ASB clinical biomechanics award winner 2016: Assessment of gaze stability within 24–48 hours post-concussion

BackgroundApproximately 90% of athletes with concussion experience a certain degree of visual system dysfunction immediately post-concussion. Of these abnormalities, gaze stability deficits are denoted as among the most common. Little research quantitatively explores these variables post-concussion. As such, the purpose of this study was to investigate and compare gaze stability between a control group of healthy non-injured athletes and a group of athletes with concussions 24–48 hours post-injury.MethodsTen collegiate NCAA Division I athletes with concussions and ten healthy control collegiate athletes completed two trials of a sport-like antisaccade postural control task, the Wii Fit Soccer Heading Game. During play all participants were instructed to minimize gaze deviations away from a central fixed area. Athletes with concussions were assessed within 24–48 post-concussion while healthy control data were collected during pre-season athletic screening. Raw ocular point of gaze coordinates were tracked with a monocular eye tracking device (240 Hz) and motion capture during the postural task to determine the instantaneous gaze coordinates. This data was exported and analyzed using a custom algorithm. Independent t-tests analyzed gaze resultant distance, prosaccade errors, mean vertical velocity, and mean horizontal velocity.FindingsAthletes with concussions had significantly greater gaze resultant distance (p = 0.006), prosaccade errors (p < 0.001), and horizontal velocity (p = 0.029) when compared to healthy controls.InterpretationThese data suggest that athletes with concussions had less control of gaze during play of the Wii Fit Soccer Heading Game. This could indicate a gaze stability deficit via potentially reduced cortical inhibition that is present within 24–48 hours post-concussion.     

Characteristics of very elderly patients in the emergency department – A retrospective analysis

IntroductionElderly people, defined by age 65 years and older, made up 18.45% of the Swiss Population in 2018 and their number is projected to rise continuously. Data investigating specific characteristics of this patient subgroup, especially in the emergency setting, is scarce.MethodsDemographic data of admission records from all patients aged 65 years or older admitted to our emergency department (ED) between January 1st 2015 and December 31st 2018 were investigated. Retrospective chart reviews of patients admitted in 2018 were conducted. Comorbidity burden was assessed by Charlson Comorbidity Index. Risk factors for death, longer hospitalization and placement in a nursing facility were identified by multivariate regression.ResultsThe prevalence of elderly patients (≥65 years) admitted to the ED between 2015 and 2018 was rising from 33% in 2015 to 37.8% in 2018. In 2018 709 patients were 90 years and older (3.6%).Age above 90 years and high comorbidity burden were identified as independent risk factors for death. Polypharmacy, hyponatremia and high comorbidity burden were independent risk factors for longer hospitalizations. Advanced age and high comorbidity burden were independent risk factors for placement in a nursing facility.ConclusionThe number of elderly patients admitted to our ED is continuously rising. There was no difference in overall disease burden, number of medications and hospital length of stay between octogenarians and nonagenarians. We identified risk factors for mortality, long hospitalizations and need of placement in a nursing facility.     

Endostatin predicts mortality in patients with acute dyspnea – A cohort study of patients seeking care in emergency departments

BackgroundIncreased levels of circulating endostatin predicts cardiovascular morbidity and impaired kidney function in the general population. The utility of endostatin as a risk marker for mortality in the emergency department (ED) has not been reported.AimOur main aim was to study the association between plasma endostatin and 90-day mortality in an unselected cohort of patients admitted to the ED for acute dyspnea.DesignCirculating endostatin was analyzed in plasma from 1710 adults and related to 90-day mortality in Cox proportional hazard models adjusted for age, sex, body mass index, oxygen saturation, respiratory rate, body temperature, C-reactive protein, lactate, creatinine and medical priority according to the Medical Emergency Triage and Treatment System–Adult score (METTS-A). The predictive value of endostatin for mortality was evaluated with receiver operating characteristic (ROC) analysis and compared with the clinical triage scoring system and age.ResultsEach one standard deviation increment of endostatin was associated with a HR of 2.12 (95% CI 1.31–3.44 p < 0.01) for 90-day mortality after full adjustment. Levels of endostatin were significantly increased in the group of patients with highest METTS-A (p < 0.001). When tested for the outcome 90-day mortality, the area under the ROC curve (AUC) was 0.616 for METTS-A, 0.701 for endostatin, 0.708 for METTS -A and age and 0.738 for METTS-A, age and levels of endostatin.ConclusionsIn an unselected cohort of patients admitted to the ED with acute dyspnea, endostatin had a string association to 90-day mortality and improved prediction of 90-day mortality in the ED beyond the clinical triage scoring system and age with 3%.     

Can mortality rates for patients who die within the emergency department,within 30 days of discharge from the emergency department,or within 30 days of admission from the emergency department be easily measured?

Objectives

Death rates are an outcome that can be used to describe a service. We measured three death rates that can be used to describe an emergency department (ED): death rates for those seen in the ED and discharged, those that die within the ED, and those that die after admission. We also wanted to establish how easy it was to obtain these rates and how frequently autopsy was performed.

Setting

ED within a large teaching hospital.

