For patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non-ECMO-referred patients.

The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care.

BackgroundDuring the first wave of pandemic H1N1 influenza in 2009, most cases outside North America occurred in the UK. The clinical characteristics of UK patients hospitalised with pandemic H1N1 infection and risk factors for severe outcome are described.MethodsA case note-based investigation was performed of patients admitted with confirmed pandemic H1N1 infection.ResultsFrom 27 April to 30 September 2009, 631 cases from 55 hospitals were investigated. 13% were admitted to a high dependency or intensive care unit and 5% died; 36% were aged <16 years and 5% were aged ≥65 years. Non-white and pregnant patients were over-represented. 45% of patients had at least one underlying condition, mainly asthma, and 13% received antiviral drugs before admission. Of 349 with documented chest x-rays on admission, 29% had evidence of pneumonia, but bacterial co-infection was uncommon. Multivariate analyses showed that physician-recorded obesity on admission and pulmonary conditions other than asthma or chronic obstructive pulmonary disease (COPD) were associated with a severe outcome, as were radiologically-confirmed pneumonia and a raised C-reactive protein (CRP) level (≥100 mg/l). 59% of all in-hospital deaths occurred in previously healthy people.ConclusionsPandemic H1N1 infection causes disease requiring hospitalisation of previously fit individuals as well as those with underlying conditions. An abnormal chest x-ray or a raised CRP level, especially in patients who are recorded as obese or who have pulmonary conditions other than asthma or COPD, indicate a potentially serious outcome. These findings support the use of pandemic vaccine in pregnant women, children <5 years of age and those with chronic lung disease.

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Mortality, although inevitable during a severe influenza outbreak or disaster, can be reduced by adequate preparation.

BackgroundAlthough generally mild, the 2009–2010 influenza A/H1N1 pandemic caused two major surges in hospital admissions in the UK. The characteristics of patients admitted during successive waves are described.MethodsData were systematically obtained on 1520 patients admitted to 75 UK hospitals between May 2009 and January 2010. Multivariable analyses identified factors predictive of severe outcome.ResultsPatients aged 5–54 years were over-represented compared with winter seasonal admissions for acute respiratory infection, as were non-white ethnic groups (first wave only). In the second wave patients were less likely to be school age than in the first wave, but their condition was more likely to be severe on presentation to hospital and they were more likely to have delayed admission. Overall, 45% had comorbid conditions, 16.5% required high dependency (level 2) or critical (level 3) care and 5.3% died. As in 1918–1919, the likelihood of severe outcome by age followed a W-shaped distribution. Pre-admission antiviral drug use decreased from 13.3% to 10% between the first and second waves (p=0.048), while antibiotic prescribing increased from 13.6% to 21.6% (p<0.001). Independent predictors of severe outcome were age 55–64 years, chronic lung disease (non-asthma, non-chronic obstructive pulmonary disease), neurological disease, recorded obesity, delayed admission (≥5 days after illness onset), pneumonia, C-reactive protein ≥100 mg/litre, and the need for supplemental oxygen or intravenous fluid replacement on admission.ConclusionsThere were demographic, ethnic and clinical differences between patients admitted with pandemic H1N1 infection and those hospitalised during seasonal influenza activity. Despite national policies favouring use of antiviral drugs, few patients received these before admission and many were given antibiotics.

a b s t r a c tThe Southern and Eastern Scalefish and Shark Fishery (SESSF) is a complex multi-species fishery, with 34 stock units under quota management, for which a harvest strategy framework was developed in 2005. The framework involves the application of a set of tier-based harvest control rules (HCR) designed to provide a precautionary approach to management. The harvest strategy framework has been applied from 2005 to 2007, resulting in substantial reductions in quotas across the fishery. The experience in implementing the framework, both positive and negative, is described, and general lessons are drawn. Key lessons include the importance of formally testing such strategies using management strategy evaluation, the impact of external management drivers on implementation of the approach, the need to define strategies for setting "bycatch quotas" in multi-species fisheries, and the need for flexibility and pragmatism in the early stages of implementing such an approach.

SummaryThe UK Influenza Pandemic Contingency Plan does not consider the impact of a pandemic on critical care services. We modelled the demand for critical care beds in England with software developed by the Centers for Disease Control (FLUSURGE 1.0), using a range of attack rates and pandemic durations. Using inputs that have been employed in UK Department of Health scenarios (25% attack rate and 8-week pandemic duration) resulted in a demand for ventilatory support that exceeded 200% of present capacity. Demand remained unsustainably high even when more favourable scenarios were considered. Current critical care bed capacity in England would be unable to cope with the increased demand provided by an influenza pandemic. Appropriate contingency planning is essential. There is general agreement regarding the increasing threat of a fresh influenza epidemic [1]. Despite public health measures, an epidemic will result in an increased number of admissions, both to hospitals and to intensive care units (ICUs). The recent Influenza Pandemic Plan from the UK Department of Health [1] addresses many aspects of an influenza pandemic, but provides no estimate of the likely impact on critical care services. We have tried to quantify the probable demands on critical care services in a UK setting by modelling the requirement for intensive care admission to ICUs in England, using a software program (FLUSURGE 1.0) developed at the Centers for Disease Control in the USA [2]. MethodsWe used FLUSURGE 1.0 [2] to calculate the impact of an influenza pandemic in England on hospital admission, occupancy of all ICU beds, and of Level 3 beds (i.e. those with facilities for mechanical ventilation). Data on population (49.97 million) and age distribution [3], acute hospital beds (109 846) [4], and intensive care bed numbers (1787) [5] were obtained from publicly available sources. We initially modelled demand based on an 8-week epidemic and a 25% attack rate, but also assessed the sensitivity of our estimates to variations in these figures. Simulations were also constructed using the assumptions that either half or all of the high dependency (or Level 2) beds (1426) [5] could be upgraded to Level 3 intensive care beds in the event of a pandemic. The age distribution bins in UK data [3] meant that we had to use the population under 19 years to provide figures for the lowest population bin in FLUSURGE 1.0 (less than 16 years) [2]. All other inputs were available without modification. We also considered the impact of neuraminidase inhibitors, which may reduce disease duration by approximately 1-2 days [6]. Their impact on disease severity is less clear, but the incidence of hospitalisation and complications requiring antibiotic therapy may be reduced by 50% [6]. ResultsThe simulation with an 8-week epidemic and 25% attack rate resulted in a peak weekly hospital admission rate of 35,738, and a peak daily hospital admission rate Anaesthesia, 2005, 60, pages 952-954