High mean arterial pressure target to improve sepsis-associated acute kidney injury in patients with prior hypertension: a feasibility study

Background The optimal mean arterial pressure (MAP) in cases of septic shock is still a matter of debate in patients with prior hypertension. An MAP between 75 and 85 mmHg can improve glomerular filtration rate (GFR) but its effect on tubular function is unknown. We assessed the effects of high MAP level on glomerular and tubular renal function in two intensive care units of a teaching hospital. Inclusion criteria were patients with a history of chronic hypertension and developing AKI in the first 24 h of septic shock. Data were collected during two 6 h periods of MAP regimen administered consecutively after haemodynamic stabilisation in an order depending on the patient's admission unit: a high-target period (80–85 mmHg) and a low-target period (65–70 mmHg). The primary endpoint was the creatinine clearance (CrCl) calculated from urine and serum samples at the end of each MAP period by the UV/P formula. Results 26 patients were included. Higher urine output (+0.2 (95%:0, 0.4) mL/kg/h; P = 0.04), urine sodium (+6 (95% CI 0.2, 13) mmol/L; P = 0.04) and lower serum creatinine (− 10 (95% CI − 17, − 3) µmol/L; P = 0.03) were observed during the high-MAP period as compared to the low-MAP period, resulting in a higher CrCl (+25 (95% CI 11, 39) mL/mn; P = 0.002). The urine creatinine, urine–plasma creatinine ratio, urine osmolality, fractional excretion of sodium and urea showed no significant variation. The KDIGO stage at inclusion only interacted with serum creatinine variation and low level of sodium excretion at inclusion did not interact with these results. Conclusions In the early stage of sepsis-associated AKI, a high-MAP target in patients with a history of hypertension was associated with a higher CrCl, but did not affect the kidneys' ability to concentrate urine, which may reflect no effect on tubular function.

865 Reducing Delays in Cholecystectomy Surgery of Patients Admitted with Gallstone-Related Disease Within Gold Standard Time Frame Set Out By NICE

Introduction As per NICE guidelines, Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) aims for 80% of eligible patients with gallstone-related disease to receive their cholecystectomy within 8 days of presentation1. Only 63.6% of eligible patients at East Lancashire Hospitals NHS Trust (ELHT) had their surgery within the target time. This project was done to identify the reasons behind ELHT not achieving the set target and to implement changes to overcome this. Method This was a retrospective review of a prospectively collected data of 444 patients from the ELHT Chole-QuIC database (July 2019-November 2020). Data were analysed in three periods: initial period (July 2019-November 2019), pre-COVID-19 period (December 2019-February 2020), COVID-19 period (March 2020-November 2020). Time to surgery was established. If the 8-day target was not met, reasons behind the delay were recorded. Results During the first cycle, the main reasons delays included the patients being temporarily unfit (13.8%), insufficient theatre capacity (13.8%) and variations in treatment plans (11.32%). 8% of patients had re-admissions related to their gallstone disease. Changes were implemented forward included a clear local gallstone disease management pathway and CholeQuIC referral system, increasing theatre capacity, and allocating pre-operative assessment slots. Gold standard cholecystectomy target period improved from 63.6% to 67.4% within three months of changes. However, the figure drastically reduced during the COVID-19 pandemic (36.3%) as elective surgeries were temporarily suspended. Conclusions The implementation of a gallstone disease management pathway, a coordinated referral system and additional theatre capacity contributed to the increase in cholecystectomies that were performed within the 8-day national target period.

