Short- and long-term mortality following acute medical admission

BACKGROUND

Short-term in-hospital mortality following acute medical admission has been widely investigated. Longer term mortality, particularly out-of-hospital mortality, has been less well studied.

AIM

The aim of this study is to evaluate short- and long-term mortality, and predictors of such, following acute medical admission.

DESIGN

Retrospective database study.

METHODS

We evaluated all acute medical admissions to our institution over 10 years (2002-11) with a minimum of a further 10 years follow-up to 2021 using the Irish National Death Register. Predictors of 30-day in-hospital and long-term mortality were analysed with logistic and Cox regression, with loss of life years estimated.

RESULTS

The 2002-11 cohort consisted of 62 184 admissions in 35 140 patients. 30-Day in hospital mortality (n = 3646) per patient was 10.4% and per admission was 5.9%. There were an additional 11 440 longer-term deaths by 2021-total mortality was 15 086 (42.9%). Deaths post hospital discharge had median age at admission of 75.4 years [interquartile range (IQR) 63.7, 82.8] and died at median age of 80 years (IQR 69, 87). The half-life of survival following admission was 195 months-representing a short fall of 8 life years (32.9%) compared with the projected population reference of 24.3 years. Age [odds ratio (OR) 1.73 (95% confidence interval (CI) 1.64, 1.81)], acute illness severity score [OR 1.39 (95% CI 1.36, 1.43)] and comorbidity score [OR 1.09 (95% CI 1.08, 1.10)] predicted long-term mortality.

CONCLUSION

Similar factors influence both short- and long-term mortality following acute medical admission, the magnitude of effect is attenuated over time.

Blood Culture and Troponin Testing in Suspected Bacteraemic Admissions - Example of Risk Stratification Based on Clinical Testing

AIM

To investigate the clinical predictive value of troponin (hscTnT) and blood culture testing.

METHODS

We examined all medical admissions from 2011-2020. Prediction of 30-day in-hospital mortality, dependent on blood culture and hscTnT requests/results, was evaluated using multiple variable logistic regression. Length of stay was related to utilization of procedures/services with truncated Poisson regression.

RESULTS

There were 77,566 admissions in 42,325 patients. With both blood cultures and hscTnT requested, 30-day in-hospital mortality increased to 20.9% (95%CI: 19.7, 22.1) vs 8.9% (95%CI: 8.5, 9.4) for blood cultures alone and 2.3% (95%CI: 2.2, 2.4) with neither. Blood culture 3.93 (95%CI: 3.50, 4.42) or hsTnT requests 4.58 (95%CI: 4.10, 5.14) were prognostic.

CONCLUSION

Blood culture and hscTnT requests and results predict worse outcomes.

Outcomes for Emergency Department Final Diagnosis of Non-specific Complaint compared to Dyspnoea and Pain

AIM

To compare outcomes in Emergency Department (ED) final diagnoses of (non-specific complaint) NSC, dyspnoea and pain.

METHODS

We studied all ED final diagnoses of NSC, dyspnoea, and pain over 6 years (2015-2020). Multivariable logistic regression was performed.

RESULTS

There were 49,965 admissions. 30-day in-hospital mortality was significantly lower for pain, 3.0% (95%CI 2.4%, 3.6%), compared to NSC, 4.2% (95%CI 3.8%, 4.7%), and dyspnoea, 4.6% (95%CI 4.2%, 5.0%). NSC did not predict 30-day in-hospital mortality- univariate OR 1.05 (95%CI 0.93, 1.19), multivariable OR 1.07 (95%CI 0.93, 1.23). Comorbidity and Acute Illness Severity Scores demonstrated a curvilinear relationship with 30-day in-hospital mortality.

CONCLUSION

An ED final diagnosis of NSC did not predict 30-day in-hospital mortality.

Enhancing the bioaccessibility of vitamin D using mixed micelles - An in vitro study

Vitamin-D deficiency is a global issue and a food fortification strategy may reduce deficiency levels. Mixed micelles (MM) are crucial to vitamin-D absorption in vivo and may enhance vitamin-D food fortification. This study compared the ability of MM based delivery systems to oil-in-water emulsions to improve vitamin-D bioaccessibility in vitro. Vitamin-D loaded emulsions were formed with olive or coconut oil alone or with added l-α-phosphatidylcholine, as well as two MM based systems. Particle size throughout digestion, fatty acid release, and vitamin-D bioaccessibility were measured. After digestion, particles in the MM size range (∼6-10 nm) were observed for emulsions but not for MM based systems. The bioaccessibility of vitamin-D in olive and coconut emulsions was 75% and 78%, respectively, and ∼ 90% with added l-α-phosphatidylcholine. Bioaccessibility for the MM alone was 93% and 90% when mixed with a protein/lactose base. Overall, MM show good potential as a delivery system for vitamin-D in vitro.

Synthesising existing research on complicated grief in intellectual disability: findings from a systematic review

BACKGROUND

Complicated grief has been identified as a phenomenon in the general population, and there is an increasing body of research investigating complicated grief in people with intellectual disability. The aim of this study is to synthesise this existing knowledge from research published between 1999 and 2022.

METHODS

A structured systematic review using PRISMA guidelines was conducted, which searched three commonly used databases (Medline, PsycINFO and CINAHL) for research on the topic of bereavement and intellectual disability. The articles identified in this search were screened to identify those that addressed the issue of 'complicated grief', with all abstracts and subsequent full texts reviewed by two researchers.

RESULTS

In total, 179 abstracts were initially identified, with 34 articles eligible for full text screening and 18 papers reaching criteria for inclusion. Data relating to the studies' objectives were extracted under the headings of definition, defining principles, signs and symptoms, risk factors and treatments for complicated grief in intellectual disability. Thematic analysis of the extracted data was performed to identify key themes.

CONCLUSIONS

This review highlights that people with intellectual disability are likely to experience complicated grief reactions and that complicated grief is both underestimated and a clinically significant condition for people with intellectual disability. Future research should work to clarify diagnostic criteria and identify appropriate interventions.

