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.

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.

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.

Routine testing of close contacts of confirmed COVID-19 cases - National COVID-19 Contact Management Programme, Ireland, May to August 2020.

OBJECTIVES: The objective of this study was to inform public health practitioners who are designing, adapting and implementing testing and tracing strategies for Coronavirus disease (COVID-19) control. STUDY DESIGN: The study design is monitoring and evaluation of a national public health protection programme. METHODS: All close contacts of laboratory-confirmed cases of COVID-19 identified between the 19th May and 2nd August were included; secondary attack rates and numbers needed to test were estimated. RESULTS: Four thousand five hundred eighty six of 7272 (63%) close contacts of cases were tested with at least one test. The secondary attack rate in close contacts who were tested was 7% (95% Confidence Interval [CI]: 6.3 - 7.8%). At the 'day 0' test, 14.6% (95% CI: 11.6-17.6%) of symptomatic close contacts tested positive compared with 5.2% (95% CI: 4.4-5.9%) of asymptomatic close contacts. CONCLUSIONS: The application of additional symptom-based criteria for testing in this high-incidence population (close contacts) is of limited utility because of the low negative predictive value of absence of symptoms.

Air pollution and comorbidity burden influencing acute hospital mortality outcomes in a large academic teaching hospital in Dublin, Ireland: a semi-ecologic analysis.

OBJECTIVE: To investigate the extent to which air pollution interacts with comorbidity in determining mortality outcomes of emergency medical admissions. STUDY DESIGN: Routinely collected data were used to study all emergency medical admissions to an academic teaching hospital in Dublin, Ireland, from 2002 to 2018. Air pollution was measured by particulate matter with aerodynamic diameter ≤10 µm (PM10) and sulphur dioxide (SO2) levels on the day of admission. Comorbidity Score was measured using a previously derived score. METHODS: A multivariable logistic regression model was used to relate air pollutant levels, Comorbidity Scores, and their interaction to 30-day in-hospital mortality. RESULTS: There were 102,483 admissions in 58,127 patients over 17 years. Both air pollutant levels and Comorbidity Score were associated with 30-day in-hospital mortality. On admission days with PM10 levels above the median, mortality was higher (Odds ratio [OR] 1.09; 95% confidence interval [CI] 1.06, 1.18) at 11.2% (95% CI 10.5, 12) compared with 10.4% (95% CI 10, 10.7) on days when PM10 levels were below the median. On admission days with SO2 levels above the median, mortality was higher (OR 1.13; 95% CI 1.10, 1.16) at 12.2% (95% CI 11.4, 13) compared with 10.7% (95% CI 10.3, 11.1) on days when SO2 levels were below the median. Comorbidity Score was strongly associated with mortality (mortality rate of 8.9% for those with a 6-point score vs mortality rate of 30.3% for those with a 16-point score). There was limited interaction between air pollutant levels and Comorbidity Score. CONCLUSION: Both air pollution levels on the day of admission and Comorbidity Score were associated with 30-day in-hospital mortality. However, there was limited interaction between these two factors.

Next Stop a Longer Life.

Aim A request was made to the Department of Public Health in early 2019 for some interesting statistics (funtistics) for a planned health promotion campaign encouraging public transport users to increase their physical activity levels by alighting one stop earlier and walking to their destination. For a novel presentation of the benefits of increasing physical activity it was decided to calculate the potential increase in life-expectancy that a given amount of physical activity would correspond to (at a population level). Method Estimated increase in weekly walking time was calculated for the Dublin Bus commuter walking the last stop of their journey. The reduced risk of mortality was estimated for this increase in physical activity and applied to Irish life tables to calculate change in life expectancy. Results Alighting from a bus one stop earlier in Dublin would lead to an average of 4.42 minutes additional walking (44.21 minutes additional walking per week for a commuter). In the Dublin Bus commuter population, this leads to an estimated 50 day increase in life expectancy (male population). Conclusion At the lower end of the dose response curve for physical activity, health benefits include: reduced risk of cardiovascular disease, reduced risk of diabetes, psychosocial benefit, reduced risk of musculoskeletal problems. For the prevention of weight gain and some cancers, activity at the upper end of the range (1000 MET.min/week, approximately 300 minutes of walking/week) is thought to be required.

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.

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.

A retrospective analysis of case-load and supervision from a large anaesthetic logbook database.

The recent development of electronic logbooks with secure off-device data storage provides a rich resource for research. We present the largest analysis of anaesthetic logbooks to date, with data from 494,235 cases logged by 964 anaesthetists over a 4-year period. Our analysis describes and compares the annual case-load and supervision levels of different grades of anaesthetists across the UK and Republic of Ireland. We calculated the number of cases undertaken per year by grade (median (IQR [range]) core trainees = 388 (252-512 [52-1204]); specialist trainees = 344 (228-480 [52-1144]); and consultants = 328 (204-500 [52-1316]). Overall, the proportion of cases undertaken with direct consultant supervision was 56.7% and 41.6% for core trainees and specialist trainees, respectively. The proportion of supervised cases reduced out-of-hours, for both core trainees (day 93.5%, evening 86.3%, night 78.6%) and specialist trainees (day 81.0%, evening 67.7%, night 56.4%).

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.

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.

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.

Ireland's recent contribution to the radiological literature; a bibliometric analysis.

The aim of this study was to identify and analyse all articles published by Irish radiology departments in the medical literature since the year 2000. The PubMed database was searched to identify and review all articles published by radiologists based in the Republic of Ireland or Northern Ireland. Citation counts were then obtained and the top ten most cited articles were identified. There were 781 articles published during the study period. Of these, 558 (71%) were published in radiology journals and the remaining 223 (29%) were published in general medical journals. Abdominal radiology was the most represented sub-specialty (33% of all articles). There was a general trend of increased publications per year. Only 75 (9.6%) of articles were collaborative efforts by more than one radiology department. Irish radiology departments have a considerable research output and this has increased since the year 2000. More collaborative research between Irish radiology departments is encouraged.

Triheptanoin treatment in patients with pediatric cardiomyopathy associated with long chain-fatty acid oxidation disorders.

Long-chain fatty acid oxidation disorders (LC-FAOD) can cause cardiac hypertrophy and cardiomyopathy, often presenting in infancy, typically leading to death or heart transplant despite ongoing treatment. Previous data on triheptanoin treatment of cardiomyopathy in LC-FAOD suggested a clinical benefit on heart function during acute failure. An additional series of LC-FAOD patients with critical emergencies associated with cardiomyopathy was treated with triheptanoin under emergency treatment or compassionate use protocols. Case reports from 10 patients (8 infants) with moderate or severe cardiomyopathy associated with LC-FAOD are summarized. The majority of these patients were detected by newborn screening, with follow up confirmatory testing, including mutation analysis; all patients were managed with standard treatment, including medium chain triglyceride (MCT) oil. While on this regimen, they presented with acute heart failure requiring hospitalization and cardiac support (ventilation, ECMO, vasopressors) and, in some cases, resuscitation. The patients discontinued MCT oil and began treatment with triheptanoin, an investigational drug. Triheptanoin is expected to provide anaplerotic metabolites, to replace deficient TCA cycle intermediates and improve effective energy metabolism. Cardiac function was measured by echocardiography and ejection fraction (EF) was assessed. EF was moderately to severely impaired prior to triheptanoin treatment, ranging from 12-45%. Improvements in EF began between 2 and 21days following initiation of triheptanoin, and peaked at 33-71%, with 9 of 10 patients achieving EF in the normal range. Continued treatment was associated with longer-term stabilization of clinical signs of cardiomyopathy. The most common adverse event observed was gastrointestinal distress. Of the 10 patients, 7 have continued on treatment, 1 elected to discontinue due to tolerability issues, and 2 patients died from other causes. Two of the case histories illustrate that cardiomyopathy may also develop later in childhood and/or persist into adulthood. Overall, the presented cases suggest a therapeutic effect of triheptanoin in the management of acute cardiomyopathy associated with LC-FAOD.

Evolution of lesion-specific management of blunt thoracic aortic injury.

Developments in diagnosis and treatment have transformed the management of blunt thoracic aortic injuries (BTAIs). For patients in stable condition, treatment practice has shifted from early open repair to nonoperative management for low-grade lesions and routine delayed endovascular repair for more significant injuries. However, effective therapy depends on accurate staging of injury grade and stability to select patients for appropriate management. Recent developments in BTAI risk stratification enable lesion-specific management tailored to the patient and aortic lesion. This review summarizes advances in lesion assessment and treatment and proposes an integrated scheme for the modern management of BTAI.

Radiology imaging delays as independent predictors of length of hospital stay for emergency medical admissions.

AIM: To investigate the extent to which the time to completion for computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound could be shown to influence the length of stay and costs incurred while in hospital, while accounting for patient acuity. MATERIALS AND METHODS: All emergency admissions, totalling 25,326 imaging investigations between 2010-2014 were evaluated. The 50(th), 75(th), and 90(th) centiles of completion times for each imaging type was entered into a multivariable truncated Poisson regression model predicting the length of hospital stay. Estimates of risk (odds or incidence rate ratios [IRRs]) of the regressors were adjusted for acute illness severity, Charlson comorbidity index, chronic disabling disease score, and sepsis status. Quantile regression analysis was used to examine the impact of imaging on total hospital costs. RESULTS: For all imaging examinations, longer hospital lengths of stay were shown to be related to delays in imaging time. Increased delays in CT and MRI were shown to be associated with increased hospital episode costs, while ultrasound did not independently predict increased hospital costs. The magnitude of the effect of imaging delays on episode costs were equivalent to some measures of illness severity. CONCLUSION: CT, MRI, and ultrasound are undertaken in patients with differing clinical complexity; however, even with adjustment for complexity, the time delay in a more expeditious radiological service could potentially shorten the hospital episode and reduce costs.