Potential Contributors to Increased Pulmonary Embolism Hospitalizations During the COVID-19 Pandemic: Insights From the German-Wide Helios Hospital Network

Background: After the first COVID-19 infection wave, a constant increase of pulmonary embolism (PE) hospitalizations not linked with active PCR-confirmed COVID-19 was observed, but potential contributors to this observation are unclear. Therefore, we analyzed associations between changes in PE hospitalizations and (1) the incidence of non-COVID-19 pneumonia, (2) the use of computed tomography pulmonary angiography (CTPA), (3) volume depletion, and (4) preceding COVID-19 infection numbers in Germany.Methods: Claims data of Helios hospitals in Germany were used, and consecutive cases with a hospital admission between May 6 and December 15, 2020 (PE surplus period), were analyzed and compared to corresponding periods covering the same weeks in 2016–2019 (control period). We analyzed the number of PE cases in the target period with multivariable Poisson general linear mixed models (GLMM) including (a) cohorts of 2020 versus 2016–2019, (b) the number of cases with pneumonia, (c) CTPA, and (d) volume depletion and adjusted for age and sex. In order to associate the daily number of PE cases in 2020 with the number of preceding SARS-CoV-2 infections in Germany, we calculated the average number of daily infections (divided by 10,000) occurring between 14 up to 90 days with increasing window sizes before PE cases and modeled the data with Poisson regression.Results: There were 2,404 PE hospitalizations between May 6 and December 15, 2020, as opposed to 2,112–2,236 (total 8,717) in the corresponding 2016–2019 control periods (crude rate ratio [CRR] 1.10, 95% CI 1.05–1.15, P < 0.01). With the use of multivariable Poisson GLMM adjusted for age, sex, and volume depletion, PE cases were significantly associated with the number of cases with pneumonia (CRR 1.09, 95% CI 1.07–1.10, P < 0.01) and with CTPA (CRR 1.10, 95% CI 1.09–1.10, P < 0.01). The increase of PE cases in 2020 compared with the control period remained significant (CRR 1.07, 95% CI 1.02–1.12, P < 0.01) when controlling for those factors. In the 2020 cohort, the number of preceding average daily COVID-19 infections was associated with increased PE case incidence in all investigated windows, i.e., including preceding infections from 14 to 90 days. The best model (log likelihood −576) was with a window size of 4 days, i.e., average COVID-19 infections 14–17 days before PE hospitalization had a risk of 1.20 (95% CI 1.12–1.29, P < 0.01).Conclusions: There is an increase in PE cases since early May 2020 compared to corresponding periods in 2016–2019. This surplus was significant even when controlling for changes in potential modulators such as demographics, volume depletion, non-COVID-19 pneumonia, CTPA use, and preceding COVID-19 infections. Future studies are needed (1) to investigate a potential causal link for increased risk of delayed PE with preceding SARS-CoV-2 infection and (2) to define optimal screening for SARS-CoV-2 in patients presenting with pneumonia and PE.

Potential contributors to increased pulmonary embolism hospitalizations during the Covid-19 pandemic

