Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital without neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)

Background The immediate management of subarachnoid hemorrhage (SAH) patients in hospitals without neurosurgical/neurointerventional facilities and their transfer to a specialized center is challenging and not well covered in existing guidelines. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance. Methods A multidisciplinary consensus panel composed by 19 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery and interventional neuroradiology) was created. A modified Delphi approach was adopted. Results A total of 14 statements have been discussed. Consensus was reached on 11 strong recommendations and 2 weak recommendations. In one case, where consensus could not be agreed upon, no recommendation could be provided. Conclusions Management of SAH in a non-specialized setting and early transfer are difficult and may have a critical impact on outcome. Clinical advice, based on multidisciplinary consensus, might be helpful. Our recommendations cover most, but not all, topics of clinical relevance.

Social inequalities in access to care at birth and neonatal mortality: an observational study

ObjectiveTo look at the association of socioeconomic status (SES) with the suitability of the maternity where children are born and its association with mortality.DesignRetrospective analysis of a prospective cohort constituted using hospital discharge databases.SettingFrancePopulationLive births in 2012–2014 in maternity hospitals in mainland France followed until discharge from the hospital.Main outcome measureUnsuitability of the maternity to newborns’ needs based on birth weight and gestational age, early transfers (within 24 hours of birth) and in-hospital mortality.Results2 149 454 births were included, among which 155 646 (7.2%) were preterm. Preterm newborns with low SES were less frequently born in level III maternities than those with high SES. They had higher odds of being born in an unsuitable maternity (OR=1.174, 95% CI 1.114 to 1.238 in the lowest SES quintile compared with the highest), and no increase in the odds of an early transfer (OR=0.966, 95% CI 0.849 to 1.099 in the lowest SES quintile compared with the highest). Overall, newborns from the lowest SES quintile had a 40% increase in their odds of dying compared with the highest (OR=1.399, 95% CI 1.235 to 1.584).ConclusionsNewborns with the lowest SES were less likely to be born in level III maternity hospitals compared with those with the highest SES, despite having higher prematurity rates. This was associated with a significantly higher mortality in newborns with the lowest SES. Strategies must be developed to increase health equity among mothers and newborns.

Management of immune thrombocytopenia during COVID-19 pandemic

Introduction. The COVID-19 pandemic has challenged health professionals and patients suffering from haematological diseases with embarrassed diagnosis, treatment, surveillance, social distancing and other constraints.Aim — addressing therapy for immune thrombocytopenia (ITP) during the COVID-19 pandemic in the light of own experience, as well as national and international professional medical community guidelines.Main findings. A standard choice in COVID-19-negative ITP patients are conventional, e.g., glucocorticosteroid (GCS) and intravenous immunoglobulin therapies. An early transfer to thrombopoietin receptor agonists (rTPO) appears optimal as reducing the infection risk in GCS withdrawal and significantly improving the stable remission rate without supportive treatment. Combined ITP–COVID-19 patients should consider a prednisolone treatment of 20 mg/day, provided an absent active bleeding. The dose may increase to 1 mg/kg/day in no response after 3–5 days. ITP patients admitted for COVID-19 should start weight‐based LMWH thromboprophylaxis upon attaining a platelet count of ≥ 30 × 109 /L. Chronic ITP patients should carry on usual treatment with standard SARS-CoV-2 preventive and social distancing measures. We exemplify three contrasting clinical cases of COVID-19-comorbid thrombocytopenia and discuss the ITP differential diagnosis and therapy. Two patients received GCSs and rTPO agonists (romiplostim, eltrombopag), while GCSs alone provided for platelet response in the third case. All patients showed a good clinical and biological response. Issues in SARS-CoV-2 vaccination are discussed.

Stability of the vaginal microbiota during pregnancy and its importance for early infant colonization

Early life microbiota has been linked to the development of chronic inflammatory diseases. It has been hypothesized that maternal vaginal microbiota is an important initial seeding source and therefore can have lifelong effects on disease risk. To understand maternal vaginal microbiota’s role in seeding the child’s microbiota and the extent of delivery mode-dependent transmission, we studied 700 mother-child dyads from the COPSAC2010 cohort.The maternal vaginal microbiota was evaluated in the third trimester and compared with the children’s fecal and airway microbiota.The vaginal samples displayed known stable community state types and only 1:6 changed over time. Only one OTU was significantly transferred to children’s fecal compartment, but an inflated number had positive transfer odds. A few taxonomic families showed early transfer enrichment to vaginally-born children, indicating vertical transfer, while half of the observed transfer effects were delivery mode independent enrichment with attenuating strength over time, indicating a common reservoir.

