Feasibility and Early Outcomes of Intensivist-Led Critical Care after Major Trauma in the Korean ICU

Purpose

Substantial evidence supports the benefits of an intensivist model of critical care delivery. However, currently, this mode of critical care delivery has not been widely adopted in Korea. We hypothesized that intensivist-led critical care is feasible and would improve ICU mortality after major trauma.

Materials and Methods

A trauma registry from May 2009 to April 2011 was reviewed retrospectively. We evaluated the relationship between modes of ICU care (open vs. intensivist) and in-hospital mortality following severe injury [Injury Severity Score (ISS) >15]. An intensivist-model was defined as ICU care delivered by a board-certified physician who had no other clinical responsibilities outside the ICU and who is primarily available to the critically ill or injured patients. ISS and Revised Trauma Score were used as measure of injury severity. The Trauma and Injury Severity Score methodology was used to calculate each individual patient''s probability of survival.

Results

Of the 251 patients, 57 patients were treated by an intensivist [intensivist group (IG)] while 194 patients were not [non-intensivist group (NIG)]. The ISS of IG was significantly higher than that for NIG (26.5 vs. 22.3, p=0.023). The hospital mortality rate for IG was significantly lower than that for NIG (15.8% and 27.8%, p<0.001).

Conclusion

The intensivist model of critical care is feasible, and there is room for improvement in the care of major trauma patients. Although trauma systems take time to mature, future studies are needed to evaluate the best model of critical care delivery for severely injured patients in Korea.     

Pre-hospital trauma care: A comparison of two healthcare systems

Introduction:

The management of trauma patients differs depending upon the healthcare system available.

Aim:

To compare the pre-hospital management and outcome of polytrauma patients between two countries with differing approaches to pre-hospital management.

Materials and Methods:

The Scottish trauma and audit group (STAG) and the German trauma registry (GTR) databases were used to compare the management and outcome of trauma patients in Scotland and Germany. Severely injured patients (injury severity score (ISS) > 16) were analyzed for a 3 year period (2000 to 2002). Patient demographics, pre-hospital interventions, ISS, revised trauma score (RTS), time from scene of injury to arrival to the emergency department (ED), 120 day mortality and standardized mortality ratios using TRISS methodology were compared.

Results:

There were 227 patients identified from the STAG registry and 6878 patients from the GTR registry. There was a significant difference in ISS (24.9 vs. 29.8, P = 0.001, respectively). No significant difference was observed for the RTS (P = 0.2). There was a significantly higher rate of pre-hospital interventions in the German group (P < 0.001). The mean time from an injury to arrival to the ED (73 vs. 247 minutes, P = 0.001) was longer for the Scottish patients. There was no difference for an unadjusted mortality rate between the groups, but the standardized mortality ratio was significantly greater for the Scottish population (3.8 vs. 2.2, P = 0.036).

Conclusion:

Despite variation in pre-hospital transfer times and interventions, no significant difference was demonstrated in RTS upon arrival, or for the unadjusted mortality rates.     

Epidemiology of Trauma Patients and Analysis of 268 Mortality Cases: Trends of a Single Center in Korea

Purpose

There is an increasing incidence of mortality among trauma patients; therefore, it is important to analyze the trauma epidemiology in order to prevent trauma death. The authors reviewed the trauma epidemiology retrospectively at a regional emergency center of Korea and evaluated the main factors that led to trauma-related deaths.

Materials and Methods

A total of 17007 trauma patients were registered to the trauma registry of the regional emergency center at Wonju Severance Christian Hospital in Korea from January 2010 to December 2012.

