Steve Harris

Melarsoprol versus eflornithine for treating late-stage Gambian trypanosomiasis in the Republic of the Congo

OBJECTIVE To compare the effectiveness of melarsoprol and eflornithine in treating late-stage Gambian trypanosomiasis in the Republic of the Congo. METHODS We analysed the outcomes of death during treatment and relapse within 1 year of discharge for 288 patients treated with eflornithine, 311 patients treated with the standard melarsoprol regimen and 62 patients treated with a short-course (10-day) melarsoprol regimen between April 2001 and April 2005. FINDINGS A total of 1.7% (5/288) of patients treated with eflornithine died compared with 4.8% (15/311) of those treated with standard melarsoprol and 6.5% (4/62) of those treated with short-course melarsoprol. Patients treated with eflornithine tended to be younger and were more likely to have trypanosomes or higher white blood cell counts in their cerebrospinal fluid. The cumulated incidence of relapse among patients who attended at least one follow-up visit 1 year after discharge was 8.1% (11/136) for those treated with eflornithine, 14% (36/258) for those treated with standard melarsoprol and 15.5% (9/58) for those treated with shortcourse melarsoprol. In a multivariate analysis, when compared with eflornithine, standard melarsoprol was found to be a risk factor for both death (odds ratio (OR) = 2.87; 95% confidence interval (CI) = 1.03-8.00) and relapse (hazard ratio (HR) = 2.47; 95% CI = 1.22-5.03); when compared with eflornithine, short-course melarsoprol was also found to be a risk factor for death (OR = 3.90; 95% CI = 1.02-14.98) and relapse (HR = 6.65; 95% CI = 2.61-16.94). CONCLUSION The effectiveness of melarsoprol treatment appears to have diminished. Eflornithine seems to be a better first-line therapy for treating late-stage Gambian trypanosomiasis in the Republic of the Congo.

Revised cardiac risk index and postoperative morbidity after elective orthopaedic surgery: a prospective cohort study

BACKGROUND The revised cardiac risk index (RCRI) is associated strongly with increased cardiac ischaemic risk and perioperative death. Associations with non-cardiac morbidity in non-cardiac surgery have not been explored. In the elective orthopaedic surgical population, morbidity is common but preoperative predictors are unclear. We hypothesized that RCRI would identify individuals at increased risk of non-cardiac morbidity in this surgically homogenous population. METHODS Five hundred and sixty patients undergoing elective primary (>90%) and revision hip and knee procedures were studied. A modified RCRI (mRCRI) score was calculated, weighting intermediate and low risk factors. The primary endpoint was the development of morbidity, collected prospectively using the Postoperative Morbidity Survey, on postoperative day (POD) 5. RESULTS Morbidity on POD 5 was more frequent in patients with mRCRI ≥ 3 {relative risk 1.7, [95% confidence interval (CI): 1.4-2.1]; P<0.001}. Time to hospital discharge was delayed in patients with mRCRI score ≥ 3 (log-rank test, P=0.0002). Pulmonary (P<0.001), infectious (P=0.001), cardiovascular (P=0.0003), renal (P<0.0001), wound (P=0.02), and neurological (P=0.002) morbidities were more common in patients with mRCRI score ≥ 3. Pre/postoperative haematocrit, anaesthetic/analgesic technique, and postoperative temperature were similar across mRCRI groups. There were significant associations with hospital stay, as measured by the area under the receiver-operating characteristic curves for mRCRI 0.64 (95% CI: 0.58-0.70) and POSSUM 0.70 (95% CI: 0.63-0.75). CONCLUSIONS mRCRI score ≥ 3 is associated with increased postoperative non-cardiac morbidity and prolonged hospital stay after elective orthopaedic procedures. mRCRI can contribute to objective risk stratification of postoperative morbidity.

Near patient blood ketone measurements and their utility in predicting diabetic ketoacidosis

Aim  To assess the utility of near patient blood ketone measurements in predicting diabetic ketoacidosis (DKA) among a group of hyperglycaemic unwell patients presenting to a hospital emergency department.

Treatment outcomes and risk factors for relapse in patients with early-stage human African trypanosomiasis (HAT) in the Republic of the Congo.