Development of a machine-learning based model for predicting multidimensional outcome after surgery for degenerative disorders of the spine

BACKGROUND

It is clear that individual outcomes of spine surgery can be quite heterogeneous. When consenting a patient for surgery, it is important to be able to offer an individualized prediction regarding the likely outcome. This study used a comprehensive set of data collected over 12 years in an in-house registry to develop a parsimonious model to predict the multidimensional outcome of patients undergoing surgery for degenerative pathologies of the thoracic, lumbar or cervical spine.

METHODS

Data from 8374 patients (mean age 63.9 (14.9-96.3) y, 53.4% female) were used to develop a model to predict the 12-month scores for the Core Outcome Measures Index (COMI) and its subdomain scores. The data were split 80:20 into a training and test set. The top predictors were selected by applying recursive feature elimination based on LASSO cross validation models. Based on the 111 top predictors (contained within 20 variables), Ridge cross validation models were trained, validated, and tested for each of 9 outcome domains, for patients with either "Back" (thoracic/lumbar spine) or "Neck" (cervical spine) problems (total 18 models).

RESULTS

Among the strongest outcome predictors in most models were: preoperative scores for almost all COMI items (especially axial pain (back or neck) and peripheral pain (leg/buttock or arm/shoulder)), catastrophizing, fear avoidance beliefs, comorbidity, age, BMI, nationality, previous spine surgery, type and spinal level of intervention, number of affected levels, and surgeon seniority. The R² of the models on the validation/test sets averaged 0.16/0.13. A preliminary online tool was programmed to present the predicted outcomes for individual patients, based on their presenting characteristics. https://linkup.kws.ch/prognostictool .

CONCLUSION

The models provided estimates to enable a bespoke prediction of the outcome of surgery for individual patients with varying degenerative pathologies and baseline characteristics. The models form the basis of a simple, freely-available online prognostic tool developed to improve access to and usability of prognostic information in clinical practice. It is hoped that, following confirmation of its validity and practical utility, the tool will ultimately serve to facilitate decision-making and the management of patients' expectations.

The 'Unwell' clinical presentation- an opportunity for admission avoidance?

BACKGROUND

An 'unwell' patient is a common presentation.

METHODS

We studied all ED 'unwell' admissions over 6 years, assessing factors influencing mortality with logistic regression.

RESULTS

From 49,965 admissions, the ED diagnosis was 'unwell' in 3650 (7.3%). 'Unwell' presentations were older and had longer length of stay. Mortality was not different 4.2% vs 4.6 % (p=0.28). Respiratory patients and those >=70 years had increased mortality, 8.3% (95%CI: 5.9%, 10.6%) and 7.1% (5.7%, 8.4%) respectively. Being unwell predicted a better outcome - univariate OR 0.35 (95%CI: 0.24, 0.52), multivariable OR 0.68 (95%CI: 0.44, 1.03).

CONCLUSION

A diagnosis of 'unwell' applied to a heterogenous group; clinical trajectories and outcomes were sufficiently different to preclude targeted admission avoidance as a strategy.

Improving vitamin D3 stability to environmental and processing stresses using mixed micelles

Deficiency of vitamin-D is prevalent globally and can lead to negative health consequences. The fat-soluble nature of vitamin-D, coupled with its sensitivity to heat, light and oxygen limits its incorporation into foods. Mixed micelles (MM) have potential to enhance bioavailability of vitamin-D. This study explores the stability of MM to food processing regimes and their ability to protect vitamin-D. Subjecting MM to a range of shearing speeds (8,000-20,500 rpm) and to high pressure processing (600 MPa, 120sec) resulted in no change in MM size (4.1-4.5 nm). MM improved the retention of vitamin-D following exposure to UV-C light, near UV/visible light, and heat treatment. MM suspensions protected vitamin-D over a four week storage period at refrigeration or freezer conditions. Overall MM show potential to protect vitamin-D from degradation encountered in food processing and storage and may be beneficial as a mechanism to fortify foods with vitamin-D.

Vitamin D3 bioaccessibility: Influence of fatty acid chain length, salt concentration and l-α-phosphatidylcholine concentration on mixed micelle formation and delivery of vitamin D3

Vitamin D (VD) is a fat-soluble vitamin with high deficiency levels evident globally. Bioaccessibility of VD is influenced by formation of mixed micelles (MM) during digestion. This study assessed the impact of fatty acid (FA) type, phospholipid concentration on MM formation and stability of MM to salts. MM formation occurred at NaCl and KCl concentrations ranging from 20 to 100 mM, when octanoic acid (C8) or stearic acid (C18) were used. MM hydrodynamic size increased with increasing l-α-phosphatidylcholine concentration (1.5-7.5 mM) for both C8 and C18, above which concentration MM did not form. FA chain length impacted MM with hydrodynamic size increasing from 3.8 nm for decanoic acid (C10) to 4.4 nm for C18. VD₃ incorporation in MM was not influenced by the FA used (C10 or C18). Understanding stability and formation of MM and VD₃ loading is an essential first step towards manipulating food structures for improving delivery of VD.

Prognostic Value Of Blood Cultures as an Illness Severity Marker In Emergency Medical Admissions

BACKGROUND

Positive blood cultures predict mortality. The prognostic value of blood culture performance itself has not been fully defined.

METHODS

We evaluated medical admissions from 2002-2017. We defined blood culture category as 1) no culture 2) negative culture 3) positive culture. We employed a multivariable logistic regression model to evaluate outcomes.

RESULTS

We evaluated 78,568 blood cultures in 106,586 admissions. 30-day in-hospital mortality for no culture was 2.8% (95%CI 2.7, 2.9), culture negative 8.9% (95%CI 8.5, 9.3) and culture positive 16.7% (95%CI 15.5, 17.9). There was significant interaction between blood culture category and illness severity, OR 1.06 (95%CI 1.05, 1.08), and comorbidity, OR 1.09 (95%CI 1.09, 1.10).

CONCLUSION

Performance and results of blood cultures are independently associated with increased mortality.

Limited Prognostic Utility of a Simplified Vital Sign Based Risk Calculator in Acute Medical Admissions

BACKGROUND

Accurate efficient prognostication in acute medical admissions remains challenging.

METHODS

We constructed a Vital Sign based Risk Calculator using vital parameters and Major Disease Categories to predict 30-day in-hospital mortality using a multivariable fractional polynomial model.