Results

The mean age of patients was 35.2 years old. The most frequent trauma mechanism was blunt injury (90.8%), as well as slip-and-fall down injury, motor vehicle accidents, and others. Aside from 142 early trauma deaths, a total of 4673 patients were admitted for further treatment. The most common major trauma sites of admitted patients were on the extremities (38.4%), followed by craniocerebral, abdominopelvis, and thorax. With deaths of 126 patients during in-hospital treatment, the overall mortality (142 early and 126 late deaths) was 5.6% for admitted patients. Ages ≥55, injury severity score ≥16, major craniocerebral injury, cardiopulmonary resuscitation at arrival, probability of survival <25% calculated from the trauma and injury severity score were independent predictors of trauma mortality in multivariate analysis.

Conclusion

The epidemiology of the trauma patients studied was found to be mainly blunt trauma. This finding is similar to previous papers in terms of demographics and mechanism. Trauma patients who have risk factors of mortality require careful management in order to prevent trauma-related deaths.     

Entrapped victims in motor vehicle collisions: characteristics and prehospital care in the city of São Paulo, Brazil

OBJECTIVE:

To examine the severity of trauma in entrapped victims and to identify risk factors for mortality and morbidity.

INTRODUCTION:

Triage and rapid assessment of trauma severity is essential to provide the needed resources during prehospital and hospital phases and for outcome prediction. It is expected that entrapped victims will have greater severity of trauma and mortality than non‐entrapped subjects.

METHODS:

A transverse, case–control, retrospective study of 1203 victims of motor vehicle collisions treated during 1 year by the prehospital service in São Paulo, Brazil was carried out. All patients were drivers, comprising 401 entrapped victims (33.3%) and 802 non‐entrapped consecutive controls (66.7%). Sex, age, mortality rates, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), corporal segments, timing of the prehospital care and resource use were compared between the groups. The results were analysed by χ², Zres, analysis of variance and Bonferroni tests.

RESULTS:

Entrapped victims were predominantly men (84.8%), aged 32±13.1 years, with immediate mortality of 10.2% and overall mortality of 11.7%. They had a probability of death at the scene 8.2 times greater than that of non‐entrapped victims. The main cause of death was hemorrhage for entrapped victims (45.2%) and trauma for non‐entrapped victims. Of the entrapped victims who survived, 18.7% had a severe GCS (OR = 10.62), 12% a severe RTS (OR = 9.78) and 23.7% were in shock (OR = 3.38). Entrapped victims were more commonly transported to advanced life support units and to tertiary hospitals.

CONCLUSION:

Entrapped victims had greater trauma severity, more blood loss and a greater mortality than respective, non‐entrapped controls.     

Epidemiology of death in the emergency department of a tertiary health centre south-south of Nigeria

Background

The emergency department (E.D) of any hospital is an important entry point of critically ill patients. The initial management of these patients is often challenging, and for valuable lives to be saved, the in fracture and manpower should be up to date.

Objective

To analyze the epidemiology of death in our Emergency Department within 72hours after admission, the death rate, and to establish any contributory factors.

Method

Demographic data, time of arrival at the ED, physical finding, the Glasgow coma scale(GCS), the injury severity score(ISS), the diagnosis, investigations done, treatment offered, the time of death and the autopsy report, were entered into a Proforma. These data was analyzed using EPI-Info statistical programme version 3.4.3 of 2007.

Results

Four thousand and eleven (4,011) patients were seen in the E.D during the period. A total of three hundred and fifty five (355) mortalities were recorded. Their ages ranged from 4–87years, with an average of 34.5years. The male: female ratio was 2.1:1. The overall mortality in the hospital during the period was 859: the E.D mortality figure representing 41.3%. Fifteen patients were brought in dead. The 355 deaths fell into two categories: trauma and non-trauma. One hundred and forty-seven (41.4%) persons died from trauma; road traffic accidents (RTAs) accounting for 118 (80.3%). Two hundred and eight (58.6%) persons died from nontrauma related causes, with chronic cardiovascular disorders been the most frequent cause of death 52[25.0]. Majority of the mortalities were between 26–50 years age range. 86.2% of the mortalities presented late, greater than 6hours after the incidence. Within the 72 hours period, only 129(36.3%) were able to do the requested tests. Out of the 355 deaths, only 4[1.1%] were autopsied. An in-hospital 72hours death rate of 8.6 was recorded.