OBJECTIVE In 2002-03, the Republic of the Congo increased the threshold separating stage 1 and 2 cases of human African trypanosomiasis (HAT) from a cerebrospinal fluid (CSF) white cell count of 5 cells/mm(3) to 10 cells/mm(3). We aimed to assess whether the increased threshold of 10 cells/mm(3) is a safe indicator of stage 2 disease. METHODS We assessed patients treated for stage 1 HAT caused by Trypanosoma brucei gambiense in the Republic of the Congo between April 2001 and April 2005. Patients with 0-10 cells/mm(3) in CSF were classed as stage 1 and treated with pentamidine. Patients with CSF of > 10 cells/mm(3) were classed as stage 2 and treated with either melarsoprol or eflornithine. We did a retrospective analysis of all patients treated after the September 2002 increase in threshold for classification of HAT disease stage 2, and who were eligible for at least 1 year of follow-up. Primary outcome was survival without death or relapse within 1 year of discharge. Risk factors for treatment failure, in particular CSF white cell count on diagnosis, were assessed. FINDINGS Between September 2002 to April 2004, 692 patients eligible for our analysis were treated with pentamidine. All were discharged alive. Relapse rate was 5% (n = 33). The only identified risk factor for relapse was a CSF white cell count of 6-10 cells/mm(3) rather than 0-5 cells/mm(3) (adjusted hazard ratio 3.27 (95% confidence interval, 1.52-7.01); P = 0.002). CONCLUSION A threshold of 5 white cells/mm(3) in CSF is safer than 10 cells/mm(3) to determine stage 2 HAT and reduce risk of relapse.

Delay to admission to critical care and mortality among deteriorating ward patients in UK hospitals: a multicentre, prospective, observational cohort study

BACKGROUND Annually, more than 11 million patients are admitted to hospital overnight in England, but the UK is ranked 24 of 31 European countries with respect to per head provision of intensive care unit (ICU) beds. This lack of beds places strain on the capacity to admit patients from the ward because of high ICU occupancy. Such delay can cause harm, but the effect of such harm is difficult to measure. Prompt admissions are prompt precisely because these patients are severely unwell. Measured severity is unlikely to completely capture the clinical judgment used to allocate early admission, and therefore risk-adjusted outcomes will be biased against the early admission. We aimed to evaluate the effect of delayed admission to critical care without this treatment selection bias. METHODS We did a prospective cohort study of deteriorating ward patients assessed for critical care admission in National Health Service hospitals in the UK. Early admission was defined as within 4 h of assessment. The primary endpoint was 90-day survival. We used critical care occupancy as an instrumental variable, assuming that a full ICU could only affect outcome of a ward patient by deflecting or delaying admission. FINDINGS 12 495 patients from 48 hospitals were available for analysis of whom 3797 (30·4%) died within 90 days. 4494 (36·0%) patients were admitted to critical care of whom 2492 (55·5%) were admitted early. The median time to admission was 2 h (IQR 1-3) with a bedside decision to admit, and 12 h otherwise (5-29). 991 patients (7·9%) were assessed when the critical care unit was fully occupied. Compared with those assessed when more than one bed was available, these patients were admitted less often (odds ratio [OR] 0·37, 95% CI 0·28-0·48), experienced greater delays (median increase 2 h, IQR 1-3), and deteriorated further while waiting (1·4 ICNARC physiology points, 95% CI 0·4-2·5). Early admission reduced mortality (OR 0·49, 95% CI 0·27-0·89). When averaged across the full population, absolute mortality fell by 13·9% (95% CI 25-23·0). INTERPRETATION Our study has shown that the deteriorating ward patient is vulnerable with a high short-term mortality (none of these patients had treatment limitations). Delays to admission were large and common, and arose both from our inability to perfectly triage these patients, and from limits to the capacity of the system. That these delays cause harm is very likely. FUNDING Wellcome Trust, National Institute for Health Research Service Support Costs, Intensive Care National Audit & Research Centre.

Relationship between patients’ outcomes and the changes in serum creatinine and urine output and RIFLE classification in a large critical care cohort database

We report the stepwise application of the RIFLE classification in 155,624 admissions in the UK Intensive Care National Audit & Research Centre Case Mix Programme database. The assumptions required to define RIFLE and their relationship with renal replacement therapy (RRT) and ICU mortality were assessed. Previous reports had not explored the method of estimating baseline creatinine, the position of class boundaries, or interactions between urine volume (AKI-U) and the peak/estimated baseline creatinine (AKI-Cr) within 24 h of ICU admission. The risk of developing AKI strongly depended on the assumed GFR increasing from 36 to 58% across the recommended range. AKI-U was often seen without AKI-Cr, and moderate oliguria (under 850 ml/24 h) was a stronger predictor of mortality than any degree of AKI-Cr partly because mortality fell when peak/estimated baseline creatinine ratios exceed fourfold. Mild oliguria (850-1500 ml/24 h) was common (38,928 admissions, 26%) and had a similar association with mortality (relative risk 1.6, 95% CI: 1.5-1.6) as did AKI-Cr defined Failure (risk ratio 1.5, 95% CI: 1.5-1.6). However, AKI-Cr was a strong predictor for RRT, which was used in 17,802 (11%) of admissions. Nearly half (48%) of the Failure patients never received RRT; nonetheless, most (66%) survived critical care. Thus, although the RIFLE classification may be attempted in large population cohorts, there is significant heterogeneity of both renal and, in particular, vital outcomes within each class.