RESULTS

We evaluated 113,807 admissions in 58,126 patients. The Vital Sign based Risk Calculator predicted 30-day inhospital mortality to increase from 2 points - 3.6% (95%CI 3.4, 3.7) to 12 points - 14.8% (95%CI 14.0, 15.7). AUROC was 0.74 (95%CI 0.72, 0.74). The addition of illness severity and comorbidity data improved AUROC to 0.90 (95%CI 0.89, 0.90).

CONCLUSION

The Vital Sign based Risk Calculator is limited by its simplicity; inclusion of illness severity and comorbidity data improve prediction.

The Problems with Risk Prediction during an Emergency Medical Admission Using Laboratory Data - Evidence from Potassium

BACKGROUND

The prediction of clinical outcomes using biochemical markers is an important tool.

METHODS

We calculated a risk score for all emergency admissions 2002-2017. We related potassium and mortality in a multivariable fractional polynomial model. We investigated the potassium distribution and relationship of potassium to mortality over time.

RESULTS

There were 106,586 admissions in 54,928 patients. Mortality was higher for those with an admission potassium above the median - 6.1% vs 4.6% (p<0.001), OR 1.07 (95%CI: 1.06, 1.09). There was a progressive increase in mortality from the lowest - 8.9% (95%CI: 8.3%, 9.4%) to highest potassium decile - 14.2% (95%CI: 13.5%, 14.8%). The frequency of admission hypokalaemia and the mortality at any given potassium decreased over time.

CONCLUSION

Admission potassium predicts mortality.

Socio-Economic Status and MultiOriginal morbidity - Fact or Fiction?

BACKGROUND

Areas of low socio-economic status (SES) have a disproportionate number of emergency medical admissions; we quantitate the profile of multi-morbidity related to SES.

METHODS

We developed a logistic multiple variable regression model, based on over 15 years of hospital data, to examine the effect of socio-demography on hospital outcomes.

RESULTS

Admissions from low SES cohort were a decade younger, and had a shorter hospital stay, and lower 30-day episode mortality outcome. The number of morbidities was equivalent between groups, but the more disadvantaged were more likely to have a respiratory diagnosis or diabetes.

CONCLUSION

Low SES emergency admissions present > 10 yr. earlier than the high SES population; their equivalent multimorbidity, despite a lower age, could reflect accelerated disease progression.

Incorporation of bioactive dairy hydrolysate influences the stability and digestion behaviour of milk protein stabilised emulsions

The physical stability of emulsions containing bioactive ingredients is an important aspect of functional food development. This research investigated the effects of a bioactive dairy hydrolysate with anti-inflammatory effects on the properties of oil-in-water emulsions (23% rapeseed oil and 1.5% w/w protein). This was determined by monitoring the effects of various combinations of sodium caseinate (NaCas) and NaCas hydrolysate (NaCasH) (NaCas : NaCasH; 100 : 0, 40 : 60, 30 : 70, 20 : 80 and 0 : 100) on the physico-chemical characteristics (particle size distribution, microstructure, adsorption of protein to the interface, viscosity and creaming stability) of emulsions. Currently, there is growing interest in designing functional foods that modulate lipid digestion. Therefore, emulsion breakdown and subsequent release of free fatty acids (FFAs) from selected NaCasH stabilised emulsions (40 : 60 and 0 : 100) was monitored during in vitro gastrointestinal digestion and compared to the behaviour of emulsions stabilised by NaCas alone. Inclusion of NaCasH generally decreased the stability of the emulsions except when added at a NaCas : NaCasH ratio of 40 : 60 which resulted in emulsions with equivalent stability to the NaCas stabilised emulsions. Although the 40 : 60 combination provided an emulsion system as stable as NaCas, during simulated digestion, these emulsions demonstrated a slower rate of FFA release. This was attributed to the 40 : 60 stabilised emulsions having much larger flocculated lipid droplets than NaCas emulsions, which resulted in reduced surface area and fewer binding sites for lipase adsorption. Accordingly, the 40 : 60 emulsions were hydrolysed more slowly. Emulsions containing only NaCasH exhibited extensive coalescence prior to and during digestion and thus displayed the slowest release of FFA. The results suggest that including NaCasH in the emulsifier blend yields emulsions with modified digestibility and may form the basis of controlling the digestion and release of fat-soluble nutrients in formulated foods. However, further studies are required to optimise the stability of these emulsions before inclusion in such applications.

In vitro evaluation of chitosan copper chelate gels as a multimicronutrient feed additive for cattle

BACKGROUND

Effective micronutrient supplementation strategies are critical to ensure optimal health and productivity in livestock. The objective of this study was to develop a copper and vitamin (multimicronutrient) delivery system based on chitosan gel beads, and test its suitability, in vitro, for use as a cattle feed additive.

RESULTS

Chitosan was chelated with copper sulfate to produce millimetre-scale gel matrices (∼2 mm). The copper content was significantly increased (from 61 to 95 mg g by adjusting pH to alkaline conditions post bead formation. The beads could subsequently be loaded with the model vitamin riboflavin to levels as high as 324 µg g^-1 beads. Restricted rehydration of the dried gel matrices in simulated rumen fluid led to a sustained release of riboflavin with no copper released in these neutral conditions for up to 24 h, demonstrating copper rumen bypass. Moreover, sustained release of the mineral was observed in abomasal conditions of pH 2 over a 3 h period.

CONCLUSIONS

The matrices showed rumen bypass for copper yet supplied nutritionally relevant levels of the free mineral in abomasal conditions, as required for effective supplementation in cattle. The controlled-release properties demonstrated by the matrices indicate their potential as a multimicronutrient functional feed additive to enhance cattle nutrition and productivity. © 2018 Society of Chemical Industry.

