Prevalence of life-sustaining treatment limitations in Polish very old intensive care patients (VIPs). A post-hoc analysis of two prospective observational studies

PURPOSE

Several initiatives have recently focused on raising awareness about limitations of treatment in Poland. We aimed to assess if the propensity to limit LST among elderly patients in 2018-2019 increased compared to 2016-2017.

METHODS

We analysed Polish cohorts from studies VIP1 (October 2016 - May 2017) and VIP2 (May 2018 - May 2019) that enrolled critical patients aged >80. We collected data on demographics, clinical features limitations of LST. Primary analysis assessed factors associated with prevalence of limitations of LST, A secondary analysis explored differences between patients with and without limitations of LST.

RESULTS

601 patients were enrolled. Prevalence of LST limitations was 16.1% in 2016-2017 and 20.5% in 2018-2019. No difference was found in univariate analysis (p = 0.22), multivariable model showed higher propensity towards limiting LST in the 2018-2019 cohort compared to 2016-2017 cohort (OR 1.07;95%CI, 1.01-1.14). There was higher mortality and a longer length of stay of patients with limitations of LST compared to the patients without limitations of LST. (11 vs. 6 days, p = 0.001).

CONCLUSIONS

The clinicians in Poland have become more proactive in limiting LST in critically ill patients ≥80 years old over the studied period, however the prevalence of limitations of LST in Poland remains low.

Predictors of outcomes of patients ≥ 80 years old admitted to intensive care units in Poland - a post-hoc analysis of the VIP2 prospective observational study

INTRODUCTION

Elderly patients pose a significant challenge to intensive care unit (ICU) clinicians. In this study we attempted to characterise the population of patients over 80 years old admitted to ICUs in Poland and identify associations between clinical features and short-term outcomes.

MATERIAL AND METHODS

The study is a post-hoc analysis of the Polish cohort of the VIP2 European prospective observational study enrolling patients > 80 years old admitted to ICUs over a 6-month period. Data including clinical features, clinical frailty scale (CFS), geriatric scales, interventions within the ICU, and outcomes (30-day and ICU mortality and length of stay) were gathered. Univariate analyses comparing frail (CFS > 4) to non-frail patients and survivors to non-survivors were performed. Multivariable models with CFS, activities of daily living score (ADL), and the cognitive decline questionnaire IQCODE as predictors and ICU or 30-day mortality as outcomes were formed.

RESULTS

A total of 371 patients from 27 ICUs were enrolled. Frail patients had significantly higher ICU (58% vs. 44.45%, P = 0.03) and 30-day (65.61% vs. 54.14%, P = 0.01) mortality compared to non-frail counterparts. The survivors had significantly lower SOFA score, CFS, ADL, and IQCODE than non-survivors. In multivariable analysis CFS (OR 1.15, 95% CI: 1.00-1.34) and SOFA score (OR 1.29, 95% CI: 1.19-1.41) were identified as significant predictors for ICU mortality; however, CFS was not a predictor for 30-day mortality ( P = 0.07). No statistical significance was found for ADL, IQCODE, polypharmacy, or comorbidities.

CONCLUSIONS

We found a positive correlation between CFS and ICU mortality, which might point to the value of assessing the score for every patient admitted to the ICU. The older Polish ICU patients were characterised by higher mortality compared to the other European countries.

Treatment of Esophago-Airway Fistula after Esophageal Resection

(1) Background: Esophago-airway fistula after esophageal resection is a rare, life-threatening complication associated with a high postoperative mortality rate. Managing this condition is challenging, and the prognosis for patients is uncertain. The results and our own approach to treatment are presented. (2) Material and Methods: We present a retrospective analysis of a group of 22 patients treated for an esophago-airway fistula between 2012 and 2022, with 21 cases after esophageal resection and one during the course of Hodgkin's disease. (3) Results: Twenty-two patients were treated for an esophago-airway fistula. Among them, a tracheobronchial fistula occurred in 21 (95.4%) patients during the postoperative period, while 1 (4.5%) was treated for Hodgkin's disease. Of these cases, 17 (70.7%) patients underwent esophageal diversion with various treatments, including intercostal flap in most cases, greater omentum in one (4.5%), latissimus dorsi muscle in two (9%), and greater pectoral muscle in one (4.5%). Esophageal stenting was performed in two patients (9.0%), and one (4.5%) was treated conservatively. Unfortunately, one patient (4.5%) died after being treated with bronchial stenting, and two (9.5%) experienced a recurrence of the fistula. (4) Conclusions: The occurrence of an esophago-airway fistula after esophagectomy is a rare but life-threatening complication with an uncertain prognosis that results in several serious perioperative sequelae.

