Background: For healthcare systems, an ageing population poses challenges in the delivery of equitable and effective care. Frailty assessment has the potential to improve care in the intensive care setting, but applying assessment tools in critical illness may be problematic. The aim of this systematic review was to evaluate evidence for the feasibility and reliability of frailty assessment in critical care. Methods: Our primary search was conducted in Medline, Medline In-process, EMBASE, CINAHL, PsycINFO, AMED, Cochrane Database of Systematic Reviews, and Web of Science (January 2001 to October 2017). We included observational studies reporting data on feasibility and reliability of frailty assessment in the critical care setting in patients 16 years and older. Feasibility was assessed in terms of timing of evaluation, the background, training and expertise required for assessors, and reliance upon proxy input. Reliability was assessed in terms of inter-rater reliability. Results: Data from 11 study publications are included, representing 8 study cohorts and 7761 patients. Proxy involvement in frailty assessment ranged from 58 to 100%. Feasibility data were not well-reported overall, but the exclusion rate due to lack of proxy availability ranged from 0 to 45%, the highest rate observed where family involvement was mandatory and the assessment tool relatively complex (frailty index, FI). Conventional elements of frailty phenotype (FP) assessment required modification prior to use in two studies. Clinical staff tended to use a simple judgement-based tool, the clinical frailty scale (CFS). Inter-rater reliability was reported in one study using the CFS and although a good level of agreement was observed between clinician assessments, this was a small and singlecentre study. Conclusion: Though of unproven reliability in the critically ill, CFS was the tool used most widely by critical care clinical staff. Conventional FP assessment required modification for general application in critical care, and an FIbased assessment may be difficult to deliver by the critical care team on a routine basis. There is a high reliance on proxies for frailty assessment, and the reliability of frailty assessment tools in critical care needs further evaluation. Prospero registration number: CRD42016052073.

Critical illness in COVID-19 is an extreme and clinically homogeneous disease phenotype that we have previously shown1 to be highly efficient for discovery of genetic associations2. Despite the advanced stage of illness at presentation, we have shown that host genetics in patients who are critically ill with COVID-19 can identify immunomodulatory therapies with strong beneficial effects in this group3. Here we analyse 24,202 cases of COVID-19 with critical illness comprising a combination of microarray genotype and whole-genome sequencing data from cases of critical illness in the international GenOMICC (11,440 cases) study, combined with other studies recruiting hospitalized patients with a strong focus on severe and critical disease: ISARIC4C (676 cases) and the SCOURGE consortium (5,934 cases). To put these results in the context of existing work, we conduct a meta-analysis of the new GenOMICC genome-wide association study (GWAS) results with previously published data. We find 49 genome-wide significant associations, of which 16 have not been reported previously. To investigate the therapeutic implications of these findings, we infer the structural consequences of protein-coding variants, and combine our GWAS results with gene expression data using a monocyte transcriptome-wide association study (TWAS) model, as well as gene and protein expression using Mendelian randomization. We identify potentially druggable targets in multiple systems, including inflammatory signalling (JAK1), monocyte–macrophage activation and endothelial permeability (PDE4A), immunometabolism (SLC2A5 and AK5), and host factors required for viral entry and replication (TMPRSS2 and RAB2A).

The aim of this research was to explore perceptions of doctors and nurses working in an English regional pediatric oncology unit, regarding their lived experiences and feelings relating to the concept of moral distress. This was undertaken to illuminate the understanding of team dynamics and the impact that the causes and repercussions of moral distress may have on that team. The qualitative methodology was influenced by the Heideggarian phenomenological approach and data analysis was undertaken using Colaizzi's (1978) phenomenological method for protocol analysis. Six main themes were identified expressing participants' experiences of morally distressing situations, with three warranting in depth exploration: "the importance of the decision-making processes," "conflict over right to treatment and withholding treatment," and "communication within the team." Moral distress does occur within pediatric oncology clinical settings and it has unavoidable triggers including emotional responses to difficult scenarios. The implications of this small study show benefits in sharing the decision-making process, thus enabling staff to recognize triggers more efficiently in clinical practice, enhancing communication through training and further research, collaborative education, de-briefing, and team meetings.

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Shared care service models are preferred in the management of children and young people with cancer so that specialist expertise is available when needed but children can be supported near to where they live. Care is co-ordinated by a primary treatment centre. Nurses in one centre were concerned about the poor quality of communication between their centre and the shared care hospitals where their patients were being supported. An action research approach was used to improve the process of discharging a child or young person with cancer. This involved clarifying the responsibilities of the nursing staff, mapping out a new discharge pathway, developing new forms to support the education and communication activities and sharing the results with partners in the discharge process. The project highlighted the importance of effective discharge for the child or young person with cancer and their family and the risks of not doing this correctly.