normal human body temperature, analysis showed mean temperature was <37.0°C during all times of day, days of the week, and seasons of the year, supporting prior arguments that the 37.0°C standard has no scientific basis. Overall, this large study showed robust and consistent behavior of the human circadian cycle at the population level, providing a strong example of circadian homeostasis.

Long-term relationships between screening rates, breast cancer characteristics, and overdiagnosis in US counties, 1975-2009

Effects of mammography screening in the general population are disputed. Screening rates differ greatly between US counties, providing a natural opportunity to investigate effects of screening. We compared mammography screening rates with the types and outcomes of breast cancers diagnosed in US counties. The county screening rate was defined as the proportion of women age ≥40 with ≥1 mammogram in the past 2 years (range, 34-91%). Two periods were analyzed: 1975-2009 (612,941 breast cancer cases, 195 counties) and 1996-2009 (645,057 cases, 211-547 counties). Multiple signs of overdiagnosis were observed: First, breast cancer incidence increased as screening became common. Second, incidence stopped increasing once screening rates stabilized. Third, the increases in incidence were limited to age groups receiving screening. Fourth, the increases were larger in counties where screening became more common. Fifth, the increases were limited to small and early-stage breast cancers (which are consistent with overdiagnosis). Sixth, compensatory reductions in large and advanced-stage breast cancers were much smaller than the increases. Difference-in-differences regression analysis suggested 31% (95% CI: 28-34%) of breast cancers diagnosed in 1996-2009 were overdiagnosed. Screening rates correlated with increased incidence for all hormone receptor statuses, HER2 statuses, and grades. Reductions in breast cancer mortality during 1975-2009 were similar in screened and unscreened age groups. Overall, we found repeated signs that breast cancer overdiagnosis is widespread in the US, but the biological nature of overdiagnosed tumors remains unclear. Mortality benefits of screening, though they may be present and substantial, could not be detected at the population level.

Urinary tract infection management – do the guidelines agree?

Urinary tract infection (UTI) is defined as the inflammatory response of the urothelium to bacterial invasion. UTI in adults is one of the most prevalent infectious diseases worldwide with a substantial financial burden on society. There is mounting concern surrounding the ongoing development of microbial resistance. In addition, the increasing resistance of organisms to broad-spectrum antibiotics is worrying. There is a continuing drive for antibiotic stewardship and more prudent prescribing of antimicrobial agents. There is currently no national UK guideline on the management of UTI in adults but the EAU, AUA and SIGN all have their separate recommendations. In this review, we discuss the existing guideline recommendations particularly relating to lower UTIs (cystitis and epididymo-orchitis), upper UTIs (pyelonephritis) and catheter-associated infections (due to their large healthcare burden). The aims are to identify common recommendations and assess how they may apply for the UK setting. This review has highlighted considerable differences in practice recommendations between the major UK, European and American guidelines. Discrepancy exists in the choice of antibiotics and for some types of infection, whether or not any guidance for treatment is offered. Antibiotic avoidance and prudent antibiotic prescribing will be key components of future strategies in reducing antimicrobial resistance.

Using non-nutritive sucking to support feeding development for premature infants: A commentary on approaches and current practice

Non-nutritive sucking is often used with premature infants by either using a pacifier or an expressed breast nipple to support the introduction and development of early oral feeding. The pattern of non-nutritive sucking is distinct in that it involves two sucks per second in contrast to nutritive sucking which is one suck per second. Although some literature has identified that non-nutritive sucking has some benefit for the premature infant's feeding development, it is not entirely clear why such an approach is helpful as neurologically, activation of non-nutritive and nutritive skills are different. A summary is presented of the main approaches that use non-nutritive sucking with reference to the literature. This paper also considers other factors and beneficial approaches to managing the introduction of infant feeding. These are: the infant's toleration of enteral feeds pre oral trials, overall development and gestational age when introducing oral experiences, developing swallowing skills before sucking, physiological stability, health status, as well as the development and interpretation of infant oral readiness signs and early communication.