Conclusion

Road traffic accidents and cardiovascular disorders are the common causes of emergency death in UCTH. A recorded death rate of 8.6% is high, suspected contributory factors include systemic deficiencies such as the lack of a trauma system, prehospital care; late presentation, the role of chemist operators, traditional healers, and delayed referral systems.     

Sleep Disturbance Immediately Prior to Trauma Predicts Subsequent Psychiatric Disorder

Study Objectives:

This study investigated the extent to which sleep disturbance in the period immediately prior to a traumatic event predicted development of subsequent psychiatric disorder.

Design:

Prospective design cohort study

Setting:

Four major trauma hospitals across Australia

Patients:

A total of 1033 traumatically injured patients were initially assessed during hospital admission and followed up at 3 months (898) after injury

Measures:

Lifetime psychiatric disorder was assessed in hospital with the Mini-International Neuropsychiatric Interview. Sleep disturbance in the 2 weeks prior to injury was also assessed using the Sleep Impairment Index. The prevalence of psychiatric disorder was assessed 3 months after traumatic injury.

Results:

There were 255 (28%) patients with a psychiatric disorder at 3 months. Patients who displayed sleep disturbance prior to the injury were more likely to develop a psychiatric disorder at 3 months (odds ratio: 2.44, 95% CI: 1.62–3.69). In terms of patients who had never experienced a prior disorder (n = 324), 96 patients (30%) had a psychiatric disorder at 3 months, and these patients were more likely to develop disorder if they displayed prior sleep disturbance (odds ratio: 3.16, 95% CI: 1.59–4.75).

Conclusions:

These findings provide evidence that sleep disturbance prior to a traumatic event is a risk factor for development of posttraumatic psychiatric disorder.

Citation:

Bryant RA; Creamer M; O''Donnell M; Silove D; McFarlane AC. Sleep disturbance immediately prior to trauma predicts subsequent psychiatric disorder. SLEEP 2010;33(1):69-74.     

Impact of glycemic control on the incidence of acute kidney injury in critically ill patients: a comparison of two strategies using the RIFLE criteria

OBJECTIVE:

To compare the renal outcome in patients submitted to two different regimens of glycemic control, using the RIFLE criteria to define acute kidney injury.

INTRODUCTION:

The impact of intensive insulin therapy on renal function outcome is controversial. The lack of a criterion for AKI definition may play a role on that.

METHODS:

Included as the subjects were 228 randomly selected, critically ill patients engaged in intensive insulin therapy or in a carbohydrate-restrictive strategy. Renal outcome was evaluated through the comparison of the last RIFLE score obtained during the ICU stay and the RIFLE score at admission; the outcome was classified as favorable, stable or unfavorable.

RESULTS:

The two groups were comparable regarding demographic data. AKI developed in 52% of the patients and was associated with a higher mortality (39.4%) compared with those who did not have AKI (8.2%) (p<0.001). Renal function outcome was comparable between the two groups (p = 0.37). We observed a significant correlation between blood glucose levels and the incidence of acute kidney injury (p = 0.007). In the multivariate logistic regression analysis, only APACHE III scores higher than 60 were identified as an independent risk factor for unfavorable renal outcome. APACHE III scores>60, acute kidney injury and hypoglycemia were risk factors for mortality.

CONCLUSION:

Intensive insulin therapy and a carbohydrate-restrictive strategy were comparable regarding the incidence of acute kidney injury evaluated using RIFLE criteria.     

A retrospective evaluation of critically ill patients infected with H1N1 influenza A virus in Bursa,Turkey, during the 2009–2010 pandemic

Background

H1N1 influenza A virus infections were first reported in April 2009 and spread rapidly, resulting in mortality worldwide. The aim of this study was to evaluate patients with H1N1 infection treated in the intensive care unit (ICU) in Bursa, Turkey.