Cancelled operations: a 7-day cohort study of planned adult inpatient surgery in 245 UK National Health Service hospitals

Background: Cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. Methods: We conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient‐ and hospital‐level factors associated with cancellation due to inadequate bed capacity. Results: We analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non‐clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care [odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12–4.02; P<0.001] and the presence of an emergency department in the treating hospital (OR=4.18; 95% CI, 2.22–7.89; P<0.001). Patients undergoing cancer surgery (OR=0.32; 95% CI, 0.22–0.46; P<0.001), obstetric procedures (OR=0.17; 95% CI, 0.08–0.32; P<0.001), and expedited surgery (OR=0.39; 95% CI, 0.27–0.56; P<0.001) were less likely to be cancelled. Conclusions: A significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations.

SNAP-2 EPICCS: the second Sprint National Anaesthesia Project-EPIdemiology of Critical Care after Surgery: protocol for an international observational cohort study.

Introduction The admission of high-risk patients to critical care after surgery is a recommended standard of care. Nevertheless, poor compliance against this recommendation has been repeatedly demonstrated in large epidemiological studies. It is unclear whether this is due to reasons of capacity, equipoise, poor quality clinical care or because hospitals are working creatively to create capacity for augmented care on normal surgical wards. The EPIdemiology of Critical Care after Surgery study aims to address these uncertainties. Methods and analysis One-week observational cohort study in the UK and Australasia. All patients undergoing inpatient (overnight stay) surgery will be included. All will have prospective data collection on risk factors, surgical procedure and postoperative outcomes including the primary outcome of morbidity (measured using the Postoperative Morbidity Survey on day 7 after surgery) and secondary outcomes including length of stay and mortality. Data will also be collected on critical care referral and admission, surgical cancellations and critical care occupancy. The epidemiology of patient characteristics, processes and outcomes will be described. Inferential techniques (multilevel multivariable regression, propensity score matching and instrumental variable analysis) will be used to evaluate the relationship between critical care admission and postoperative outcome. Ethics and dissemination The study has received ethical approval from the National Research Ethics Service in the UK and equivalent in Australasia. The collection of patient identifiable data without prior consent has been approved by the Confidentiality Advisory Group (England and Wales) and the Public Privacy and Patient Benefit Panel (Scotland). In these countries, patient identifiable data will be used to link prospectively collected data with national registers of death and inpatient administrative data. The study findings will be disseminated using a multimedia approach with the support of our lay collaborators, to patients, public, policy-makers, clinical and academic audiences.

An unusual electrocardiographic abnormality

Answers on p 545. A 70 year old man with chronic obstructive pulmonary disease and hypertension was admitted to hospital with a two month history of worsening dyspnoea on exertion and ankle swelling. On examination, the patient was in atrial fibrillation with an …

Man vs machine: how good are clinicians at predicting perioperative risk?

The National Tracheostomy Safety Project (NTSP) has published strategies tomanage and prevent airway emergencies in patients with tracheostomies and laryngectomies. However, front-line healthcare professionals most likely to benefit from guidance may not have access to or are unlikely to read publications in traditional medical literature. To improve dissemination of such guidelines, The Health Foundation launched Evidence into Practice in 2017. The NTSP’s aim for this project was to produce assessable, digestible resources, and target and influence relevant front-line staff via social media platforms. The NTSP engaged a social mediamarketing and production company (FeedFirst Ltd.) to produce short (<2 min) videos around key tracheostomy themes, coupled with a branding exercise. The themes were the following: (i) problems can be preventedbybasic care, donewell; (ii) emergencies canbemanaged by following NTSP algorithms; and (iii) vocalisation should be a routine goal of daily care. Amarketing campaignwas devised to target key staff groups (ICU nurses, ENT nurses, paramedics, physiotherapists, speech therapists, doctors, and hospital managers) identified via social media profiles on Facebook, LinkedIn, Twitter, and YouTube. Strategies included themed events, paid advertising, and encouraging peer-to-peer sharing of resources. Engagement metrics were captured using social media listening tools from January 1, 2018 to March 31, 2018. A total of 629 270 social media impressions of new NTSP video and infographic resources were captured, including over 267 000 Twitter impressions, 275 430 Facebook impressions, 82 880 YouTube video views (over 80 000minwatched; Fig. 7), and 3960 LinkedIn impressions. Only 85 000 (31.8%) of the Twitter impressions resulted from paid advertising, demonstrating significant social mobilisation around the content, and peerto-peer sharing.