Publication rate of abstracts presented at the British Association of Urological Surgeons Annual Meeting – 10 years on

Introduction:

Acceptance of abstracts at the BAUS Annual Meeting is sought after by trainees and encouraged by trainers; however, it is the publication of this research in a peer-reviewed journal that validates the significance of the work. We aimed to compare current publication rates with those detailed in a previous study 10 years ago to examine for changes on the rate and time to peer-reviewed publications of abstracts presented. We also assessed whether there was a difference in the presentation and publication rates between UK deaneries.

Methods:

All abstracts accepted for presentation at the annual BAUS 2012 and 2013 meetings were identified from the published supplements in the BJU International journal. Listed abstracts were searched for in October 2015 using the Medline Plus (PubMed) database to assess for successful conversion to a peer-reviewed paper listed on the Medline database.

Results:

In total 281 abstracts were presented; of these, 265 (94.3%) were from the UK. A total of 24.2% of the abstracts presented over the two-year period resulted in a successful conversion to a peer-reviewed publication. Mean time to publication was 11.59 months and mean impact factor of the publishing journal was 3.854. There appeared to be no correlation between the number of abstracts presented per deanery and the subsequent successful conversion to peer-reviewed publication.

Conclusions:

There has been a decline over the past decade in the number of BAUS abstracts being successfully converted into peer-reviewed publications, from 42% to 24.2%. The quality of any scientific meeting can be quantified by the number of peer-reviewed publications arising from its abstracts. Possible reasons for this observed reduction include a lack of time to prepare manuscripts, the actual quality and relevance of work being presented and data that may be of questionable validity. In addition, indicative numbers set for publications to enable successful awarding of Certificate of Completion of Training are low.

Human temperatures for syndromic surveillance in the emergency department: data from the autumn wave of the 2009 swine flu (H1N1) pandemic and a seasonal influenza outbreak

Background

The emergency department (ED) increasingly acts as a gateway to the evaluation and treatment of acute illnesses. Consequently, it has also become a key testing ground for systems that monitor and identify outbreaks of disease. Here, we describe a new technology that automatically collects body temperatures during triage. The technology was tested in an ED as an approach to monitoring diseases that cause fever, such as seasonal flu and some pandemics.

Methods

Temporal artery thermometers that log temperature measurements were placed in a Boston ED and used for initial triage vital signs. Time-stamped measurements were collected from the thermometers to investigate the performance a real-time system would offer. The data were summarized in terms of rates of fever (temperatures ≥100.4 °F [≥38.0 °C]) and were qualitatively compared with regional disease surveillance programs in Massachusetts.

Results

From September 2009 through August 2011, 71,865 body temperatures were collected and included in our analysis, 2073 (2.6 %) of which were fevers. The period of study included the autumn–winter wave of the 2009–2010 H1N1 (swine flu) pandemic, during which the weekly incidence of fever reached a maximum of 5.6 %, as well as the 2010–2011 seasonal flu outbreak, during which the maximum weekly incidence of fever was 6.6 %. The periods of peak fever rates corresponded with the periods of regionally elevated flu activity.

Conclusions

Temperature measurements were monitored at triage in the ED over a period of 2 years. The resulting data showed promise as a potential surveillance tool for febrile disease that could complement current disease surveillance systems. Because temperature can easily be measured by non-experts, it might also be suitable for monitoring febrile disease activity in schools, workplaces, and transportation hubs, where many traditional syndromic indicators are impractical. However, the system’s validity and generalizability should be evaluated in additional years and settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-016-0080-7) contains supplementary material, which is available to authorized users.

