Real-world implementation of the National Early Warning Score-2 in an acute respiratory unit

INTRODUCTION

The National Early Warning Score-2 (NEWS-2) is used to detect deteriorating patients in hospital settings. We aimed to understand how NEWS-2 functions in the real-life setting of an acute respiratory unit.

METHODS

Clinical observations data were extracted for adult patients (age ≥18 years), admitted under the care of respiratory medicine services from July to December 2019, who had at least one recorded task relating to clinical deterioration. The timing and nature of urgent out-of-hours medical reviews (escalations) were extracted through manual review of the case notes.

RESULTS

The data set comprised 765 admission episodes (48.9% women) with a mean (SD) age of 69.3 (14.8). 8971 out of 35 991 out-of-hours observation sets (24.9%) had a NEWS-2 ≥5, and 586 of these (6.5%) led to an escalation. Out of 687 escalations, 101 (14.7%) were associated with observation sets with NEWS-2<5. Rising oxygen requirement and extreme values of individual observations were associated with an increased risk of escalation. 57.6% of escalations resulted in a change in treatment. Inpatient mortality was higher in patients who were escalated at least once, compared with those who were not escalated.

CONCLUSIONS

Most observation sets with NEWS-2 scores ≥5 did not lead to a medical escalation in an acute respiratory setting out-of-hours, but more than half of escalations resulted in a change in treatment. Rising oxygen requirement is a key indicator of respiratory patient acuity which appears to influence the decision to request urgent out-of-hours medical reviews.

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

Intensive dietary intervention by a dietitian as a case manager among community dwelling older adults: the EDIT study

BACKGROUND

Clinical trials that have assessed the best approach for treating under-nutrition in old age are scarce.

OBJECTIVE

To determine the impact of an intensive nutritional intervention program led by a dietitian on the health and nutritional status of malnourished community dwelling older adults.

METHODS

Sixty-eight eligible participants (age<75) were randomly assigned to a Dietetic Intervention Treatment (DIT), an intensive nutritional intervention led by a dietitian, or a Medical Treatment (MT), a physician-led standard care group, with an educational booklet regarding dietary requirements and recommendations for older adults. An additional 59 eligible participants who were unable to participate in the randomization were included as a non-randomized "untreated nutrition" group (UNG).

RESULTS

Over the 6-month follow-up, the DIT group showed significant improvement in cognitive function (from 25.8±4.5 to 26.8±4, p=0.04), and depression score (from 7.3±3.9 to 5.4±3.9, p=0.04) compared with the change in the other 2 groups. The DIT group showed a significant improvement in intake of carbohydrates (+15% vs. +1% in the MT and +3% in the UNG), protein (+8% vs. +2% in the MT and -3% in the UNG), vitamin B6 (+20% vs. +7% in the MT and +8% in the UNG), and vitamin B1 (+22% vs. +11% in the MT and 0% in the UNG). The DIT group had a significantly lower cost of physician visits than the other 2 groups ($172.1±232.0 vs. $417.2±368.0 in the MT and $428.1±382.3 in the UNG, p=0.005).

CONCLUSION

Intensive dietary intervention was moderately effective in lowering cost of services used and improving medical and nutritional status among community dwelling older adults.

Regression of transitional cell carcinoma of the bladder with radiotherapy: progression-free control in the bladder at 5 years

The five-year survival and the local control in the bladder at 5 years were determined for 67 patients with transitional cell carcinoma of the bladder. These 67 patients had been included in a previous study of the regression of carcinoma of the bladder with radical radiotherapy. For these 67 patients treated with radiotherapy alone after transurethral biopsy or excision, the cause-specific 5-year survival was 38.4% (95% confidence interval (CI), 26.5-50.3%), with an overall survival of 31.1% (95% CI, 20-42.2%). The local control in the bladder was 42.6% (95% CI, 29.2-56.0%) at 5 years.