583 Impacting the Length of Stay of Burn Patients in the Emergency Department

Introduction Burn patients represent a challenging patient population and require early interventions. Advance Burn Life Support classes have been developed to guide first responders with assessing and treating burn patients in the pre-hospital setting. In the emergency department (ED) patients may experience hypothermia, delayed resuscitation, inadequate pain control, and delayed wound cares. Methods ED length of stay (LOS) was retrospectively reviewed for burn patient who met trauma activation criteria from 2013–2018. Patients were categorized based on ED disposition to burn stepdown, burn unit intensive care (BICU), or directly to the burn operating room (OR). Patients who died in the ED or were discharged home were excluded. In 2019, guidelines for burn activations, responses, and consults were developed to mirror the activation criteria for a Level 1 trauma institution. ED nurses and physicians were educated on burn assessment, wound care, and the new triage guidelines with emphasis on the importance of early transfer out of the ED. Results Prior to the change in burn activation guidelines, rapid transfer of burn patients out of the ED had not been emphasized. Of the 144 patients examined, ED LOS was 5.4 hours for those going to burn stepdown, 4.3 hours for BICU, and 3.7 hours for those who went directly to the burn OR. Several barriers to early transfer out of the ED were identified including lack of bed availability, lack of cleaning staff on nights and weekends, difficult lateral transfers of non-burn patients out of the Burn Unit, and a lack of education on the importance of early interventions by nursing staff. Since the implementation of the guidelines, there has been an improvement in LOS for BICU patients, but the goal of less than one hour in the ED has not yet been achieved. Conclusions Unacceptable ED LOS for burn patients were identified, triage guidelines were developed, and education was provided to staff. Guidelines and education, in conjunction with emphasizing the importance of having available beds in the Burn Unit, have led to a decrease in ED length of stay. Ongoing education and process improvement are key for rapid transfer of burn patients out of the ED. Applicability of Research to Practice Burn Centers can improve patient accounts by identifying areas that put burn patients at risk. Implementation of protocols can lead to process improvement and lead to better patient outcomes.

Inpatient TIA and stroke care in adult patients in Germany - retrospective analysis of nationwide administrative data sets of 2011 to 2017

Background Comprehensive administrative data on TIA and stroke cases and treatment modalities are fundamental for improving structural conditions and adjusting future strategies of stroke care. Methods The nationwide administrative database (German federal statistical office) was used to extract all adult inpatient TIA and stroke cases and corresponding procedural codes for the period 2011–2017. Numbers were specified according to age, sex, stroke unit (SU) and critical care treatment (ICU), early transfer, and in-hospital mortality. Findings Inpatient adult TIA/stroke cases increased from annually 102,406 / 250,199 (2011) to 106,245 / 264,208 (2017). 84% of strokes were ischemic (AIS) also having the highest relative increase most likely due to more accurate coding within the time period, 68.2% of AIS were treated on SUs. 78% of hemorrhagic strokes were intracerebral hematomas (ICH; rather than subarachnoid hemorrhages [SAH]). Hemorrhagic strokes were increasingly treated on SUs (32.6% [2011], 37.8% [2017]). 68.8% of SAH were treated on ICUs (ICH:36.3%, AIS:10.3%). Early transfer in AIS increased (2.0 to 3.1%). Hemorrhagic strokes were associated with higher in-hospital mortality (SAH:19.6%, ICH:28.2%, AIS:7.3%). Interpretation The absolute increase of strokes presumably reflects the aging society and more awareness for cerebrovascular disease. The relative increase of AIS may be attributable to an increased neurological expertise. The increasing amount of early transfers in AIS reflects new specialized treatment options. Our findings reflect the need for structural adjustments in inpatient stroke care.

How do species barriers decay? Concordance and local introgression in mosaic hybrid zones of mussels

The Mytilus complex of marine mussel species forms a mosaic of hybrid zones, found across temperate regions of the globe. This allows us to study “replicated” instances of secondary contact between closely-related species. Previous work on this complex has shown that local introgression is both widespread and highly heterogeneous, and has identified SNPs that are outliers of differentiation between lineages. Here, we developed an ancestry-informative panel of such SNPs. We then compared their frequencies in newly-sampled populations, including samples from within the hybrid zones, and parental populations at different distances from the contact. Results show that close to the hybrid zones, some outlier loci are near to fixation for the heterospecific allele, suggesting enhanced local introgression, or the local sweep of a shared ancestral allele. Conversely, genomic cline analyses, treating local parental populations as the reference, reveal a globally high concordance among loci, albeit with a few signals of asymmetric introgression. Enhanced local introgression at specific loci is consistent with the early transfer of adaptive variants after contact, possibly including asymmetric bistable variants (Dobzhansky-Muller incompatibilities), or haplotypes loaded with fewer deleterious mutations. Having escaped one barrier, however, these variants can be trapped or delayed at the next barrier, confining the introgression locally. These results shed light on the decay of species barriers during phases of contact.

Fifteen-minute consultation: Obvious and not-so-obvious mediastinal masses

ObjectivesTo present a structured approach to the management of a child with a mediastinal mass presenting to the emergency department. To raise awareness of presenting features of less-obvious mediastinal masses and to encourage consideration of mediastinal masses in differential diagnoses.MethodsReview of the relevant literature and review of London Paediatric Cancer Network supportive guidelines and subsequent description of the approach to a child presenting with features suggestive of a mediastinal mass.ConclusionsA systematic approach to history taking, clinical examination and investigation of a child presenting with a mediastinal mass will assist in the safe and timely management of children presenting when they are critically unwell. Anticipation of potential management complications and early transfer for ongoing management will improve patient outcomes and minimise morbidity.