Peptidomic screening of bitter and nonbitter casein hydrolysate fractions for insulinogenic peptides

Sodium caseinate hydrolysates (NaCaH) contain biologically active peptides that can positively influence human health. However, their intense bitterness hinders their inclusion in food products. To our knowledge, no studies have investigated whether a correlation between bitterness and bioactivity exists in NaCaH, so it is not yet known what effect selective removal of bitterness has on NaCaH bioactivity. A deeper understanding of the physicochemical characteristics affecting both bitterness and bioactivity is therefore needed. The aim of this study was to use in silico analysis to elucidate the relationship between bitterness and bioactivity of the insulinogenic NaCaH. The NaCaH fractions were generated by membrane filtration and flash chromatography and were subsequently evaluated for bitterness by a sensory panel. In this present study, peptidomic and bioinformatic processing of these NaCaH fractions allowed for the identification of insulinogenic peptides as well as other literature-identified peptides in each of the fractions. The results showed that the most bitter fraction contained the highest abundance of insulinogenic peptides, whereas another bitter fraction contained the highest abundance of other literature-identified bioactive peptides exhibiting angiotensin-converting enzyme-inhibition activity. Although some bioactive peptides were identified in the least bitter fractions, the abundance of these peptides was very low. These observations show a correlation between bitter taste and bioactivity, highlighting potential complications in removing bitterness while maintaining bioactivity. However, as the most bitter fraction contained the highest abundance of insulinogenic peptides, there is potential for using a lower dose of this enriched bioactive fraction to exert health benefits. The second most bitter fraction contained a very low abundance of insulinogenic peptides and other bioactive peptides. Therefore, removal of this fraction could reduce the NaCaH product's bitterness without significantly altering overall bioactive potential.

Mortality outcomes and emergency department wait times - the paradox in the capacity limited sytem

BACKGROUND

There is concern that undue ED wait times may result in adverse outcomes.

METHODS

We studied 30-day in-hospital mortality (2002-2017) for all medical admissions (106,586 episodes; 54,928 patients) focusing on clinical risk profile.

RESULTS

Comparing 2002-09 vs. 2010-17, median ED waits > 6 hours (hr) increased 10h (95% CI: 8,13) to 15h (95% CI: 9,19). 30-day mortality declined 6.2% to 4.9%- (RRR- 20.8%/ NNT- 78). 30-day-mortality by ED wait: - < 4hr 6.6% (95% CI: 6.3%, 6.9%), 4-8hr 4.8% (95% CI: 4.6%, 5.0%), 8-12hr 4.3% (95% CI: 4.1%, 4.5%) or >=12hr 4.2% (95% CI: 3.9%, 4.5%).

CONCLUSION

Admissions with shorter waits are overrepresented with high clinical acuity. Higher Risk Score patient with extended wait times had worse clinical outcomes.

Interaction of Broadband Access and Education Levels in Determining the Rate of Emergency Medical Admissions

Background We examined the effect of broadband access, educational status and their interaction on local population health. Methods We calculated the annual admission incidence rates for each small area population unit within our hospital catchment, relating quintiles of broadband access to two groups a) full time education to primary level (less than or equal to 15 years) and b) full time education to tertiary level (>18 years). Univariate and multivariable risk estimates were calculated, using truncated Poisson regression. Results 82,368 admissions in 44,628 patients were included. Broadband access was a linear predictor of the admission incidence rate with decreases from Q1 (least access) 50.8 (95%CI 30.2 to 71.4) to Q5 (highest access) 17.9 (95%CI 13.4 to 22.4). Areas with greater numbers educated only to primary level were more influenced by broadband access. Conclusion Broadband access is a predictor of the emergency medical admission rate; this effect is modulated by the baseline education level.

Validation of a paper-disk approach to facilitate the sensory evaluation of bitterness in dairy protein hydrolysates from a newly developed food-grade fractionation system

Casein-hydrolysates (NaCaH) are desirable functional ingredients, but their bitterness impedes usage in foods. This study sought to validate a paper-disk approach to help evaluate bitterness in NaCaHs and to develop a food-grade approach to separate a NaCaH into distinct fractions, which could be evaluated by a sensory panel. Membrane filtration generated <0.2-μm and <3-kDa permeates. Further fractionation of the <3-kDa permeate by flash-chromatography generated four fractions using ethanol (EtOH) concentrations of 5, 10, 30 and 50%. As some fractions were poorly soluble in water, the fractions were resolubilzed in EtOH and impregnated into paper-disks for sensory evaluation. Bitterness differences observed in the membrane fractions using this sensory evaluation approach reflected those observed for the same fractions presented as a liquid. The flash-chromatography fractions increased in bitterness with an increase in hydrophobicity, except for the 50% EtOH fraction which had little bitterness. Amino acid analysis of the fractions showed enrichment of different essential amino acids in both the bitter and less bitter fractions.

Practical Applications

The developed food-grade fractionation system, allowed for a simple and reasonably scaled approach to separating a NaCaH, into physicochemically different fractions that could be evaluated by a sensory panel. The method of sensory evaluation used in this study, in which NaCaH samples are impregnated into paper-disks, provided potential solutions for issues such as sample insolubility and limited quantities of sample. As the impregnated paper-disk samples were dehydrated, their long storage life could also be suitable for sensory evaluations distributed by mail for large consumer studies. The research, in this study, allowed for a greater understanding of the physicochemical basis for bitterness in this NaCaH. As some essential amino acids were enriched in the less bitter fractions, selective removal of bitter fractions could allow for the incorporation of the less bitter NaCaH fractions into food products for added nutritional value, without negatively impacting sensory properties. There is potential for this approach to be applied to other food ingredients with undesirable tastes, such as polyphenols.

Survival analysis of weekend emergency medical admissions

BACKGROUND

We previously reported weekend emergency admissions to have a higher mortality; we have now examined the time profile of deaths, by weekday or weekend admission, in all emergency medical patients admitted between 2002 and 2014.

METHODS

We divided admissions by a weekday or weekend (After 17.00 Friday-Sunday) hospital arrival. We examined survival following an admission using Cox proportional hazard models and Kaplan-Meier time to event analysis.

RESULTS

In total 82 368 admissions were recorded in 44, 628 patients. Weekend admissions had an increased mortality of 5.0% (95% CI 4.7, 5.4) compared with weekday admissions of 4.5% (95% CI 4.3, 4.7) ( P = 0.007). The univariate adjusted Odds Ratio (OR) of death for a weekend admission was significantly increased OR = 1.15 (95% CI 1.05, 1.24) ( P = 0.001). Mortality following an admission declined exponentially over time with a long tail, ∼25% of deaths occurred after day 28. Only 11.4% of deaths occurred on the weekend of the admission. Survival curves showed no mortality difference at 28 days ( P = 0.21) but a difference at 90 days ( P = 0.05). The higher mortality for a weekend admission was attributable to late deaths in the cohort with an extended stay; compared with weekday, these weekend admissions were more likely to be older and have greater co-morbidity.