Methods

Demographic characteristics, clinical features, and outcome relating to H1N1 infection were retrospectively analysed in patients treated in the ICU.

Results

Twenty-three cases of H1N1 infection were treated in the ICU. The mean age of patients was 37 years range: (17–82). Fifteen patients were female (65.2%). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 19 range: (5–39). The most common symptoms were dyspnea (73.9%), fever (69.6%), and cough (60.9%). Mechanical ventilation was required for all patients. Oseltamivir and antibiotics were administered to all patients. Six (26.1%) patients died. APACHE II scores were higher in the deceased 28.5 range: [16–39] vs. 14 range: [5–28] in survivors; p = 0.013).

Conclusion

When compared to the literature, the demographic, epidemiological, and clinical characteristics were similar in the cases we encountered. The mortality rate was high despite the use of appropriate treatment. We believe that the high mortality is related to higher APACHE II scores. The H1N1 virus should be considered in community acquired pneumonia, especially in younger patients presenting with severe pneumonia.     

Validation of the Simplified Acute Physiology Score 3 scoring system in a Korean intensive care unit

Purpose

The Simplified Acute Physiology Score (SAPS) 3 was recently proposed to reflect contemporary changes in intensive care practices. SAPS 3 features customized equations for the prediction of mortality in different geographic regions. However, the usefulness of SAPS 3 and its customized equation (Australasia SAPS 3) have never been externally validated in Korea. This study was designed to validate SAPS 3 and Australasia SAPS 3 for mortality prediction in Korea.

Materials and Methods

A retrospective analysis of the prospective intensive care unit (ICU) registry was conducted in the medical ICU of Samsung Medical Center. Calibration and discrimination were determined by the Hosmer-Lemeshow test and area under the receiver operating characteristic (aROC) curve from 633 patients.

Results

The mortalities (%) predicted by SAPS 3, Australasia SAPS 3, and SAPS II were 42 ± 28, 39 ± 27 and 37 ± 31, respectively. The calibration of SAPS II was poor (p = 0.003). SAPS 3 and Australasia SAPS 3 were appropriate (p > 0.05). The discriminative power of all models yielded aROC values less than 0.8.

Conclusion

In Korea, mortality rates predicted using general SAPS 3 and Australasia SAPS 3 exhibited good calibration and modest discrimination. However, Australasia SAPS 3 did not improve the mortality prediction. To better predict mortality in Korean ICUs, a new equation may be needed specifically for Korea.     

Demographic profile and epidemiology of injury in Mthatha,South Africa

Objective

To determine the magnitude, socio-demographic and epidemiological characteristics of injury at a Provincial referral hospital.

Methods

This review was conducted on all trauma patients admitted at the Mthatha Hospital Complex and Nelson Mandela Academic Hospital from the 1^st January 1997 to the 31^st December 2000.

Results

The incident rate of injuries was 3.2% (n=2460/75,833 total admissions). Injured patients were mostly black (80%) and males (ratio: 5 men: 1 woman). Only 8.1% of injured patients were transported to hospital by ambulances. The leading causes of injuries were inter-personal violence accounting for 60% of cases, and motor vehicle accidents accounting for 19%; of them 38% were due to poor visibility, over speeding, and fatigue. The overall mortality was 33% (n=821) independently predicted by poverty (OR=8.2 95%CI 6–11.1; P<0.0001) and age>40 years(OR=7.8 95%CI 7.7–12.1;P<0.0001).

Conclusion

The burden of injury is a mass issue that warrants regional attention with quality of care and training.     

Case-fatality of adult tetanus at Jimma University Teaching Hospital, Southwest Ethiopia

Background

Tetanus remains a major health problem in Ethiopia like in most other developing countries.

Objectives

To assess the clinical presentation, complications and outcome of tetanus patients.