Hand hygiene improvement of individual healthcare workers: results of the multicentre PROHIBIT study

BACKGROUND

Traditionally, hand hygiene (HH) interventions do not identify the observed healthcare workers (HWCs) and therefore, reflect HH compliance only at population level. Intensive care units (ICUs) in seven European hospitals participating in the "Prevention of Hospital Infections by Intervention and Training" (PROHIBIT) study provided individual HH compliance levels. We analysed these to understand the determinants and dynamics of individual change in relation to the overall intervention effect.

METHODS

We included HCWs who contributed at least two observation sessions before and after intervention. Improving, non-changing, and worsening HCWs were defined with a threshold of 20% compliance change. We used multivariable linear regression and spearman's rank correlation to estimate determinants for the individual response to the intervention and correlation to overall change. Swarm graphs visualized ICU-specific patterns.

RESULTS

In total 280 HCWs contributed 17,748 HH opportunities during 2677 observation sessions. Overall, pooled HH compliance increased from 43.1 to 58.7%. The proportion of improving HCWs ranged from 33 to 95% among ICUs. The median HH increase per improving HCW ranged from 16 to 34 percentage points. ICU wide improvement correlated significantly with both the proportion of improving HCWs (ρ = 0.82 [95% CI 0.18-0.97], and their median HH increase (ρ = 0.79 [0.08-0.97]). Multilevel regression demonstrated that individual improvement was significantly associated with nurse profession, lower activity index, higher nurse-to-patient ratio, and lower baseline compliance.

CONCLUSIONS

Both the proportion of improving HCWs and their median individual improvement differed substantially among ICUs but correlated with the ICUs' overall HH improvement. With comparable overall means the range in individual HH varied considerably between some hospitals, implying different transmission risks. Greater insight into improvement dynamics might help to design more effective HH interventions in the future.

AB0502 STRESS AS POTENTIAL PATHOGENIC FACTOR IN PRIMARY SJOGREN’S SYNDROME

Background

Sjogren’s Syndrome (SS) is a common autoimmunological disorder characterized by infiltration of exocrine glands by autoreactive immune cells that lead to the disease’s two most common symptoms — dry eyes and a dry mouth, also known as sicca syndrome. The etiopathogenesis considers the coexistence of genetic predisposition and environmental factors, such as viral infections or sex hormones imbalance.

Objectives

The aim of the study was to determine whether major stressful life events are also risk factors for developing SS.

Methods

We performed a matched case-control study. Cases were patients with an established diagnosis of primary SS (pSS) within the previous five years. Controls were patients with osteoarthritis in whom systemic connective tissue disease has been ruled out. Data on major stressful life events were collected using the modified Holmes-Rahe stress scale. Data were collected for the period of the year before the disease onset.

Results

100 patients were enrolled in the study (pSS group = 50, control group = 50), mean age was 55.8±10.4 years for pSS and 61.3±9.59 years for control group, in both groups 96 % of patients were female. pSS patients had significantly higher total score on Holmes-Rahe stress scale within the preceding 1 year before the onset of disease symptoms than control group (pSS group = 152±66.3 vs control group = 50±54.6; p<0.001). In pSS group 50 % of patients reported the subjective impression that the symptoms were caused by stress, while in control group it was 12 % (p<0.001). The most frequently mentioned life events in the pSS group were divorce or marital separation, death or change in health of family member and stress related to work.

Conclusion

Patients with pSS are significantly more likely to have had a major stressful life event within the preceding 1 year before the disease onset. The relationship between stress and the occurrence of many diseases and their exacerbations is well documented, especially within autoimmune diseases. Stress is a ubiquitous problem these days, therefore it is of fundamental importance to understand the biological mechanisms underlying its influence on the development of diseases. It is crucial to properly recognize the stressful situation in the patient’s life and undertake appropriate interventions in order to prevent health consequences.

References

[1]Sandhya P, Kurien BT, Danda D, Scofield RH. Update on Pathogenesis of Sjogren’s Syndrome. Curr Rheumatol Rev. 2017;13(1):5-22. doi: 10.2174/1573397112666160714164149. PMID: 27412602; PMCID: PMC5280579.

[2]Sharif K, Watad A, Coplan L, Lichtbroun B, Krosser A, Lichtbroun M, Bragazzi NL, Amital H, Afek A, Shoenfeld Y. The role of stress in the mosaic of autoimmunity: An overlooked association. Autoimmun Rev. 2018 Oct;17(10):967-983. doi: 10.1016/j.autrev.2018.04.005. Epub 2018 Aug 14. PMID: 30118900.

[3]Skopouli FN, Katsiougiannis S. How stress contributes to autoimmunity-lessons from Sjögren’s syndrome. FEBS Lett. 2018 Jan;592(1):5-14. doi: 10.1002/1873-3468.12933. Epub 2017 Dec 22. PMID: 29223133.