CONCLUSION

Survival rates following a weekend or weekday admission were similar out to 28 days. The higher overall mortality for weekend admissions is due to divergence in survival between 28 and 90 days. Most deaths in weekend admissions occurred when the hospital was fully staffed.

Age and the economics of an emergency medical admission-what factors determine costs?

BACKGROUND

The ageing of the population may be anticipated to increase demand on hospital resources. We have investigated the relationship between hospital episode costs and age profile in a single centre.

METHODS

All Emergency Medical admissions (33 732 episodes) to an Irish hospital over a 6-year period, categorized into three age groups, were evaluated against total hospital episode costs. Univariate and adjusted incidence rate ratios (IRRs) were calculated using zero truncated Poisson regression.

RESULTS

The total hospital episode cost increased with age ( P < 0.001). The multi-variable Poisson regression model demonstrated that the most important drivers of overall costs were Acute Illness Severity-IRR 1.36 (95% CI: 1.30, 1.41), Sepsis Status -1.46 (95% CI: 1.42, 1.51) and Chronic Disabling Disease Score -1.25 (95% CI: 1.22, 1.27) and the Age Group as exemplified for those 85 years IRR 1.23 (95% CI: 1.15, 1.32).

CONCLUSION

Total hospital episode costs are a product of clinical complexity with contributions from the Acute Illness Severity, Co-Morbidity, Chronic Disabling Disease Score and Sepsis Status. However age is also an important contributor and an increasing patient age profile will have a predictable impact on total hospital episode costs.

Influence of social deprivation, overcrowding and family structure on emergency medical admission rates

BACKGROUND

Patients from deprived backgrounds have a higher in-patient mortality following emergency medical admission.

AIM

To evaluate the influence of Deprivation Index, overcrowding and family structure on hospital admission rates.

DESIGN

Retrospective cohort study.

METHODS

All emergency medical admissions from 2002 to 2013 were evaluated. Based on address, each patient was allocated to an electoral division, whose small area population statistics were available from census data. Patients were categorized by quintile of Deprivation Index, overcrowding and family structure, and these were evaluated against hospital admission rate, calculated as rate/1000 population. Univariate and multivariable risk estimates (Odds Ratios or Incidence Rate Ratios) were calculated, using logistic or zero truncated Poisson regression as appropriate.

RESULTS

There were 66 861 admissions in 36 214 patients over the 12-year study period. Deprivation Index quintile independently predicted the admission rate, with rates of Q1 12.0 (95% CI 11.8-12.2), Q2 19.5 (95% CI 19.3-19.6), Q3 33.7 (95% CI 33.3-34.0), Q4 31.4 (95% CI 31.2-31.6) and Q5 38.1 (95% CI 37.7-38.5). Similarly the proportions of families with children <15 years old, was an independent predictor of the admission rate with rates of Q1 20.8 (95% CI 20.4-21.1), Q2 23.0 (95% CI 22.7-23.3), Q3 32.2 (95% CI 31.9-32.5), Q4 32.4 (95% CI 32.2-32.7) and Q5 37.2 (95% CI 36.6-37.8). The proportion of families with children ≥15-years old was also predictive but quintile of overcrowding was only predictive in the univarate model.

CONCLUSION

Deprivation Index and family structure strongly predict emergency medical hospital admission rates.

Social deprivation and the rate of emergency medical admission for older persons

BACKGROUND

Deprivation Status increases the annual admission incidence of emergency medical admissions; the extent to which deprivation influences the admission of older persons is less well known.

AIM

To examine whether deprivation within a hospital catchment area influences emergency medical admissions for the elderly population.

DESIGN

The relationship between Deprivation Status, Dependency Ratio (population proportion of non-working age (<15 or ≥65 years) and age for all emergency admissions (82 368 episodes of 44 628 patients), over a 13-year period, were examined and ranked by quintile.

METHODS

Univariate and multi-variable risk estimates (incidence rate ratios) were calculated, using truncated Poisson regression.

RESULTS

The Dependency Ratio and the Deprivation index independently predicted the annual incidence rate of medical emergencies; however, when calculated for older persons, the corresponding incidence rate ratios showed a falling trend with increasing Deprivation Status-Q2 0.51 (95% confidence interval [CI]: 0.50, 0.52), Q3 0.59 (95% CI: 0.58, 0.60), Q4 0.51 (95% CI: 0.50, 0.52) and Q5 0.37 (95% CI: 0.36, 0.38). Thus, with increasing Deprivation Status, the proportion of total admission from the ≥65-year cohort fell substantially.

CONCLUSION

The admission incidence rate for emergency medical patients is strongly influenced by the catchment area Deprivation Status. However, because of its greater impact on the younger population, increasing deprivation alters the ratio of younger to older persons as a proportion of total emergency admissions.

Patient risk profiling in acute medicine: the way forward?

BACKGROUND

The identification of high-risk patients could form a basis for targetted intervention following an emergency medical admission.

METHODS

All emergency admissions to our institution over 12 years (2002-13) were included. An Illness Severity method based on admission laboratory parameters, previously developed between 2002 and 2007, was investigated for the 2008-13 cohort. We compared the area under the receiver operating characteristic (AUROC) to predict a 30-day in-hospital death between the original and validating cohorts using logistic multiple variable analyses. We defined six risk subgroups, based on admission laboratory data and examined the frequency of 30-day in-hospital mortality within these subgroups.

RESULTS

About 66 933 admissions were recorded in 36 271 patients. Between 2002 and 2007, the 30-day in-hospital mortality was 11.3% but between 2008 and 2013 was 6.7% (P < 0.001). This represented an absolute risk reduction (ARR) of 4.6%, a relative risk reduction (RRR) of 41.0%, and a number needed to treat of 21.6. The laboratory model was similarly predictive in both cohorts-for 2002-07, the AUROC was 0.82 (95% CI 0.81, 0.82) and for 2008-13 was 0.82 (95% CI 0.81, 0.83). Two high-risk subgroups were identified within each cohort; for 2002-07, these contained 15.0 and 30.2% of admitted patients but 95.5% of in-hospital deaths. For 2008-13, these two groups contained 15.7 and 31.0% of admitted patients but 97.0% of in-hospital deaths.