Background: After the first Covid-19 infection wave, a constant increase of pulmonary embolism (PE) hospitalizations not linked with active PCR-confirmed Covid-19 has been observed but potential contributors to this observation are unclear. Therefore, we analyzed associations between changes in PE hospitalizations and (1) the incidence of non-Covid-19 pneumonia, (2) the use of computed tomography pulmonary angiography (CTPA), (3) volume depletion and (4) preceding Covid-19 infection numbers in Germany. Methods: Claims data of Helios hospitals in Germany were used and consecutive cases with a hospital admission between May 6 and December 15, 2020 (PE surplus period) were analyzed and compared to corresponding periods covering the same weeks in 2016–2019 (control period). We analyzed the number of PE cases in the target period with multivariable Poisson general linear mixed models (GLMM) including (a) cohorts of 2020 versus 2016–2019, (b) the number of cases with pneumonia, (c) CTPA, and (d) volume depletion and adjusted for age and sex. In order to associate the daily number of PE cases in 2020 with the number of preceding SARS-CoV-2 infections in Germany, we calculated the average number of daily infections (divided by 10,000) occurring 14 up to 90 days with increasing window sizes before PE cases and modelled the data with Poisson regression. Results: There were 2,404 PE hospitalizations between May 6 and December 15, 2020 as opposed to 2,112–2,236 (total 8,717) in the corresponding 2016–2019 control periods. (crude rate ratio [CRR] 1.10, 95% CI 1.05–1.15, P<0.01). Using multivariable Poisson GLMM adjusted for age, sex and volume depletion, PE cases were significantly associated with the number of cases with pneumonia (CRR 1.09, 95 % CI 1.07–1.10, P<0.01), and with CTPA (CRR 1.10, 95 % CI 1.09–1.10, P<0.01). The increase of PE cases in 2020 compared with the control period remained significant (CRR 1.07, 95 % CI 1.02–1.12, P<0.01) when controlling for those factors. In the 2020 cohort, number of preceding average daily Covid-19 infections were associated with increased PE case incidence in all investigated windows, i.e. including preceding infections from 14 to 90 days. The best model (log likelihood –576) was with a window size of 4 days, i.e. average Covid-19 infections 14–17 days before PE hospitalization had a risk of 1.20 (95 % CI 1.12–1.29, P<0.01). Conclusions: There is an increase in PE cases since early May 2020 compared to corresponding periods in 2016–2019. This surplus was significant even when controlling for changes in potential modulators such as demographics, volume depletion, non-Covid-19 pneumonia, CTPA use and preceding Covid-19 infections. Future studies are needed (1) to investigate a potential causal link for increased risk of delayed PE with preceding SARS-CoV-2 infection, and (2) to define optimal screening for SARS-CoV-2 in patients presenting with pneumonia and PE.

Opioid Prescriptions in Chronic Pain Rehabilitation. A Prospective Study on the Prevalence and Association between Individual Patient Characteristics and Opioids

While against recommendations, long-term opioid therapy (LTOT) for chronic pain is common. This study aimed to describe the prevalence of opioid prescriptions and to study the association of patient characteristics (demographics, pain characteristics, anxiety, depressive symptoms and pain coping) with future LTOT. The sample included N = 1334 chronic musculoskeletal pain patients, aged 18–65, who were assessed for Interdisciplinary Multimodal Pain Rehabilitation (IMMR) in Swedish specialist rehabilitation. Prescriptions were tracked across a two-year target period after assessment. In total, 9100 opioid prescriptions were prescribed to 55% of the sample (Mmedian = 6, IQR = 14). Prediction of LTOT was analyzed separately for those who did (24%) and did not (76%) receive IMMR. The odds of receiving opioids was similar for these subsamples, after controlling for differences in baseline characteristics. In both samples, there were significant associations between patient characteristics and future opioid prescriptions. Dysfunctional pain coping was a unique predictor of LTOT in those who received IMMR while pain intensity and depressive symptoms were unique predictors in those who did not receive IMMR. The results underscore that opioid treatment is common among patients in chronic pain rehabilitation and relates to pain and psychological factors. Understanding in detail why these factors relate to opioid prescription patterns is an important future study area as it is a prerequisite for better management and fundamental for preventing overuse.

Estimating the increased transmissibility of the B.1.1.7 strain over previously circulating strains in England using fractions of GISAID sequences and the distribution of serial intervals

The B.1.1.7 strain, a variant strain of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is thought to have higher transmissibility than previously circulating strains in England. The fraction of the B.1.1.7 strain among SARS-CoV-2 viruses in England have grown rapidly. In this paper, we propose a method to estimate the selective advantage of a mutant strain over previously circulating strains using the time course of the fraction of B.1.1.7 strains. Based on Wallinga-Teunis's method to estimate the instantaneous reproduction numbers, our method allows the reproduction number to change during the target period of analysis. Our approach is also based on the Maynard Smith's model of allele frequencies in adaptive evolution, which assumes that the selective advantage of a mutant strain over previously circulating strains is constant over time. Applying this method to the sequence data in England using serial intervals of COVID-19, we found that the transmissibility of the B.1.1.7 strain is 40% (with a 95% confidence interval (CI) from 40% to 41%) higher than previously circulating strains in England. The date of the emergence of B.1.1.7 strains in England was estimated to be September 20, 2020 with its 95% CI from September 11 to September 20, 2020. The result indicated that the control measure against the B.1.1.7 strain needs to be strengthened by 40% from that against previously circulating strains. To get the same control effect, contact rates between individuals need to be restricted to 0.71 of the contact rates that have been achieved form the control measure taken for previously circulating strains.