Methods

In this retrospective study, patients (age > 13 years) who were admitted to Jimma University Teaching Hospital from 1996 to 2009 were included.

Results

Data from 171 patients were analyzed (129 males, 42 females, mean age 33 years). The mean hospital stay for patients discharged cured and deceased was 21.5±12 and 6.5±6.7 days, respectively. None of our patients was immunized for tetanus. Tracheostomy and mechanical ventilation (MV) was done in 10.5% and 11 %, respectively. The case-fatality was 38%. The mean annual admission and case-fatality increased over the study period from 9 to 20.5 and from 21 % to 51%, respectively. Establishment of intensive care unit (ICU) did not improve mortality due to infrequent tracheostomy and MV.

Conclusions

The case-fatality was high like in most other studies and the majority of patients died in the first few days indicating that adequate respiratory support was not given. Establishment of ICU did not improve mortality. Tetanus can be prevented by vaccination and if it occurs it needs well equipped ICU.     

Causes of injuries resulting in a visit to the emergency department of a Provincial General Hospital, Nyanza, western Kenya

Background

There is increasing importance of trauma not only as a major cause of surgical admissions, but also a significant cause of morbidity, mortality and disability.

Objective

To document injury-related visits and hospitalization in a provincial hospital, western Kenya.

Methods

On-site review of records of all patients who visited emergency department (ED) from January 2002 through December 2003, and admissions of year 2003.

Results

A total of 15365 patients visited the ED, of which 41% (6319/15395) were injury cases. The leading causes of injury were assault (42%), road traffic crashes (RTC) (28%), unspecified soft tissue injury (STI) (11%). Cut-wounds, dog-bites, falls, burns and poisoning were infrequently reported (each <10%). The age group 15–44 years formed the largest proportion (75%). A total of 3253 patients were admitted in 2003, of which 1010 (31%) were due to injuries. RTC were leading cause of hospitalization (49%) followed by assault (16%). Men were more likely to be hospitalized due to assault (OR=2.22; CI = 1.45 – 3.41) and not burns or poisoning (p<0.01). There were 64 (6.3%) injury-related deaths, mainly resulting from RTC (41.9%), burns (19.4%) and assault (16.1%).

Conclusions

This study provides considerable information on major causes of injuries, useful for epidemiological surveillance and injury prevention campaigns.     

Delirium in Hospitalized Elderly Patients and Post-Discharge Mortality

OBJECTIVE:

To determine the impact of delirium on post-discharge mortality in hospitalized older patients.

INTRODUCTION:

Delirium is frequent in hospitalized older patients and correlates with high hospital mortality. There are only a few studies about its impact on post-discharge mortality.

METHODS:

This is a prospective study of patients over 60 years old who were hospitalized in the Geriatric Unit at Hospital das Clínicas of São Paulo between May 2006 and March 2007. Upon admission, demographics, comorbidities, number of drugs taken, and serum albumin concentration were evaluated for each patient. Delirium was diagnosed according to the DSM-IV criteria. Patients were divided into group A (with delirium) and group B (without delirium). One year after discharge, the patients or their caregivers were contacted to assess days of survival.

RESULTS:

The sample included 199 patients, 66 (33%) of whom developed delirium (Group A). After one year, 33 (50%) group A patients had died, and 45 (33.8%) group B patients had died (p = 0.03). There was a significant statistical difference in average age (p = 0.001) and immobility (p <0.001) between groups A and B. There were no statistically significant differences between groups A and B in number of drugs taken greater than four (p = 0.62), sex (p = 0.54) and number of diagnoses greater than four (p = 0.21). According to a multivariate analysis, delirium was not an independent predictor of post-discharge mortality. The predictors of post-discharge mortality were age ≥ 80 years (p = 0.029), albumin concentration < 3.5 g/dl (p = 0.001) and immobility (p = 0.007).

CONCLUSION:

Delirium is associated with higher post-discharge mortality as a dependent predictor.     