[4]Roberts AL, Malspeis S, Kubzansky LD, Feldman CH, Chang SC, Koenen KC, Costenbader KH. Association of Trauma and Posttraumatic Stress Disorder With Incident Systemic Lupus Erythematosus in a Longitudinal Cohort of Women. Arthritis Rheumatol. 2017 Nov;69(11):2162-2169. doi: 10.1002/art.40222. Epub 2017 Oct 12. PMID: 28929625; PMCID: PMC5659907.

[5]Lee YC, Agnew-Blais J, Malspeis S, Keyes K, Costenbader K, Kubzansky LD, Roberts AL, Koenen KC, Karlson EW. Post-Traumatic Stress Disorder and Risk for Incident Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2016 Mar;68(3):292-8. doi: 10.1002/acr.22683. PMID: 26239524; PMCID: PMC4740283.

[6]Warren S, Greenhill S, Warren KG. Emotional stress and the development of multiple sclerosis: case-control evidence of a relationship. J Chronic Dis. 1982;35(11):821-31. doi: 10.1016/0021-9681(82)90047-9. PMID: 7142361.

Disclosure of Interests

None declared

Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs

BACKGROUND

Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear.

OBJECTIVE

To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function.

DESIGN

Prospective cohort study.

SETTING

241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019.

SUBJECTS

Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2.

METHODS

Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected.

RESULTS

Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001).

CONCLUSIONS

There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.

POS0120 INCIDENCE OF MALIGNANCIES IN PATIENTS WITH GRANULOMATOSIS WITH POLYANGIITIS AND MICROSCOPIC POLYANGIITIS DIAGNOSED BETWEEN 1988 AND 2020

Background:

Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is a group of systemic necrotizing small vessel vasculitides. Microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) are two most common types of AAV affecting mainly middle-aged and elderly people. Previous data indicated an increased occurrence of cancer in AAV patients [1], which has been mainly attributed to exposure to cyclophosphamide [2].

Objectives:

The purpose of this paper was to analyze cancer incidence in unselected patients with GPA and MPA treated in one academic center since 1988 with follow-up until 2020.

Methods:

With case record review, the baseline characteristics, outcomes and malignancy development in a cohort of 251 patients were assessed. Patients were followed up from time of diagnosis to their death or most recent hospital or outpatient’s assessment.

Results:

Twenty-eight of 251 patients with AAV (65 % cANCA, 26% pANCA, 9.0 % ANCA-negative) developed a total of 32 malignancies during a mean follow-up of 8.6 years. Patients characteristic is presented in table 1. Mean time since AAV onset to cancer diagnosis was 5.86±6.78 years. Of these malignancies, 2 melanoma, 6 were non-melanoma skin cancers, 4 gastrointestinal tract cancer (2 colon, 1 stomach, 1 liver), 3 bladder cancer, 2 breast cancer, 2 uterine cancer, 1 ovarian cancer, 2 prostate cancer, 1 testis cancer, 2 lung cancer, 6 haematological malignancies (1 lymphoma, 1 chronic myeloid leukemia, 4 monoclonal gammopathy of unknown significance), additionally 1 benign salivary gland tumor was found. Four of the 16 patients with renal transplants developed a total of 6 malignancies. There were no differences in the incidence of cancer by gender, age, severity and activity of the disease, ANCA status, smoking status, number of relapses and treatment. There was no association between cancer and cumulative dose of cyclophosphamide.

Conclusion:

In the AAV group, 11% of patients developed different type of cancer. The most common was non-melanoma skin cancer. The risk of developing malignancy increased with follow-up time. We found no association of tumor development and cumulative cyclophosphamide dose.

References:

[1]Rahmattulla et al. Incidence of malignancies in patients with antineutrophil cytoplasmic antibody-associated vasculitis diagnosed between 1991 and 2013. Arthritis Rheum. 2015;67(12):3270–3278.

[2]Faurschou M et al. Prolonged risk of specific malignancies following cyclophosphamide therapy among patients with granulomatosis with polyangiitis. Rheumatology (Oxford) 2015; 54:1345–1350.

Table 1.

Characteristics of the AAV patients included in the study.