CONCLUSION

A previously described laboratory score method, based on admission biochemistry, identified patients at high risk for an in-hospital death. Risk profiling at admission is feasible for emergency medical admissions and could offer a means to outcome improvement.

Medical Record Documentation Among Interns: A Prospective Quality Improvement Study

Comprehensive record keeping is a key aspect of medical practice. The National Hospitals Office (NHO) and Irish Medical Council (IMC) have published guidelines in this area. A prospective audit of 100 patients assessed by interns was performed to quantify adherence with these guidelines followed by an educational session and email reminders. Adherence was reassessed in an incidental manner. Compliance was recorded in a number of areas including the reason for review and documentation of a plan both 98 (98%). However less than half of interns recorded the patient's name, background history or their impression of the case. Only 31(31%) noted the patient's MRN and only 1(1%) the information they gave to the patient. Significant improvements following the intervention were found, however significant deficits remained in a number of areas including the noting of an impression of the case 62(62%) and information given to patients 18(18%). Suboptimal documentation can be improved through education and clinical auditing.

Chronic disabling disease--impact on outcomes and costs in emergency medical admissions

BACKGROUND

Chronic disabling disease is present in nearly 90% of emergency medical admissions. We have examined its impact on outcomes and costs in one institution, using a database of episodes collected prospectively over 12 years.

METHODS

All emergency admissions (66,933 episodes; 36,271 patients) to St James' Hospital over a 12-year period (2002-13) were evaluated in relation to 30-day in-hospital mortality, length of stay (LOS) and hospital costs. Predictor variables (identified univariately) were entered into a multi-variable logistic regression model to predict 30-day in-hospital mortality. The data were also modelled as count data (absolute LOS, total cost) using zero-truncated Poisson regression.

RESULTS

Acute illness severity was the best independent predictor of mortality; chronic disabling disease was an independent predictor (P < 0.001) for patients with 4+ disabling conditions. Age, adjusted for other predictors, was only independently predictive of mortality for patient 85+ years. Chronic disabling disease was an independent predictor of LOS increasing linearly with incidence rate ratios of 1.35 (95% CI: 1.29, 1.42), 1.59 (95% CI: 1.51, 1.66), 1.73 (95% CI: 1.65, 1.83) and 1.74 (95% CI: 1.65, 1.84) for those with 1, 2, 3 or 4+ disabling conditions, respectively. Age, as a predictor of LOS was strongly correlated with the presence of disabling disease. Chronic disabling disease independently predicted costs non-linearly; those with 2 or more disabling conditions had particularly high total hospital costs.

CONCLUSION

Chronic disabling disease is an independent predictor of hospital LOS and costs in unselected emergency admissions; adjusted for illness severity, it is only a mortality predictor for those with multiple disabling conditions.

Improved outcomes of high-risk emergency medical admissions cared for by experienced physicians

BACKGROUND

Physician experience has been shown to improve clinical outcomes. Limited numbers of experienced clinicians make it unfeasible that they would care for all patients. We hypothesized that physician experience would impact outcomes for patients with high, but not low, risk of mortality.

METHODS

All emergency admissions from 2002 to 2013 were studied. Two groups at low and high risk for mortality (1.3% (95% CI: 1.13, 1.62) vs. 19.4% (95% CI: 18.5, 20.3)) were defined by a risk prediction method comprising acute Illness Severity Score, Charlson Comorbidity Index and sepsis status. Length of stay (LOS) and 30-day in-hospital mortality were the primary end points. Consultant experience was studied univariately and also entered into a multiple logistic regression model to predict 30-day in-hospital survival. A zero-truncated Poisson regression model assessed LOS and incidence rate ratios (IRR) were calculated.

RESULTS

Over the 12-year study period 66 933 admissions were recorded in 36 271 patients. High-risk patients cared for by more experienced (≥20 years qualified) physicians had a lower 30-day in-hospital mortality (19.4 vs. 17.1% P < 0.001), relative risk reduction 11.9%. The multivariable odds ratio of a 30-day in-hospital death for an experienced physician was 0.89 (95% CI: 0.82, 0.97; P = 0.009). LOS was shorter for high-risk patients allocated to experienced physicians with a multivariable IRR of 0.77 (95% CI: 0.94, 0.99; P = 0.02). No difference in outcomes was found for low-risk patients.

CONCLUSION

High-risk but not low-risk patients have improved outcomes when cared for by physicians with greater experience.

An in vivo study examining the antiinflammatory effects of chamomile, meadowsweet, and willow bark in a novel functional beverage

The antioxidant and antiinflammatory properties of polyphenols are well documented in vitro but there are few human studies. A herbal beverage composed of chamomile, meadowsweet, and willow bark (CMW) was developed and tested for its antiinflammatory effect in a cohort of healthy adults (n = 20) during a 4-week intervention. Subjects were randomised to either the treatment (TG) or placebo group (PG). The three herbs under study, which have been used in traditional and alternative medicine, were delivered in a berry extract matrix. This berry extract was used as a control in the experiment. The objective was to assess the herbs' effects on systemic inflammation and joint function by examining circulating cytokines and mechanical joint flexibility. Blood serum was analyzed for cytokines IL-1β, IL-6, and TNFα. There was an average decrease of 21.7% IL-1β in the treatment group, whereas the decrease seen in the placebo group was 3% but these were not statistically significant. Quartile analysis based on baseline production of TNFα demonstrated a decrease in the treatment group's IL-6 levels. This group showed improvements in mechanical joint function and pain upon movement of joints specific to the knee and lower back. Overall, no significant antiinflammatory effects were seen. The evidence is therefore inconclusive and further investigations are required using a larger cohort with some degree of elevated inflammatory activity.

Air quality impacts mortality in acute medical admissions

BACKGROUND

Air quality degraded by black smoke (particulate matter, PM10), sulphur dioxide (SO2) and nitrogen oxide (NO(x)) affects human health. Improvements following national legislation have lowered death rates. Whether background air pollution levels continue to affect human health remains unclear.

AIM

To determine impact of air pollutant concentrations (PM10, SO2 and NO(x)) on in-hospital mortality for acute medical admissions to St James's Hospital over a decade (2002-11).

DESIGN

All emergency admissions (55,596 episodes in n = 32,581 patients) were tracked prospectively and mortality assessed. Daily levels of PM10, SO2 and NO(x) were obtained from monitoring stations in our catchment area.