Mechanical ventilation in patients in the intensive care unit of a general university hospital in southern Brazil: an epidemiological study

OBJECTIVES:

To determine the characteristics, the frequency and the mortality rates of patients needing mechanical ventilation and to identify the risk factors associated with mortality in the intensive care unit (ICU) of a general university hospital in southern Brazil.

METHOD:

Prospective cohort study in patients admitted to the ICU who needed mechanical ventilation for at least 24 hours between March 2004 and April 2007.

RESULTS:

A total of 1,115 patients admitted to the ICU needed mechanical ventilation. The mortality rate was 51%. The mean age (± standard deviation) was 57±18 years, and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 22.6±8.3. The variables independently associated with mortality were (i) conditions present at the beginning of mechanical ventilation, age (hazard ratio: 1.01; p<0.001); the APACHE II score (hazard ratio: 1.01; p<0.005); acute lung injury/acute respiratory distress syndrome (hazard ratio: 1.38; p=0.009), sepsis (hazard ratio: 1.33; p=0.003), chronic obstructive pulmonary disease (hazard ratio: 0.58; p=0.042), and pneumonia (hazard ratio: 0.78; p=0.013) as causes of mechanical ventilation; and renal (hazard ratio: 1.29; p=0.011) and neurological (hazard ratio: 1.25; p=0.024) failure, and (ii) conditions occurring during the course of mechanical ventilation, acute lung injuri/acute respiratory distress syndrome (hazard ratio: 1.31; p<0.010); sepsis (hazard ratio: 1.53; p<0.001); and renal (hazard ratio: 1.75; p<0.001), cardiovascular (hazard ratio: 1.32; p≤0.009), and hepatic (hazard ratio: 1.67; p≤0.001) failure.

CONCLUSIONS:

This large cohort study provides a comprehensive profile of mechanical ventilation patients in South America. The mortality rate of patients who required mechanical ventilation was higher, which may have been related to the severity of illness of the patients admitted to our ICU. Risk factors for hospital mortality included conditions present at the start of mechanical ventilation conditions that occurred during mechanical support.     

Prognostic performance of the Simplified Acute Physiology Score II in major Croatian hospitals: a prospective multicenter study

Aim

To perform an external validation of the original Simplified Acute Physiology Score II (SAPS II) system and to assess its performance in a selected group of patients in major Croatian hospitals.

Methods

A prospective, multicenter study was conducted in five university hospitals and one general hospital during a six-month period between November 1, 2007 and May 1, 2008. Standardized hospital mortality ratio (SMR) was calculated from the mean predicted mortality of all the 2756 patients and the actual mortality for the same group of patients. The validation of SAPS II was made using the area under receiver operating characteristic curve (AUC), 2 × 2 classification tables, and Hosmer-Lemeshow tests.

Results

The predicted mortality was as low as 14.6% due to a small proportion of medical patients and the SMR being 0.89 (95% confidence interval [CI], 0.78-0.98). The SAPS II system demonstrated a good discriminatory power as measured by the AUC (0.85; standard error [SE] = 0.012; 95% CI = 0.840-0.866; P < 0.001). This system significantly overestimated the actual mortality (Hosmer-Lemeshow goodness-of-fit H statistic: χ² = 584.4; P < 0.001 and C statistics: χ²₈ = 313.0; P < 0.001) in the group of patients included in the study.