Total sample (n=251)No malignancy occurrence (n=223)Malignancy occurrence (n=28)P valueAge at diagnosis, mean ± SD years53.0±15.952.4±16.457.9±9.45NSFemale, n (%)115 (45.8%)106 (47.5 %)9 (32.1 %)NSMean observation time (years)5.72±5.175.35±4.938.61±6.170.002BVASv318.9±8.4918.9±8.4618.6±8.90NSDEI7.03±2.867.04±2.906.96±2.62NSOrgan involvement, n (%) Upper respiratory tract170 (67.7 %)151 (67.7 %)19 (67.9 %)NS Lungs163 (64.9 %)142 (63.7 %)21 (75.0 %)NS Kidney171 (68.1 %)151 (67.7 %)20 (71.4 %)NS Skin62 (24.7 %)54 (21.5 %)55 (24.7 %)49 (22.0 %)7 (25.0 %)NS Eyes11 (4.4 %)11 (4.9 %)5 (17.9 %)NS Heart30 (12.0 %)24 (10.8 %)0 (0.0 %)NS Gastrointestinal tract34 (13.5 %)32 (14.3 %)6 (21.4 %)NSFollow-up 0–5 years145 (57.8 %)136 (61.0 %)9 (32.1 %)0.004 > 5–10 years62 (24.7 %)52 (23.3 %)10 (35.7 %)NS > 10 years44 (17.5 %)35 (15.7 %)9 (32.1 %)0.031Deaths, n(%)56 (23.0 %)45 (20.8 %)11 (39.3 %)0.029Renal transplantation, n(%)16 (6.4 %)12 (5.4 %)4 (14.3 %)NSCumulative Cyclophosphamide dose (g)14.7±30.014.5±30.816.6±23.6NS

Disclosure of Interests:

None declared

SAT0265 RISK FACTORS FOR INFECTIOUS COMPLICATIONS FOLLOWING RITUXIMAB TREATMENT – MULTICENTER POLISH EXPERIENCE

Background:

Rituximab (RTX) is a B cell depleting monoclonal antibody with proven efficacy in the treatment of ANCA-associated vasculitis (AAV). The infectious complications occur in 15-25%.

Objectives:

We aimed to assess the frequency and risk factors of infections in patients with AAV receiving RTX among Polish patients.

Methods:

7 tertiary referral centers experienced in the treatment of vasculitis completed a questionnaire regarding AAV patients treated with RTX.

Results:

Among 49 patients included in the analysis (47 with GPA, 2 with MPA; 36/73% men; mean age at diagnosis 42,45±14,9 yrs., mean age on RTX initiation 46,14±14,72 yrs.,) at least one infection occurred in 20 patients (40.82%) after mean time of 16,65±16,01 weeks since the administration of RTX. Patients were followed for a mean time of 26,88±21,94 months. There were no differences in the incidence of infectious complications by gender, age, BMI, smoking status, severity of the disease, activity of the disease (BVAS), time from diagnosis to RTX initiation, carriage of staphylococcus aureus in the upper respiratory tract, total dose of CYC before RTX treatment. We didn’t observe severe hypogammaglobulinemia or neutropenia after RTX treatment. 40% of the observed infections occurred during the first month, 35% between second and sixth month of follow-up, while 25% were observed between 6 and 12 months after the RTX initiation. Of the 20 patients who developed infection, 12 (24.5%) had further infections. Antibiotic prophylaxis with trimethoprim–sulfamethoxazole was administered in 40 out of 49 (81.63%). Upper respiratory tract infection was the most common infectious complication (n=11), followed by lower respiratory tract (n=4), soft tissues (n=4) and urinary tract infections (n=4), lacrimal gland abscess (n=2) and abdomen (n=1). In cases with a positive microbial result Staphylococcus aureus (n=4), Klebsiella pneumoniae (n=2), Pseudomonas aeruginosa (n=1), Candida (n=1) and others (n=6) were identified. No fatalities were recorded and only 3 patients had severe infection with the necessity of prolonged treatment.

Conclusion:

Despite the high number of infections in our group treated with RTX, most of them were not severe. Upper respiratory tract was the most common site of infection.

Disclosure of Interests:

None declared

FRI0210 ORBITAL PSEUDOTUMOR AMONG PATIENTS WITH GRANULOMATOSIS WITH POLYANGIITIS – DATA FROM THE POLISH REGISTRY POLVAS

Background:

Orbital inflammatory masses have been described as the common manifestation of granulomatosis with polyangiitis (GPA) occuring in 7- 45% of patients.

Objectives:

Identification and characterization of patients with orbital pseudotumor among Polish patients based on the national vasculitis registry, POLVAS.

Methods:

Clinical presentation and management of all GPA patients fulfilling ACR criteria or Chapel Hill Consensus Conference definition included to the Polish registry POLVAS who developed orbital masses in the course of GPA were evaluated.

