Purpose: Fluid overload is common in critical illness and is associated with mortality. This study investigated the feasibility of a randomised trial comparing conservative fluid administration and deresuscitation (active removal of accumulated fluid using diuretics or ultrafiltration) with usual care in critical illness. Methods:Open-label, parallel-group, allocation-concealed randomised clinical feasibility trial. Mechanically ventilated adult patients expected to require critical care beyond the next calendar day were enrolled between 24 and 48 h following admission to the intensive care unit (ICU). Patients were randomised to either a 2-stage fluid strategy comprising conservative fluid administration and, if fluid overload was present, active deresuscitation, or usual care. The primary endpoint was fluid balance in the 24 h up to the start of study day 3. Secondary endpoints included cumulative fluid balance, mortality, and duration of mechanical ventilation.Results: One hundred and eighty patients were randomised. After withdrawal of 1 patient, 89 patients assigned to the intervention were compared with 90 patients assigned to the usual care group. The mean plus standard deviation (SD) 24-h fluid balance up to study day 3 was lower in the intervention group (− 840 ± 1746 mL) than the usual care group (+ 130 ± 1401 mL; P < 0.01). Cumulative fluid balance was lower in the intervention group at days 3 and 5. Overall, clinical outcomes did not differ significantly between the two groups, although the point estimate for 30-day mortality favoured the usual care group [intervention arm: 19 of 90 (21.6%) versus usual care: 14 of 89 (15.6%), P = 0.32]. Baseline imbalances between groups and lack of statistical power limit interpretation of clinical outcomes. Conclusions:A strategy of conservative fluid administration and active deresuscitation is feasible, reduces fluid balance compared with usual care, and may cause benefit or harm. In view of wide variations in contemporary clinical practice, large, adequately powered trials investigating the clinical effectiveness of conservative fluid strategies in critically ill patients are warranted.

Background The BCR-ABL1 fusion gene underlying the pathogenesis of CML can arise from a variety of breakpoints. The e13a2 and e14a2 transcripts formed by breakpoints occurring around exon 13 and exon 14 of the BCR gene respectively are the most common. Methods We undertook a retrospective audit using local laboratory database and electronic patient care records of 69 CML patients with an e13a2 or e14a2 transcript type identified in our regional population. Results The e13a2 group was on average significantly younger (45.0 years v 54.5 years), had a higher average white cell count (189.8 × 10 9 /l v 92.40 × 10 9 /l) and lower platelet count (308 × 10 9 /l v 644 × 10 9 /l) in comparison to the e14a2 group suggesting that these are distinct biological entities. Over an average follow-up of 33.8 months and 27.2 months for the e13a2 and e14a2 groups we observed an inferior molecular response to imatinib in the e13a2 group. A significantly lower number of patients in the e13a2 arm met European Leukemia Net criteria for optimal response at 12 months therapy (17.64% v 50.0%) and were slower to obtain deep molecular responses MR 4 or MR 4.5 . Conclusion Patients with an e13a2 transcript demonstrate an inferior molecular response to imatinib in our regional population.

Objectives: To describe the patient demographic characteristics and organisational factors that influence length of stay (LOS) among emergency medical admissions. Also, to describe differences in investigation practice among consultant physicians and to examine the impact of these on LOS. Design: Prospective observational study. Setting: General medicine department of a teaching hospital in Belfast, UK. Participants: Data were recorded for patients who were admitted as emergencies and reviewed on the post-take ward rounds (PTWR) attended by the investigation coordinator. Outcome measures: Non-laboratory investigations requested, LOS, and diagnosis on discharge. Results: Of 830 episodes evaluated, the median LOS was 7 days (interquartile range 3-12 days); this was significantly longer for admissions on Fridays (p = 0.0011) and for patients managed on medical wards (p,0.0001). There was a positive correlation between patient age and LOS (r = 0.32, p,0.0001). Chest radiographs (p = 0.002) and echocardiography (p = 0.015) were associated with a prolonged LOS; no investigations were associated with a shortened LOS. Diagnoses of congestive heart failure, respiratory disease, and cancer were associated with a longer LOS; a diagnosis of angina was associated with a shorter LOS. Considerable variation in investigation ordering, but no difference in LOS, was observed between consultants. High use of a given medical test did not correlate with high use of other tests. Conclusion: A systematic means of dealing with the NHS resource crisis should include an improved organisational strategy as well as social care provision. A more unified approach to investigation practice should also have a sparing effect on resources. W hile several investigators have previously reported factors responsible for the increasing use of medical investigations in various settings, [1][2][3][4][5][6][7] as well as factors contributing to prolonged hospital inpatient episodes, there are few data describing the demographic characteristics, patterns of investigation, and length of stay (LOS) of patients admitted as emergencies to general medicine units in the UK. The principal objective of this study is to report these characteristics in a general medical department of a teaching hospital in Belfast, Northern Ireland. Furthermore, we aim to describe variations in the ordering of medical tests between general physicians and to identify correlations between the ordering of specific investigations and LOS. Moreover, we wished to determine, first, whether high use of a specific diagnostic procedure correlated with high use of other diagnostic procedures and, second, whether high use of such investigations influenced LOS. PATIENTS AND METHODS Data relating to emergency medical patients admitted toBelfast City Hospital between 1 June 2000 and 31 December 2000 were recorded. Belfast City Hospital, although a tertiary referral centre for various specialties, operates an alternate day acute general medical take-in serving as a secondary care centre for emerg...

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