Conclusion

The SAPS II had a good discrimination, but it significantly overestimated the observed mortality in comparison with the predicted mortality in this group of patients in Croatia. Therefore, caution is required when an evaluation is performed at the individual level.In the recent decades, scoring systems for assessing the severity of disease on admission to intensive care units (ICU) have been used for performance evaluation in different ICUs in different countries. The comparison is based on the calculation of the standardized mortality ratio (SMR) from the mean value of all predicted mortalities and the observed mortality in the same group of patients (1). The SMR calculation method is widely used for a comparison of ICUs that are specialized for the treatment of very different patients with regard to their age, comorbidities, and current condition (the reason for admission and disorder of physiological variables) (2).One of the most frequently used disease-severity scoring systems, created by Le Gall et al (3) in 1993, is the second version of the Simplified Acute Physiology Score (SAPS II). The SAPS II was developed on the basis of a large number of patients as an upgrade of the first version created by the same authors in 1984 (3,4). As opposed to the SAPS I, the SAPS II resulted from the selection and weighing of each variable by logistic regression. The SAPS II total score is the sum of scores of the worst value for each variable within the first 24 hours after ICU admission. The score is then converted into the probability of dying, that is, predicted mortality, by using the model equation.The SAPS II has been validated in different populations of ICU patients in different countries. Research on the topic was first performed in the Western countries, and the reported SMRs ranged between 0.7 and 1.2 (5-17). Subsequent studies were mostly performed in single institutions in non-Western countries and reported poorer SMR results (somewhere, SMR were >1.5) (18-22). To the best of our knowledge, only two multicenter studies from non-Western countries have been published, and none from the countries in Eastern Europe (23,24).The primary aim of the study was to perform an external validation of the SAPS II system in a group of the ICU patients treated in the major hospitals in Croatia. In addition, this study aimed to determine the actual severity of disease on ICU admission, before the Diagnosis Related Groups system is introduced in Croatia, which will require SAPS II score assessment on ICU admission.     

Validity of British Thoracic Society guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis

Background

The CRB-65 score is a clinical prediction rule that grades the severity of community-acquired pneumonia in terms of 30-day mortality.

Aim

The study sought to validate CRB-65 and assess its clinical value in community and hospital settings.

Design of study

Systematic review and meta-analysis of validation studies of CRB-65.

Method

Medline (1966 to June 2009), Embase (1988 to November 2008), British Nursing Index (BNI) and PsychINFO were searched, using a diagnostic accuracy search filter combined with subject-specific terms. The derived (index) rule was used as a predictive model and applied to all validation studies. Comparison was made between the observed and predicted number of deaths stratified by risk group (low, intermediate, and high) and setting of care (community or hospital). Pooled results are presented as risk ratios (RRs) in terms of over-prediction (RR>1) or under-prediction (RR<1) of 30-day mortality.

Results

Fourteen validation studies totalling 397 875 patients are included. CRB-65 performs well in hospitalised patients, particularly in those classified as intermediate (RR 0.91, 95% confidence interval [CI] = 0.71 to 1.17) or high risk (RR 1.01, 95% CI = 0.87 to 1.16). In community settings, CRB-65 over-predicts the probability of 30-day mortality across all strata of predicted risk, low (RR 9.41, 95% CI = 1.75 to 50.66), intermediate (RR 4.84, 95% CI = 2.61 to 8.69), and high (RR 1.58, 95% CI = 0.59 to 4.19).

Conclusion

CRB-65 performs well in stratifying severity of pneumonia and resultant 30-day mortality in hospital settings. In community settings, CRB-65 appears to over-predict the probability of 30-day mortality across all strata of predicted risk. Caution is needed when applying CRB-65 to patients in general practice.     

The assessment of routine electroencephalography in patients with altered mental status

Purpose

Changes in electroencephalography (EEG) patterns may offer a clue to the cause of altered mental status and suggest the prognoses of patients with such mental status. We aimed to identify the EEG patterns in patients with altered mental status and to correlate EEG findings with clinical prognoses.

Materials and Methods

We included 105 patients with altered mental status who underwent EEG. EEG and clinical chart reviews with ongoing patient follow-ups were performed to determine the clinical prognosis of the patients. Clinical data were sorted using the Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS). EEG findings were classified according to a method suggested by Scollo-Lavizzari. The EEGs were analyzed to find out whether any correlation existed with the prognoses of patients.