Results:

Ocular involvement was found in 114 (27%) of 417 GPA patients registered in POLVAS, 34 (8%) developed orbital masses. Mean patients’ age was 47.8 (range from 19-75) yrs., 23 (67%) were women. Forty four per cent of the patients developed tumor at the beginning of the disease, 56% during relapse. Patients’ characteristics on diagnosis of orbital mass: 24 cANCA, 2 pANCA, and 8 ANCA negative, 9% active smokers and 31% past smokers, 29% had localized disease, 21% early systemic and 50% systemic with organ involvement, 29% had other type of ophthalmological involvement before pseudotumor occurred, 88% had active paranasal sinus involvement, 41% lungs, 15% CNS, 15% skin and 6% heart manifestations. Thirty seven per cent of patients had positive nasal swabs cultures, 50% of which were positive for Staphylococcus aureus. In 65%, tumor occurred during steroid therapy (46% had prednisone more than 5mg/d) and 45% on immunosuppressive treatment (19% when treated with AZA, 16% MTX, 6,5% MMF and 3,5% CYC). Due to orbital mass 86.5% were treated with CYC and 13.5% with RTX. Twenty one per cent had complete remission of the pseudotumor, 76% partial remission and in 3% patients there was no response to the treatment; 43% developed visual impairment, 20% suffered from blindness.

Conclusion:

Orbital inflammatory mass was not common manifestation of GPA among our patients. The mass developed at the beginning or in the course of the disease, even during immunosuppressive treatment. Orbital masses have been resistant to therapeutic interventions and were accompanied by high risk of visual impairment.

Disclosure of Interests:

Anna Masiak: None declared, Marcin Ziętkiewicz: None declared, Krzysztof Wójcik: None declared, Katarzyna Wawrzycka-Adamczyk: None declared, Radoslaw Jeleniewicz: None declared, Marta Madej: None declared, Joanna Kur-Zalewska: None declared, Katarzyna Jakuszko: None declared, Małgorzata Wisłowska: None declared, Hanna Storoniak: None declared, Michał Komorniczak: None declared, Barbara Bułło-Piontecka: None declared, Iwona Brzosko: None declared, Małgorzata Stasiek: None declared, Eugeniusz Kucharz: None declared, Alicja Dębska-Ślizień: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Jacek Musiał: None declared, Zbigniew Zdrojewski: None declared

THU0493 IMPACT OF AGE, GENDER AND EDUCATION LEVEL ON THE CHOICE OF TREATMENT METHOD FOR BACK PAIN AMONG PEOPLE OVER 50 YEARS OF AGE

Background:

According to data collected by the Statistics Poland in 2014, lower back pain is the second most common complaint reported by people over the age of 60 and occurs in about 40% of them. Another 29% of respondents suffer from pain in other spine sections. Treatment of such a common condition can be a challenge due to the multitude of causes of pain, accompanying diseases and the patient’s approach to his own health.

Objectives:

The aim of the study was to investigate whether factors such as gender, age, level of education and pain severity affect self-chosen methods of treating back pain.

Methods:

A survey was conducted on students of Pomeranian Universities Of The Third Age. There were collected socio-demographic characteristics of the participants, features of back pain and detailed information on analgesic methods, including drugs, ointments, exercises and physiotherapy treatments (laser, cryotherapy, hydromassage, ultrasound, heat treatments and other). The responses of participants over the age of 50 were included in the analysis. The answers were divided into groups by age (younger - 50–69 years and older - over 70 years), sex, level of education (lower, medium and higher) and intensity of pain assessed on the VAS scale (<6 and ≥6). The collected data were compared in these groups.

Results:

546 answers were received. 291 respondents were 50-69 years old, 255 aged 70-90 and more, 86% (471) of participants were women. 43% of respondents had secondary education and the same number had higher education. Over 90% (494) declared that they have suffered from back pain. Most of them described pain as chronic (56%), the median pain intensity assessed on the VAS scale was 6 [1-10], and the mean pain intensity was 5.89 ± 1.79. 82.6% of respondents declared doing physical exercises to relieve back pain, 75.9% were using physiotherapy, 60.7% were taking analgesic drugs and 54.3% were using ointments, gels, patches and other local analgesic methods. The higher pain severity was observed in group of females (5.74 vs. 5.61, p=0.002) and people with lower education level (6.52) than in other groups (5.89 and 5.68, p=0.005). Analgesic drugs were taken more often by younger people (66.9% vs. 53.7%, p=0.003), women (62.5% vs. 49.2%, p=0.042), people of lower education level group (80.6% vs. 62.2% secondary education group vs. 52.5% higher education group, p<0.001) and by people with pain severity ≥6 (81.5% vs. 68.9%, p<0.001). Analgesic gels, ointments, patches and other pharmaceuticals were used more often only in group with higher pain severity (62.9% vs. 43.4%, p<0.001). Performing exercises to relieve pain was more often declared by women (84.4% vs. 70.8%, p=0.003) and people with higher education (85.1% vs. 81.3% secondary education group vs. 79.1% lower education group, p<0.001). The study showed that only in groups with varying intensity of pain there was a significant difference in the frequency of using physiotherapy treatments - 68.9% in group with pain severity <6 vs. 81.5% with pain severity ≥6 (p<0.001).