Posterior tibial nerve stimulation in adults with overactive bladder syndrome: A systematic review of the literature

Overactive bladder (OAB) is a common condition that can significantly impact on a patient’s quality of life. Treatments include conservative methods (patient education, lifestyle modifications, bladder retraining), pharmacotherapy (anticholinergics and adrenoreceptor agonists), intravesical botulinum toxin A injections and surgical strategies (including neuromodulation, augmentation cystoplasty and urinary diversion). There has been increased interest in neuromodulation over recent years and accumulating evidence for percutaneous tibial nerve stimulation (PTNS). We have reviewed the currently available clinical evidence in a systematic, reproducible fashion. PTNS has been shown in randomised controlled studies (against sham/placebo and against anticholinergics) to be safe and effective in treating OAB. Cost effectiveness analyses for PTNS have shown mixed results depending on the length of follow-up. PTNS is a useful adjunct to therapy in OAB for patients who have failed conservative and pharmacotherapy. Further research is required to define its place in the OAB treatment algorithm.

A study examining the relationship between alexithymia and challenging behaviour in adults with intellectual disability

BACKGROUND

Research suggesting that people with intellectual disabilities (ID) have difficulties in recognising emotions provides a rationale for studying alexithymia in this population. A number of studies have found a relationship between alexithymia and challenging behaviours in various populations and this study aims to discover if this is the case for people with ID.

METHOD

Cross-sectional data were collected from 96 participants with ID and 95 of their carers. The service user participants completed an alexithymia questionnaire for children while carers completed the checklist for challenging behaviour and the observer alexithymia scale. Correlational analyses were employed to explore relationships between the variables.

RESULTS

The relationship between service user and carer-rated alexithymia was very weak. The analysis did show significant associations between observer-rated alexithymia and challenging behaviour frequency, management difficulty and severity, but there was no significant relationship between challenging behaviour and alexithymia as rated by service users themselves.

CONCLUSIONS

This study suggests that observer-rated alexithymia is important in understanding challenging behaviour presented by people with ID. Service user-rated alexithymia had no association with challenging behaviour, in contrast to the results from similar research with other challenging populations.

Breast Cancer Screening, Incidence, and Mortality Across US Counties

IMPORTANCE

Screening mammography rates vary considerably by location in the United States, providing a natural opportunity to investigate the associations of screening with breast cancer incidence and mortality, which are subjects of debate.

OBJECTIVE

To examine the associations between rates of modern screening mammography and the incidence of breast cancer, mortality from breast cancer, and tumor size.

DESIGN, SETTING, AND PARTICIPANTS

An ecological study of 16 million women 40 years or older who resided in 547 counties reporting to the Surveillance, Epidemiology, and End Results cancer registries during the year 2000. Of these women, 53,207 were diagnosed with breast cancer that year and followed up for the next 10 years. The study covered the period January 1, 2000, to December 31, 2010, and the analysis was performed between April 2013 and March 2015.

EXPOSURES

Extent of screening in each county, assessed as the percentage of included women who received a screening mammogram in the prior 2 years.

MAIN OUTCOMES AND MEASURES

Breast cancer incidence in 2000 and incidence-based breast cancer mortality during the 10-year follow-up. Incidence and mortality were calculated for each county and age adjusted to the US population.

RESULTS

Across US counties, there was a positive correlation between the extent of screening and breast cancer incidence (weighted r = 0.54; P < .001) but not with breast cancer mortality (weighted r = 0.00; P = .98). An absolute increase of 10 percentage points in the extent of screening was accompanied by 16% more breast cancer diagnoses (relative rate [RR], 1.16; 95% CI, 1.13-1.19) but no significant change in breast cancer deaths (RR, 1.01; 95% CI, 0.96-1.06). In an analysis stratified by tumor size, we found that more screening was strongly associated with an increased incidence of small breast cancers (≤2 cm) but not with a decreased incidence of larger breast cancers (>2 cm). An increase of 10 percentage points in screening was associated with a 25% increase in the incidence of small breast cancers (RR, 1.25; 95% CI, 1.18-1.32) and a 7% increase in the incidence of larger breast cancers (RR, 1.07; 95% CI, 1.02-1.12).

CONCLUSIONS AND RELEVANCE

When analyzed at the county level, the clearest result of mammography screening is the diagnosis of additional small cancers. Furthermore, there is no concomitant decline in the detection of larger cancers, which might explain the absence of any significant difference in the overall rate of death from the disease. Together, these findings suggest widespread overdiagnosis.