METHODS

Univariate and multivariate logistic regression was employed to examine relationships between pollutant concentration and odds ratio (OR) for death following adjustment for other mortality predictors.

RESULTS

Mortality related to each pollutant variable assessed (as quintiles of increasing atmospheric concentration) was significantly predictive. For PM10 and SO2, mortality in the highest three quintile concentrations (compared with base quintile) was significantly increased (P < 0.001) with univariate ORs of 1.24, 1.36 and 1.25 for PM10 and 1.43, 1.54 and 1.58 for SO2, respectively. Mortality in all quintile concentrations (compared with base quintile) was significantly increased (P < 0.05) for NO(x) with univariate ORs of 1.14, 1.18, 1.28 and 1.35, respectively. Following adjustment for other mortality predictors such as acute illness severity, all three air pollutants were independently predictive of mortality.

CONCLUSION

Despite improvement to air quality in Dublin, the prevailing background pollutant concentrations continue to affect human health at levels considered safe and below that previously recognized.

A Risk Index for Geriatric Acute Medical Admissions (RIGAMA)

AIM

to create and validate a Risk Index for Geriatric Acute Medical Admissions (RIGAMA) for those aged ≥ 65, based on accumulation of deficits.

METHODS

we retrospectively validated a 30-item RIGAMA against inpatient mortality, length of stay (LOS), discharge to long-term care (LTC) and 30-day readmission, adjusted for age.

RESULTS

≥ 1 RIGAMA deficit was superior to age in predicting mortality and prolonged LOS, with a clear incremental effect. The latter was true for ≥3 deficits in predicting 30-day readmission. Three to 5 deficits predicted discharge to LTC better than age.

CONCLUSIONS

RIGAMA is easy to collect by the admitting junior doctor and may help trigger early senior support and inform the appropriate use of hospital resources by older patients.

Does admission via an acute medical unit influence hospital mortality? 12 years' experience in a large Dublin hospital

BACKGROUND

Following an emergency medical admission, patients may be admitted an acute medical assessment unit (AMAU) or directly into a ward. An AMAU provides a structured environment for their initial assessment and treatment.

METHODS

All emergency admissions (66,933 episodes in 36,271 patients) to an Irish hospital over an 12-year period (2002-2013) were studied with 30-day in-hospital mortality as the outcome measure. Univariate Odds Ratios, by initial patient allocation, and the fully adjusted Odds Ratios were calculated, using a validated logistic regression model.

RESULTS

Patients, by design, were intended to be admitted initially to the AMAU (<= 5 day stay). Capacity constraints dictated that only 39.8% of patients were so admitted; the remainder bypassed the AMAU to a ward (60.2%). All patients remained under the care of the admitting consultant/team. We computed the risk profile for each group, using a multiple variable validated model of 30-day in-hospital mortality; the model indicated the same risk profile between these groups. The univariate OR of an in-hospital death by day 30 for a patient initially allocated to the AMAU, compared with an initial ward allocation was 0.76 (95% CI: 0.71, 0.82- p<0.001). The fully adjusted risk for patients was 0.67 (95% CI: 0.62, 0.73- p<0.001).

CONCLUSION

Patients, with equivalent mortality risk, allocated initially to AMAU or a more traditional ward, appeared to have substantially different outcomes.

Long-term outcome of an AMAU--a decade's experience

BACKGROUND

There is interest in emergency medical admissions, the outcomes of major reconfigurations and the development of systems and processes for Acute Medicine. We report on the long-term outcomes of an Acute Medical Admissions Unit, using a database of emergency admissions to St James' Hospital, Dublin, from 2002 to 2012.

METHODS

All emergency admissions (67,971 episodes in 37,828 patients) were tracked and in-hospital mortality, length of stay and emergency 'wait' numbers and times summarized. We examined outcomes using generalized estimating equations, an extension of generalized linear models that permitted adjustment for correlated observations (readmissions). Margins statistics used adjusted predictions to test for interactions of key predictors while controlling for other variables using computations of the average marginal effect.

RESULTS

By episode, the in-hospital mortality averaged 5.8% (95% CI 5.6-5.9%); the relative risk reduction (RRR) was 35.0% between 2002 and 2012, from 7.0% to 4.6% (P = 0.001), with a number needed to treat (NNT) of 40.7. By unique patient the in-hospital mortality averaged 10.3% (95% CI 10.0-10.6%) with a RRR of 60.0% from 14.5% to 5.7% (P = 0.001), with an NNT of 11.4. Emergency Department 'wait' numbers decreased by 43%. The main mortality outcome predictors were Illness Severity, Charlson Comorbidity, Manchester Triage Category, O2 saturation, blood culture results, transfusion requirement and a primary respiratory or neurological diagnosis; the model had a high AUROC of 0.88 (95% CI 0.87, 0.88).

CONCLUSION

Institution reform can result in substantial outcome and process measure benefits, improving care delivery to emergency medical admissions.

Venous thromboembolism prophylaxis in acute medical admissions to a university teaching hospital

The objective of this study was to assess appropriate thromboprophylaxis prescription rates in a university hospital and to re-audit after a series of interventions. The notes of all acute medical patient admissions over a 4-week period were assessed for VTE risk factors and prescription of thromboprophylaxis. Subsequently, a series of hospital wide interventions including educational initiatives and a new drug prescription chart were introduced. 2 years post intervention the audit was repeated. Pre-intervention, 104 of 265 (39%) "at risk" patients were prescribed appropriate thromboprophylaxis. Post intervention the prescription rate increased to 108 of 188 (57%) "at risk patients". The results of the pre- intervention audit are consistent with the published literature. While there was a significant increase in prescription rates post intervention, over 40% of "at risk" patients still did not receive thromboprophylaxis highlighting the challenge in attempting to close the gap between guidelines and actual practice.

Consultant volume, as an outcome determinant, in emergency medical admissions

BACKGROUND

Increasing hospital or specialist volumes has been shown to improve outcomes; there are little data on volumes and outcomes in emergency medical admissions. We have examined the hospital length of stay (LOS) and 30-day mortality for patients admitted under a consultant 'of the day' having high- or low-admission volumes.