Conclusion:

1. The severity of pain has the greatest impact on the choice of back pain relief method, but this is not the only important factor.

2. People with lower levels of education and men less often perform physical exercises for treatment regardless of the severity of back pain.

3. In the treatment of back pain, attention should be given to recommending the patient an appropriate analgesic method, which will be easily used and more effective.

References:

Population aged 60+. Demographic structure and health. 2016. Statistics Poland.

Disclosure of Interests: :

None declared

Classical Microbiological Diagnostics of Bacteremia: Are the Negative Results Really Negative? What is the Laboratory Result Telling Us About the "Gold Standard"?

Standard blood cultures require at least 24–120 h to be reported as preliminary positive. The objective of this study was to compare the reliability of Gram staining and fluorescent in-situ hybridization (FISH) for detecting bacteria in otherwise negative blood culture bottles. Ninety-six sets were taken from patients with a diagnosis of sepsis. Six incomplete blood culture sets and eight blood cultures sets demonstrating positive growth were excluded. We performed Gram stain and FISH on 82 sets taken from post-operative septic patients: 82 negative aerobic blood cultures, 82 anaerobic blood cultures, and 82 blood samples, as well as 57 blood samples taken from healthy volunteers. From the eighty-two blood sets analyzed from the septic patients, Gram stain visualized bacteria in 62.2% of blood samples, 35.4% of the negative aerobic bottles, and in 31.7% of the negative anaerobic bottles. Utilizing FISH, we detected bacteria in 75.6%, 56.1%, and 64.6% respectively. Among the blood samples from healthy volunteers, FISH detected bacteria in 64.9%, while Gram stain detected bacteria in only 38.6%. The time needed to obtain the study results using Gram stain was 1 h, for FISH 4 h, and for the culture method, considering the duration of growth, 5 days. Gram stain and FISH allow quick detection of bacteria in the blood taken directly from a patient. Finding phagocytosed bacteria, which were also detected among healthy individuals, confirms the hypothesis that blood microbiome exists.

Frailty is associated with an increased mortality among patients ≥ 80 years old treated in Polish ICUs

BACKGROUND

The increasing population of very old intensive care patients (VIPs) is a major challenge currently faced by clinicians and policymakers. Reliable indicators of VIPs' prognosis and purposefulness of their admission to the intensive care unit (ICU) are urgently needed.

METHODS

This is a report from the Polish sample of the VIP1 multicentre cohort study (NCT03134807). Patients ≥ 80 years of age admitted to the ICU were included in the study. Information on the type and reason for admission, demographics, utilisation of ICU procedures, ICU length of stay, organ dysfunction and the decision to apply end-of-life care was collected. The primary objective was to investigate the impact of frailty syndrome on ICU and 30-day survival of VIPs. Frailty was assessed with the Clinical Frailty Scale (≥ 5 points on a scale of 1-9).

RESULTS

We enrolled 272 participants with a median age of 84 (81-87) years. Frailty was diagnosed in 170 (62.5%) patients. The ICU and 30-day survival rates were equal to 54.6% and 47.3% respectively. Three variables were found to significantly increase the odds of death in the ICU in a multiple logistic regression model: SOFA score (OR = 1.16; 95%CI 1.16-1.24), acute mode of admission (OR = 5.1; 95%CI 1.67-15.57) and frailty (OR = 2.25; 95%CI 1.26-4.01).

CONCLUSION

Measuring frailty in critically ill older adults can facilitate making more informed clinical decisions and help avoid futile interventions.

Difficulties in funding of VA-ECMO therapy for patients with severe accidental hypothermia

BACKGROUND

Severe accidental hypothermia is defined as a core temperature below 28 Celsius degrees. Within the last years, the issue of accidental hypothermia and accompanying cardiac arrest has been broadly discussed and European Resuscitation Council (ERC) Guidelines underline the importance of Extracorporeal Rewarming (ECR) in treatment of severely hypothermic victims. The study aimed to evaluate the actual costs of ECR with VA-ECMO and of further management in the Intensive Care Unit of patients admitted to the Severe Accidental Hypothermia Centre in Cracow, Poland.

METHODS

We carried out the economic analysis of 31 hypothermic adults in stage III-IV (Swiss Staging) treated with VA ECMO. Twenty-nine individuals were further managed in the Intensive Care Unit. The actual treatment costs were evaluated based on current medication, equipment, and dressing pricing. The costs incurred by the John Paul II Hospital were then collated with the National Health Service (NHS) funding, assessed based on current financial contract.

RESULTS

In most of the cases, the actual treatment cost was greater than the funding received by around 10000 PLN per patient. The positive financial balance was achieved in only 4 (14%) individuals; other 25 cases (86%) showed a financial loss.