Results

Nonconvulsive status epilepticus (NCSE) was detected in only three patients (2.9%). Specific EEG patterns were observed in 28 patients. Twenty-nine (27.6%) patients expired, and 45 (42.9%) patients were in a vegetative state. EEG grade and GCS significantly correlated with GOS. EEG grade alone had a correlation with GCS. Patients with a severe EEG finding had a poor prognosis.

Conclusion

EEG findings reflect the mental status of patients, and EEG grades are correlated with the clinical prognosis of patients. Although EEG is not frequently performed on patients with altered mental state, it can play a supplemental role in establishing a prognosis. Thus, the use of EEG should be emphasized in clinical setting.     

Relationship between climate conditions and nosocomial infection rates

Background

Nosocomial infections constitute a global health problem.

Objectives

To explore the relationship between nosocomial infection rates (NIRs) and climatic factors including temperature and relative humidity in Guangzhou area of China.

Methods

30892 patients in our hospital in 2009 were investigated for nosocomial infection status, and the contemporaneous temperature and relative humidity were analyzed statistically. NIRs increased with relative humidity and temperature in central ICU and geriatric department.

Results

No statistical differences were found between each quarter of 2009 in the distribution of nosocomial infection sites. There were no statistical differences in the pathogenic species of nosocomial infections between high-temperature and low-temperature months in different departments. NIRs had a correlation with temperature and relative humidity in geriatric department and central ICU.

Conclusions

To decrease NIRs and improve health care quality, it is necessary to strengthen the control of temperature and humidity especially for geriatric department and central ICU.     

Value of sonography combined with clinical assessment to evaluate muscle injury severity in athletes

Context:

Predicting when an athlete can return to sport after muscle injury is a major concern.

Objective:

To determine whether combining objective clinical and ultrasound findings at presentation accurately predicted time to sport resumption in athletes with muscle injuries.

Design:

Cohort study.

Setting:

Sports medicine clinic.

Patients or Other Participants:

A total of 93 consecutive patients, 87 male and 6 female, were seen over a 1-year period for sudden-onset muscle pain while engaging in a sporting activity within the last 5 days and inability to continue the training session or game.

Intervention(s):

Standardized physical examination and sonogram.

Main Outcome Measure(s):

Statistical associations between clinical and sonographic features at presentation and time to sport resumption (<40 days or ≥40 days) were evaluated using multivariate models. Correlations between time to sport resumption predicted by a sports medicine specialist and actual time to sport resumption were evaluated using the Spearman rank correlation coefficient.

Results:

The 93 patients had 95 injuries, caused by muscle contraction in 86 cases and impact in 9 cases. Only 7 injuries had normal sonogram findings. Late sport resumption was associated with 4 clinical criteria (bruising, tenderness to palpation, range-of-motion limitation compared with the other limb, and increased pain with isometric contraction during passive limb straightening) and 4 sonographic criteria (disorganized fibrous tissue, intramuscular hematoma, intermuscular hematoma, and power Doppler signal). The Spearman rank correlation coefficient between predicted and actual times was 0.669 (P < .0001) for mild exercise resumption and 0.804 (P < .0001) for full sport resumption.

Conclusion:

A combination of physical and sonographic data collected during the acute phase of sport-related muscle injury was effective in predicting time to sport resumption.     

Recombinant factor VIIa is associated with an improved 24-hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients

OBJECTIVE:

To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications.

INTRODUCTION:

Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use.

METHODS:

Consecutive massively transfused (≥ 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24‐hour and in‐hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24‐hour and in‐hospital survival.

RESULTS:

Three‐hundred and twenty‐eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non‐rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24‐hour survival (odds ratio (OR) =  2.65; confidence interval 1.26–5.59; p = 0.01) but not of in‐hospital survival (OR = 1.63; confidence interval 0.79–3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events.

CONCLUSIONS:

Despite being associated with improved 24‐hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients.