Provision of trauma teams in Scotland: a national survey

<b>Background and Aims:</b> Trauma is still the leading cause of mortality in the first four decades of life. Despite multiple reports on how trauma care could be improved in the UK, treatment has been shown to be inconsistent and of poor quality. Trauma teams have been shown to have a positive effect on outcome. We aimed to determine the prevalence of trauma teams in Scotland. <b>Methods:</b> We performed a telephone survey of 24 hospitals with Emergency Departments and spoke to the senior clinician regarding provision of trauma teams. <b>Results:</b> 5 (21%) of the hospitals questioned had trauma teams. The most common reasons for not having one were: no problem with current system 8 (44%) and inability to include senior enough staff on the team 6 (24%). <b>Conclusions:</b> There are few trauma teams in Scottish acute hospitals. There was little enthusiasm for introducing them for a variety of reasons. Local evidence of benefit is likely needed before their adoption becomes widespread

Risk of critical illness among patients with solid cancers: a population-based observational study of 118,541 adults

Importance: Critical illness may be a potential determinant of cancer outcomes and geographic variations, but its role has not been described before. Objective: To determine the incidence of admission to intensive care units (ICUs) within 2 years following cancer diagnosis. Design, Setting, and Participants: This was a retrospective observational study using cancer registry data in 4 datasets from 2000 to 2009 with linked ICU admission data from 2000 to 2011, in the West of Scotland region of the United Kingdom (population, 2.4 million; all 16 ICUs within the region). All 118 541 patients (≥16 years) diagnosed as having solid (nonhematological) cancers. Their median age was 69 years, and 52.0% were women. Main Outcomes and Measures: Demographic and clinical variables associated with admission to an ICU and death in an ICU. Results: A total of 118 541 patients met the study criteria. Overall, 6116 patients (5.2% [95% CI, 5.0%-5.3%]) developed a critical illness and were admitted to an ICU within 2 years. Risk of critical illness was highest at ages 60 to 69 years and higher in men. The cumulative incidence of critical illness was greatest for small intestinal (17.2% [95% CI, 13.3%-21.8%]) and colorectal cancers (16.5% [95% CI, 15.9%-17.1%]). The risk following breast cancer was low (0.8% [95% CI, 0.7%-1.0%]). The percentage who died in ICUs was 14.1% (95% CI, 13.3%-15.0%), and during the hospital stay, 24.6% (95% CI, 23.5%-25.7%). Mortality was greatest among emergency medical admissions and lowest among elective surgical patients. The risk of critical illness did not vary by socioeconomic circumstances, but mortality was higher among patients from deprived areas. Conclusions and Relevance: In this study, about 1 in 20 patients experienced a critical illness resulting in ICU admission within 2 years of cancer diagnosis. The associated high mortality rate may make a significant contribution to overall cancer outcomes

Critical care provision after colorectal cancer surgery

Background: Colorectal cancer (CRC) is the 2nd largest cause of cancer related mortality in the UK with 40 000 new patients being diagnosed each year. Complications of CRC surgery can occur in the perioperative period that leads to the requirement of organ support. The aim of this study was to identify pre-operative risk factors that increased the likelihood of this occurring. Methods: This is a retrospective observational study of all 6441 patients who underwent colorectal cancer surgery within the West of Scotland Region between 2005 and 2011. Logistic regression was employed to determine factors associated with receiving postoperative organ support. Results: A total of 610 (9 %) patients received organ support. Multivariate analysis identified age ≥65, male gender, emergency surgery, social deprivation, heart failure and type II diabetes as being independently associated with organ support postoperatively. After adjusting for demographic and clinical factors, patients with metastatic disease appeared less likely to receive organ support (p = 0.012). Conclusions: Nearly one in ten patients undergoing CRC surgery receive organ support in the post operative period. We identified several risk factors which increase the likelihood of receiving organ support post operatively. This is relevant when consenting patients about the risks of CRC surgery

The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit

Purpose: This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting.<p></p> Methods: This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed.<p></p> Results: Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86).<p></p> Conclusions: This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores

Organ failure, outcomes and deprivation status among critically ill cirrhosis patients — a one-year cohort study

No abstract available

A randomised, controlled, double blind, non-inferiority trial of ultrasound-guided fascia iliaca block vs. spinal morphine for analgesia after primary hip arthroplasty