CONCLUSION

Performed analysis clearly shows that hospitals undertaking ECR may experience financial loss due to implementation of effective treatment recommended by international guidelines. Thanks to new NHS funding policy since January 2017 such loss can be avoided, what shall encourage hospitals to perform this expensive, yet effective method of treatment.

A comparison of the ultrasound measurement of the inferior vena cava obtained with cardiac and convex transducers

Background

Ultrasound measurement of the inferior vena cava diameter and its respiratory variability are amongst the predictors of fluid volume status. The primary purpose of the present study was to compare the consistency of inferior vena cava diameter measurements and the collapsibility index, obtained with convex and cardiac transducers. A secondary aim was to assess the agreement of the patient's allocation to one of the two groups: "fluid responder" or "fluid non-responder", based on inferior vena cava collapsibility index calculation made with two different probes.

Methods

20 experienced clinicians blinded to the purpose of the study analysed forty anonymized digital clips of images obtained during ultrasound examination of 20 patients. For each patient, one digital loop was recorded with a cardiac and the second with a convex probe. The participants were asked to determine the maximal and minimal diameters of the inferior vena cava in all presented films. An independent researcher performed a comparative analysis of the measurements conducted with both probes by all participants. The calculation of the collapsibility index and allocation to "fluid responder" or "fluid non-responder" group was performed at this stage of the study.

Results

The comparison of measurements obtained with cardiac and convex probes showed no statistically significant differences in the measurements of the maximal and minimal dimensions and in the collapsibility index. We also noticed that the decision of allocation to the "fluid responder" or "non-responder" group was not probe-dependent.

Conclusion

Both transducers can be used interchangeably for the estimation of the studied dimensions.

Measuring core temperature using the proprietary application and thermo-smartphone adapter

Fast and accurate measurement of core body temperature is crucial for accidental hypothermia treatment. We have developed a novel light and small adapter to the headset jack of a mobile phone based on Android. It has been applied to measure temperature and set up automatic notifications (e.g. Global Positioning System coordinates to emergency services dispatcher, ECMO coordinator). Its validity was confirmed in comparison with Vital Signs Monitor Spacelabs Healthcare Elance 93300 as a reference method, in a series of 260 measurements in the temperature range of 10-42 °C. Measurement repeatability was verified in a battery of 600 measurements (i.e. 100 readings at three points of 10, 25, 42 °C for both esophageal and tympanic catheters). Inter-method difference of ≤0.5 °C was found for 98.5% for esophageal catheter and 100% for tympanic catheter measurements, with concordance correlation coefficient of 0.99 for both. The readings were almost completely repeatable with water bath measurements (difference of ≤0.5 °C in 10 °C: 100% for both catheters; in 25 °C: 99% for esophageal catheter and 100% tympanic catheter; in 42 °C: 100% for both catheters). This lightweight adapter attached to smartphone and standard disposable probes is a promising tool to be applied on-site for temperature measurement in patients at risk of hypothermia.

Severe Hypothermia Management in Mountain Rescue: A Survey Study

Podsiadło, Paweł, Tomasz Darocha, Sylweriusz Kosiński, Kinga Sałapa, Mirosław Ziętkiewicz, Tomasz Sanak, Rachel Turner, and Hermann Brugger. Severe hypothermia management in mountain rescue: A survey study. High Alt Med Biol 18:411–416, 2017.

Introduction: Severe hypothermia is a rare but demanding medical emergency. Although mortality is high, if well managed, the neurological outcome of survivors can be excellent. The aim of the study was to assess whether mountain rescue teams (MRTs) are able to meet the guidelines in the management of severe hypothermia, regarding their equipment and procedures.

Methods: Between August and December 2016, an online questionnaire, with 24 questions to be completed using Google Forms, was sent to 123 MRTs in 27 countries.

Results: Twenty-eight MRTs from 10 countries returned the completed questionnaire. Seventy-five percent of MRTs reportedly provide advanced life support (ALS) on-site and 89% are regularly trained in hypothermia management. Thirty-two percent of MRTs transport hypothermic patients in cardiac arrest to the nearest hospital instead of an Extracorporeal Life Support facility; 39% are equipped with mechanical chest compression devices; 36% measure core body temperature on-site and no MRT is equipped with a device to measure serum potassium concentration on-site in avalanche victims.

Conclusions: Most MRTs are regularly trained in the treatment of severe hypothermia and provide ALS. The majority are not equipped to follow standard procedural guidelines for the treatment of severely hypothermic patients, especially with cardiac arrest. However, the low response rate—23% (28/123)—could have induced a bias.