[Correlation between levels of prolactin in maternal serum, fetal serum and amniotic fluid in childbirth at term]

In 117 parturients with 38-41 gestation weeks, prolactin was analysed by the radioimmunologic method in the mother serum, the umbilical cord serum and vein, and in the amnionic fluid. Three groups of parturients and their newborns were examined: the group (n = 44) with the birth having started spontaneously with the appearance of labour pains 1/10 minutes, the group (n = 38) with a programmed birth induced by the infusion of oxytocin, and the group (n = 35) with the birth comprising elective cesarean section. The concentration of prolactin in the examined sera is characterized by considerable individual oscillations. The highest prolactin level was in the amnionic fluid (395.6 +/- 130.1 mu/L) and the lowest in the mother serum (174.6 +/- 84.1 mu/L) which shows a statistically significant difference (p less than 0.01). Prolactin values in the umbilical artery (244.6 +/- 98.3 mu/L) and vein (230.4 +/- 91.7 mu/L) are significantly (p less than 0.001) higher than the value in the mother sera and significantly lower (p less than 0.001) than the prolactin concentration in the amnionic fluid. The difference of the prolactin values in the sera of the umbilical cord blood vessels has no statistical significance (p greater than 0.05). Nor is there any statistically significant difference between prolactin concentrations in spontaneous and induced deliveries versus those in deliveries terminated with elective cesarean section (p greater than 0.05). A correlation analysis of the functional connection of prolactin in the sera of the mother, fetus, and amnionic fluid gives the correlation coefficient values of high statistical significance (0.482 less than r less than 0.906; p less than 0.001).

[Prolactin in the serum of mothers and neonates and in the amniotic fluid of pregnant women with hypertensive disease]

In 106 pregnant women (32-41 gestation weeks) prolactin values were determined in the sera of mothers and fetuses and in the amniotic fluid by the radioimmunological method in m IU L. Four group of parturients and their newborns were examined: Group I (n = 18) contained parturients with hypertensive disease and pre-term delivery, group II (n = 27) parturients with pre-term delivery, group III (n = 25) parturients with hypertensive disease and at-term delivery, and group IV (n = 36) normal parturients with at-term delivery. Prolactin values (mean +/- SD) in the serum of parturients with pre-term delivery (group I 8,311 +/- 2,654 and group II 8,203 +/- 2,647) and in those with at-term delivery (group III 9,656 +/- 3,145 and group IV 9,873 +/- 3,062) showed no significant differences (p greater than 0.05). Prolactin values in the serum of the umbilical cord artery proved significantly higher (p less than 0.05) in parturients with pre-term delivery (group I 11,598 +/- 2,923, group II 9,632 +/- 3,009) and at-term delivery (group III 13,266 +/- 3,015, group IV 11,243 +/- 3,123) in hypertension-affected women. A significantly higher (p less than 0.01) prolactin value was recorded in the amniotic fluid of parturients with pre-term delivery (group I 23,367 +/- 3,896, group II 19,715 +/- 4,128) and at-term delivery (group III 22,755 +/- 4,938, group IV 18,638 +/- 4,724) affected by hypertensive disease. The difference between the prolactin level in parturients with the meconium and clear amniotic fluid (22,059 +/- 5,465 and 19,263 +/- 5,673) was not significant (p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Five year experience using PTFE vascular grafts for lower limb ischaemia

The 5 year results using polytetrafluoroethylene (PTFE-Gore-Tex) grafts mainly for superficial femoral occlusion have been reviewed. The majority of these grafts were inserted in an elderly poor risk group of patients with critical ischaemia of the lower limb. The overall cumulative patency at 2 years was 29% falling to 18% at 5 years. Further analyses were performed to take into account risk factors, namely, patient's age, diabetes, hypertension, continuation of smoking, peroperative angiographic findings and the site of the distal graft anastomosis. Peroperative angiographic run off was found to be the only risk factor significantly affecting the cumulative graft patency. The presence of diabetes was found to have a significant detrimental effect on limb salvage.

Alpha-feto protein in the serum of patients with primary gastric cancer and liver metastases

The authors presented a patient with primary gastric cancer and liver metastases. They permanently observed the AFP concentrations before, during and after cytostatic therapy. At the same time they examined possible sites of AFP production. It is supposed that AFP neo-synthesis takes place in the secondary site with participation of altered liver cells. In such cases it is important to watch the AFP values, and this is also necessary when the primary source of the secondary liver cancer is not known. Cytostatic drugs act only in a palliative way i.e. AFP concentrations drop to a lower level and the patient feels temporarily better.