We performed a single centre, double blind, randomised, controlled, non-inferiority study comparing ultrasound-guided fascia iliaca block with spinal morphine for the primary outcome of 24-h postoperative morphine consumption in patients undergoing primary total hip arthroplasty under spinal anaesthesia with levobupivacaine. One hundred and eight patients were randomly allocated to receive either ultrasound-guided fascia iliaca block with 2 mg.kg−1 levobupivacaine (fascia iliaca group) or spinal morphine 100 μg plus a sham ultrasound-guided fascia iliaca block using saline (spinal morphine group). The pre-defined non-inferiority margin was a median difference between the groups of 10 mg in cumulative intravenous morphine use in the first 24 h postoperatively. Patients in the fascia iliaca group received 25 mg more intravenous morphine than patients in the spinal morphine group (95% CI 9.0–30.5 mg, p < 0.001). Ultrasound-guided fascia iliaca block was significantly worse than spinal morphine in the provision of analgesia in the first 24 h after total hip arthroplasty. No increase in side-effects was noted in the spinal morphine group but the study was not powered to investigate all secondary outcomes

Management of the patient with acute pancreatitis

No abstract available

The influence of alcohol abuse on agitation, delirium and sedative requirements of patients admitted to a general intensive care unit

Purpose: Patients with alcohol-related disease constitute an increasing proportion of those admitted to intensive care unit. There is currently limited evidence regarding the impact of alcohol use on levels of agitation, delirium and sedative requirements in intensive care unit. This study aimed to determine whether intensive care unit-admitted alcohol-abuse patients have different sedative requirements, agitation and delirium levels compared to patients with no alcohol issues. Methods: This retrospective analysis of a prospectively acquired database (June 2012–May 2013) included 257 patients. Subjects were stratified into three risk categories: alcohol dependency (n ¼ 69), at risk (n ¼ 60) and low risk (n ¼ 128) according to Fast Alcohol Screening Test scores and World Health Organisation criteria for alcohol-related disease. Data on agitation and delirium were collected using validated retrospective chart-screening methods and sedation data were extracted and then log-transformed to fit the regression model. Results: Incidence of agitation (p ¼ 0.034) and delirium (p ¼ 0.041) was significantly higher amongst alcohol-dependent patients compared to low-risk patients as was likelihood of adverse events (p ¼ 0.007). In contrast, at-risk patients were at no higher risk of these outcomes compared to the low-risk group. Alcohol-dependent patients experienced suboptimal sedation levels more frequently and received a wider range of sedatives (p ¼ 0.019) but did not receive higher daily doses of any sedatives. Conclusions: Our analysis demonstrates that when admitted to intensive care unit, it is those who abuse alcohol most severely, alcohol-dependent patients, rather than at-risk drinkers who have a significantly increased risk of agitation, delirium and suboptimal sedation. These patients may require closer assessment and monitoring for these outcomes whilst admitted

The characteristics and outcomes of patients with solid tumours admitted to Intensive Care in the West of Scotland