Should capnography be used as a guide for choosing a ventilation strategy in circulatory shock caused by severe hypothermia? Observational case-series study

Background

Severe accidental hypothermia can cause circulatory disturbances ranging from cardiac arrhythmias through circulatory shock to cardiac arrest. Severity of shock, pulmonary hypoperfusion and ventilation-perfusion mismatch are reflected by a discrepancy between measurements of CO₂ levels in end-tidal air (EtCO₂) and partial CO₂ pressure in arterial blood (PaCO₂). This disparity can pose a problem in the choice of an optimal ventilation strategy for accidental hypothermia victims, particularly in the prehospital period. We hypothesized that in severely hypothermic patients capnometry should not be used as a reliable guide to choose optimal ventilatory parameters.

Methods

We undertook a pilot, observational case-series study, in which we included all consecutive patients admitted to the Severe Hypothermia Treatment Centre in Cracow, Poland for VA-ECMO in stage III hypothermia and with signs of circulatory shock. We performed serial measurements of arterial blood gases and EtCO₂, core temperature, and calculated a PaCO₂/EtCO₂ quotient.

Results

The study population consisted of 13 consecutive patients (ten males, three females, median 60 years old). The core temperature measured in esophagus was 20.7–29.0 °C, median 25.7 °C. In extreme cases we have observed a Pa-EtCO₂ gradient of 35–36 mmHg. Median PaCO₂/EtCO₂ quotient was 2.15.

Discussion and Conclusion

Severe hypothermia seems to present an example of extremely large Pa-EtCO₂ gradient. EtCO₂ monitoring does not seem to be a reliable guide to ventilation parameters in severe hypothermia.

Beta-thromboglobulin as a marker of perioperative myocardial infarction in patients undergoing coronary artery bypass grafting following aspirin discontinuation

Perioperative myocardial infarction (PMI) following coronary artery bypass grafting (CABG) is associated with significant morbidity and mortality. The aim of this study was to assess platelet activation and oxidative stress in the setting of PMI in patients undergoing CABG. We studied 108 consecutive patients who stopped taking low-dose aspirin 7-10 days prior to elective isolated on- or off-pump CABG. β-thromboglobulin (β-TG), thromboxane B2 (TXB2) and 8-iso-prostaglandin F2α (8-iso-PGF2α), a marker of oxidative stress, were measured at the baseline and 5-7 days postoperatively. Aspirin (150 mg/d) was administered every morning since 12 hours after CABG. Mean baseline β-TG was 58.5 ± 10.3 IU/ml, TXB2 was 143.6 ± 28.5 ng/ml and 8-iso-PGF2α was 355.2 ± 40.7 pg/ml. Postoperatively, after administration of 4-6 doses of aspirin, β-TG increased by 16.7% and 8-iso-PGF2α increased by 17.2% 5-7 days after surgery (p = 0.005 and p < 0.001, respectively). TXB2 decreased by 99.7% to 410.3 ± 52.1 pg/ml (p < 0.001). Nine patients (8.3%) developed PMI. Baseline β-TG and TXB2, together with postoperative β-TG and 8-iso-PGF2α were higher in PMI patients than in the remaining subjects (all, p < 0.05). Multivariate analysis showed that baseline β-TG (OR: 1.28; 95% CI: 1.05-1.57, p = 0.015) was the only independent predictor of PMI. In conclusion, we demonstrated that increased platelet activation and thromboxane production, observed in patients not taking aspirin till the day of CABG, contribute to the occurrence of PMI in early postoperative period.

Intraoperative awareness--recommendations of the Committee on Quality and Safety in Anaesthesia, Polish Society of Anaesthesiology and Intensive Therapy

Modern general anaesthesia is complex and reversible.It involves a temporary loss of consciousness, analgesia,a decrease in muscle tension or complete muscle relaxation,suppressed reactions of the autonomic nervous system,and the provision of amnesia of events after its completion.

Factors influencing the occurence of nosocomial bloodstream infections observed in thoracic and cardiosurgical postoperative care units

BACKGROUND

The aim of this study was to analyse the epidemiology and aetiology of laboratoryconfirmed bloodstream infections (LC-BSI) and central line-associated bloodstream infections (CLABSI) after pulmonary and coronary surgery, in postoperative intensive care units in 2009.

METHODS

Sources of infections were identified by the hospital Infection Control Team in cooperation with ITU personnel using the CDC definitions.

RESULTS

A total of 37 LC-BSI and 21 CLA-BSI cases in 3.096 patients were detected. Central line device utilization ratio was 0.50. The total cumulative LC-BSI incidence rate was 1.2% and CLA-BSI rate 8.7 per 1,000 central line days. The most common causes of LC-BSI were Gram-positive cocci (Staphylococcus aureus - 5.9%, CNS - 50.0%, Enterococcus faecium - 5.9%).

CONCLUSIONS

We found that in those units in which surveillance of CLA-BSI had been conducted since 2002, BSI incidence rates were higher than those reported in the NHSN programme.