Examining the Trends of Educational Variables in the Past Affecting Egypt’s Ability to Becoming Future-Proof in Facing Unemployment

This study aims to investigate the relationship between some educational variables and unemployment in Egypt, thus determining the most important educational variables influencing the high rates of unemployment during the period (2002–2012). According to the data that were available from each source for the synthesis of time series, it could be sufficient to examine the trends in the past as a suitable retrieval case. By excluding any fluctuations such as epidemics or revolutions affecting the systems of government, the findings may be utilized in shaping the future by decision makers in Egypt in optimal manner. Thus, it can determine the priorities of the Egyptian government when dealing seriously in order to solve the unemployment problem appropriately, with regard to the reduction of unemployment rates in the near future. More importantly, the results have shown that the number of graduates of theoretical facilities has a significant impact on increasing the number of unemployed in Egypt, according to the target period by the current study. Keywords: education, unemployment, Higher Education Systems (HES), Egypt

Telehealth in Times of COVID-19: Spotlight on Austria

Introduction: With the spread of Coronavirus disease 2019 (COVID-19), the world has been experiencing an extraordinary state of emergency. As patients entering a doctor’s practice can potentially infect medical staff and other patients, using digital alternatives wherever possible is a potential solution to avoiding face-to-face encounters. In these conditions, telemedicine is becoming increasingly relevant. Hence, the aim of this study was to examine telemedicine use and gathered experiences during the COVID-19 pandemic in Austria. Materials and Methods: In June 2020, a representative group of Austrian respondents (n = 1000) was asked via online survey whether they had contacted a doctor during spring of 2020, and, if so, whether they had used a telemedical method to do so. The survey also reflected gathered experiences and degrees of satisfaction with the use of telemedicine. Results: A third (33%) of those who contacted a doctor during the target period did so using telemedical tools. The majority of those with previous telehealth experience were satisfied with the help they received. Patients commonly used a telephone to contact their doctors. The overall assessment of telemedical aids tended to be positive, with more than half (53%) of those surveyed seeing significant advantages, and a 90% satisfaction rate among the respondents who used telehealth services. Conclusion: The outcomes from this work hint at fairly high acceptance of telemedical communication tools in the studied group of the Austrian population. Based on the high rate of satisfaction among patients who used telehealth, it is expected that the use of telehealth services will increase further in the near future.

Empirical Analysis on How Financial Development Influences Low-Carbon Economic Gain Efficiency Considering the Panel Data of Yangtze River Economic Corridor

This paper establishes an evaluation metric system (EMS) for low-carbon economic gain efficiency (LCEGE) containing the carbon sink element, and measures the LCEGEs in the 11 provincial administrative regions in the Yangtze River Economic Corridor (YREC) of 2000-2017 with the directional distance function (DDF) model. Furthermore, the Tobit model was selected for the empirical analysis on the influence of financial development on LCEGE. The results show that: the provinces in YREC had certain disparities in LCEGE. Most provinces achieved desirable LCEGEs, but a few provinces failed to do so. The LCEGE in the lower part changed little in the target period, while that in the middle part and upper part varied in two phases. Besides, there are obvious differences in the mean LCEGE between the lower part, middle part, and upper part. In the target period, the three parts of the YREC can be ranked as lower part, middle part, and upper part by LCEGE. The results of Tobit model reveal that the LCEGE in the YREC can be greatly promoted by financial scale, and clearly suppressed by financial structure. Among the control variables, foreign direct investment significantly promotes LCEGE; technical innovation, and energy structure significantly suppresses LCEGE; industrial structure and environmental regulation have an insignificant influence on LCEGE.