Cancer is one of the commonest conditions among patients admitted to Intensive Care Units (ICU). However, little is known about how it affects likelihood of ICU admission and subsequent clinical progress. What literature does exist is often not generalisable to current UK practice. The aims of the studies presented in this thesis are to determine the features that are associated with ICU admission in patients with solid tumours; to describe how the solid tumour population in ICU differs from the ICU population without cancer; how this impacts upon survival; and finally, to describe the long-term outcomes of solid tumour patients that have survived ICU and those features associated with mortality. I undertook a detailed systematic review of the international literature relating to survival following ICU admission for patients with solid tumours. This revealed a paucity of high quality studies and led to recommendations for improving the conduct and reporting of future research in this field. Using retrospective cohorts from prospectively collected databases, variables relating to patients in the West of Scotland diagnosed with a cancer between 1st January 2000 and 31st December 2009 were analysed. The rate of ICU admission within two years following cancer incidence was investigated, and the factors associated with admission described. The Scottish Intensive Care Society Audit Group (SICSAG) database was used to detail information pertaining to critical illness and to provide data on patients without an underlying tumour that were admitted to ICU during the same study period. Three cohorts were defined: patients with a solid tumour that were admitted to ICU, patients with a solid tumour that were not admitted to ICU, and ICU patients without a cancer diagnosis. One in twenty patients diagnosed with a solid tumour (5.2%) were admitted to ICU with the majority receiving organ support during their ICU stay. ICU admission tended to occur soon after cancer diagnosis and was therefore likely related to the cancer diagnosis or its treatment. The rate of ICU admission was greatest for bowel malignancies (16.5% of colorectal cancer patients) and for those tumours that require peri-operative ICU support for tumour resection surgery such as head and neck cancers (12.8%), stomach cancer (11.3%) and oesophageal cancer (10.2%). When compared with the ICU population without cancer, patients with solid tumours tended to be older (median age 68 years vs. 59 years, respectively), with a higher proportion of elective hospitalisations (52.7% vs. 10.0%) and were predominantly admitted to ICU with a surgical illness (89.3% vs. 55.0%). Surgical ICU admissions have a favourable ICU and hospital mortality if they have an underlying cancer diagnosis compared with surgical ICU patients without cancer (hospital mortality 22.9% vs. 28.1%, respectively). A potential explanation for this would be a higher proportion of level 2 admissions, lower utilisation of multi-organ support and an opportunity for pre-operative optimisation within the cancer group. ICU cancer patients admitted with a medical diagnosis have poorer short-term survival than those without cancer (hospital mortality 49.1% vs. 41.7%, respectively) and this difference is even more pronounced in those that received organ support (62.5% vs. 46.2%). In patients that survive an admission to ICU the presence of cancer has the largest impact upon mortality risk in the longer-term with a risk of death over three times greater than in the population of ICU survivors without cancer. Long-term survival varies considerably by underlying tumour type with four-year survival varying from 10.0% in patients with hepatocellular carcinoma to 73.3% in patients with testicular cancer. Cancer-related factors such as tumour stage have an important role in determining mortality risk in the longer term for survivors of ICU with cancer. In patients with colorectal cancer that had survived an ICU admission the risk of death after six-months was significantly higher in patients with Dukes D stage vs. Dukes A (HR 8.66). The work presented in this thesis systematically reviews and summarises the current published outcomes of patients with solid tumours admitted to ICU, demonstrates that among the solid tumour population ICU admission is common and shows that short-term outcomes vary significantly by features associated with both the critical illness and the underlying tumour type. In patients that survive an ICU admission the presence, type and stage of cancer is important for determining on-going mortality risk. This information may be used when clinicians are discussing potential outcomes following admission to critical care with cancer patients. Future studies should focus on the administration of treatments for cancer after critical illness and whether they differ from those received by those patients without an ICU admission. Prospective studies are required to describe the pre-ICU deteriorations in physiology in cancer patients with critical illness including those considered, but not admitted, to ICU. Outcomes for this latter group are unknown and given the high burden of illness severity documented in ICUs within the UK, these studies may identify a group of patients for whom critical care would be beneficial but is not currently provided

Viruses inhibit CO2 fixation in the most abundant phototrophs on Earth

R.J.P. was the recipient of a NERC studentship and Warwick University IAS fellowship. This work was supported in part by NERC grant NE/J02273X/1 and Leverhulme Trust grant RPG-2014-354 to A.D.M., D.J.E., and D.J.S.Summary. Marine picocyanobacteria of the genera Prochlorococcus and Synechococcus are the most numerous photosynthetic organisms on our planet [1, 2]. With a global population size of 3.6 × 1027 [3], they are responsible for approximately 10% of global primary production [3, 4]. Viruses that infect Prochlorococcus and Synechococcus (cyanophages) can be readily isolated from ocean waters [5–7] and frequently outnumber their cyanobacterial hosts [8]. Ultimately, cyanophage-induced lysis of infected cells results in the release of fixed carbon into the dissolved organic matter pool [9]. What is less well known is the functioning of photosynthesis during the relatively long latent periods of many cyanophages [10, 11]. Remarkably, the genomes of many cyanophage isolates contain genes involved in photosynthetic electron transport (PET) [12–18] as well as central carbon metabolism [14, 15, 19, 20], suggesting that cyanophages may play an active role in photosynthesis. However, cyanophage-encoded gene products are hypothesized to maintain or even supplement PET for energy generation while sacrificing wasteful CO2 fixation during infection [17, 18, 20]. Yet this paradigm has not been rigorously tested. Here, we measured the ability of viral-infected Synechococcus cells to fix CO2 as well as maintain PET. We compared two cyanophage isolates that share different complements of PET and central carbon metabolism genes. We demonstrate cyanophage-dependent inhibition of CO2 fixation early in the infection cycle. In contrast, PET is maintained throughout infection. Our data suggest a generalized strategy among marine cyanophages to redirect photosynthesis to support phage development, which has important implications for estimates of global primary production.Publisher PDFPeer reviewe