METHODS

An analysis was performed on all emergency medical patients admitted between 1 January 2002 and 31 December 2011, using anonymous patient data. We calculated the numbers of unique patients admitted to each 'on call' consultant and allocated the latter to a high- (70th centile with 8/22 consultants) or low-volume (14/22 consultants) category. We examined outcomes (LOS and in-hospital 30-day mortality), by these cut-offs employing logistic regression to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

The hospital LOS was shorter (P < 0.001) for high [median 4.2, inter-quartile range (IQR) 1.7, 8.7] compared with the lower volume group (median 4.8, IQR 1.9, 9.7). There was a reduced 30-day in hospital mortality for high-volume (8.2%) compared with low-volume consultants (9.6%: P < 0.01). An admission under a high-volume consultant was independently predictive of survival, after adjustment for other outcome predictors including co-morbidity; the relative risk reduction was 25% [OR 0.75 (95% CI 0.68-0.82): P < 0.001].

CONCLUSION

In an era of increasing specialization, these data provide support for the concept that the frequency of being 'on-call' contributes to maintaining competence with an associated improvement in patient outcomes.

Deprivation as an outcome determinant in emergency medical admissions

BACKGROUND

Deprivation in the general population predicts mortality. We have investigated its relevance to an acute medical admission, using a database of all emergency admissions to St James' Hospital, Dublin, over a 10-year period (2002-11).

METHODS

All emergency admissions, based on geocoding of residence, were allocated to a Small Area Health Research Unit division, with a corresponding deprivation index. We then examined this index as a univariate (unadjusted) and independent (adjusted) predictor of 30-day in-hospital mortality.

RESULTS

The 30-day in-hospital mortality, over the 10-year period, was higher for those in the upper half of the deprivation distribution (9.6 vs. 8.6%; P = 0.002). Indeed, there was a stepwise increase in 30-day mortality over the quintiles of deprivation from 7.3% (Quintile 1) to 8.8, 10.0, 10.0 and 9.3%, respectively. Univariate logistic regression of the deprivation indices (quintiles) against outcome showed an increased risk (P = 0.002) of a 30-day death with odds ratios (ORs), respectively (compared with lowest deprivation quintile) of 1.39 [95% confidence intervals (CI) 1.21, 1.58], 1.47 (95% CI 1.29, 1.68), 1.44 (95% CI 1.26, 1.64) and 1.39 (95% CI 1.22, 1.59). The deprivation index was an independent predictor of outcome in a model when adjusted for illness severity and co-morbidity. The fully adjusted OR for a 30-day death was increased by 31% (P = 0.001) for patients in the upper half of the deprivation index distribution (OR 1.35; 95% CI 1.23, 1.48; P < 0.001).

CONCLUSION

Deprivation, independent of co-morbidity or acute illness severity, is an independent predictor of 30-day mortality in acute medical admissions.

Laparoscopic surgery for complicated diverticular disease: a single-centre experience

AIM

The role of laparoscopic surgery in the management of patients with diverticular disease is still not universally accepted. The aim of our study was to evaluate the results of laparoscopic surgery for diverticular disease in a centre with a specialist interest in minimally invasive surgery.

METHOD

All diverticular resections carried out between 2006 and 2010 were reviewed. Data recorded included baseline demographics, indication for surgery, operative details, length of hospital stay and complications. Complicated diverticular disease was defined as diverticulitis with associated abscess, phlegmon, fistula, stricture, obstruction, bleeding or perforation.

RESULTS

One hundred and two patients (58 men) who had surgery for diverticular disease were identified (median age 59 years, range 49-70 years). Sixty-four patients (64%) had surgery for complicated diverticular disease. The indications were recurrent acute diverticulitis (37%), colovesical fistula (21%), stricture formation (17%) and colonic perforation (16%). Sixty-nine cases (88%) were completed by elective laparoscopy. Postoperative mortality was 0%. For elective cases there was no difference in morbidity rates between patients with complicated and uncomplicated diverticular disease. The overall anastomotic leakage rate was 1% and the wound infection rate 7%. There was a nonsignificant trend to higher conversion to open surgery in the elective group in complicated (11.4%) compared with uncomplicated patients (5.2%) (P=0.67). Electively, the rate of stoma formation was higher in the complicated (31.6%) than the uncomplicated group (5.2%) (P<0.02).

CONCLUSION

Laparoscopic surgery for both complicated and uncomplicated diverticular disease is associated with low rates of postoperative morbidity and relatively low conversion rates. Laparoscopic surgery is now the standard of care for complicated and uncomplicated diverticular disease in our institution.

The bothersomeness of patient self-rated "complications" reported 1 year after spine surgery

PURPOSE

The last few decades have witnessed a paradigm shift in the assessment of outcome in spine surgery, with patient-centred questionnaires superseding traditional surgeon-based assessments. The assessment of complications after surgery and their impact on the patient has not enjoyed this same enlightened approach. This study sought to quantify the incidence and bothersomeness of patient-rated complications 1 year after surgery.

METHODS

Patients with lumbar degenerative disorders, operated with the goal of pain relief between October 2006 and September 2010, completed a questionnaire 1 year postoperatively enquiring about complications arising as a consequence of their operation. They rated the bothersomeness of any such complications on a 5-point scale. Global outcome of surgery and satisfaction at the 12-month follow-up were also rated on 5-point Likert scales. The multidimensional Core Outcome Measures Index (COMI) was completed preoperatively and at the 12-month follow-up.

RESULTS

Of 2,282 patients completing the questionnaire (92% completion rate), 687 (30.1%) reported complications, most commonly sensory disturbances (36% of those with complications) or ongoing/new pain (26%), followed by motor problems (8%), pain plus neurological disturbances (11%), and problems with wound healing (6%). The corresponding "bothersomeness" ratings for these were: 1% not at all, 23% slightly, 27% moderately, 31% very, and 18% extremely bothersome. The greater the bothersomeness, the worse the global outcome (Rho = 0.51, p < 0.0001), patient satisfaction (Rho = 0.44, p < 0.0001) and change in COMI score (Rho = 0.52, p < 0.0001).

CONCLUSION

Most complications reported by the patient are perceived to be at least moderately bothersome and hence are not inconsequential. Complications and their severity should be assessed from both the patient's and the surgeon's perspectives--not least to better understand the reasons for poor outcome and dissatisfaction with treatment.