Results

Between 1 December 2003 and 1 December 2004, 76 060 patients attended the ED of which 205 died within the department. A total of 16 489 were admitted of which 876 died within 30 days. A total of 59 366 were discharged home of which 111 subsequently died over the next 30 days. The rates were 0.19% (111/59 366) for those discharged, 4.6% (766/16 489) for those admitted, and 0.27% (205/76 060) for those patients attending the ED who died within it. The autopsy rate was low (20%) and was more likely if the patient died in the department, died within the first few days of admission, or was young. The data were easy to collect.

Conclusions

These three death rates were easy to calculate and could be used to describe the outcome of an ED service. Further research to establish the range of rates for different departments is now required to determine their potential use.     

End-of-life decisions in the Intensive Care Unit (ICU) – Exploring the experiences of ICU nurses and doctors – A critical literature review

BackgroundEnd-of-life decision making in the Intensive Care Unit (ICU), can be emotionally challenging and multifaceted. Doctors and nurses are sometimes placed in a precarious position where they are required to make decisions for patients who may be unable to participate in the decision-making process. There is an increasing frequency of the need for such decisions to be made in ICU, with studies reporting that most ICU deaths are heralded by a decision to withdraw or withhold life-sustaining treatment.ObjectivesThe purpose of this paper is to critically review the literature related to end-of-life decision making among ICU doctors and nurses and focuses on three areas: (1) Who is involved in end-of-life decisions in the ICU?; (2) What challenges are encountered by ICU doctors and nurses when making decisions?; and (3) Are these decisions a source of moral distress for ICU doctors and nurses?Review methodThis review considered both qualitative and quantitative research conducted from January 2006 to March 2014 that report on the experiences of ICU doctors and nurses in end-of-life decision making. Studies with a focus on paediatrics, family/relatives perspectives, advance care directives and euthanasia were excluded. A total of 12 papers were identified for review.ResultsThere were differences reported in the decision making process and collaboration between doctors and nurses (which depended on physician preference or seniority of nurses), with overall accountability assigned to the physician. Role ambiguity, communication issues, indecision on futility of treatment, and the initiation of end-of-life discussions were some of the greatest challenges. The impact of these decisions included decreased job satisfaction, emotional and psychological ‘burnout’.ConclusionsFurther research is warranted to address the need for a more comprehensive, standardised approach to support clinicians (medical and nursing) in end-of-life decision making in the ICU.     

A prospective study on adrenal cortex responses and outcome prediction in acute critical illness: results from a large cohort of 203 mixed ICU patients

Objective To assess whether adrenal cortex hormones predict ICU mortality in acute, mixed, critically ill patients. Design and setting Prospective study in consecutive intensive care patients in the general ICU of a teaching hospital. Patients 203 severely ill patients with multiple trauma (n = 93), medical (n = 57), or surgical (n = 53) critical states. Measurements and results Within 24 h of admission in the ICU a morning blood sample was obtained to measure baseline cortisol, corticotropin (ACTH), and dehydropiandrosterone sulfate (DHEAS). Subsequently a low-dose (1 μg) ACTH test was performed to determine stimulated cortisol. The incremental rise in cortisol was defined as stimulated minus baseline cortisol. Overall, 149 patients survived and 54 died. Nonsurvivors were older and in a more severe critical state, as reflected by higher SOFA and APACHE II scores. Nonsurvivors had a lower incremental rise in cortisol (5.0 vs. 8.3 μg/dl and lower DHEAS (1065 vs. 1642 ng/ml) than survivors. The two groups had similar baseline and stimulated cortisol. Multivariate logistic regression analysis revealed that age (odds ratio 1.02), SOFA score (1.36), and the incremental rise in cortisol (0.88) were independent predictors for poor outcome. Conclusions In general ICU patients a blunted cortisol response to ACTH within 24 h of admission is an independent predictor for poor outcome. In contrast, baseline cortisol or adrenal androgens are not of prognostic significance.     

Fluid management in patients with acute kidney injury – A post-hoc analysis of the FINNAKI study

PurposeWhether positive fluid balance among patients with acute kidney injury (AKI) stems from decreased urine output, overzealous fluid administration, or both is poorly characterized.Materials and methodsThis was a post hoc analysis of the prospective multicenter observational Finnish Acute Kidney Injury study including 824 AKI and 1162 non-AKI critically ill patients.ResultsWe matched 616 AKI (diagnosed during the three first intensive care unit (ICU) days) and non-AKI patients using propensity score. During the three first ICU days, AKI patients received median [IQR] of 11.4 L [8.0–15.2]L fluids and non-AKI patients 10.2 L [7.5–13.7]L, p < 0.001 while the fluid output among AKI patients was 4.7 L [3.0–7.2]L and among non-AKI patients 5.8 L [4.1–8.0]L, p < 0.001. In AKI patients, the median [IQR] cumulative fluid balance was 2.5 L [−0.2–6.0]L compared to 0.9 L [−1.4–3.6]L among non-AKI patients, p < 0.001. Among the 824 AKI patients, smaller volumes of fluid input with a multivariable OR of 0.90 (0.88–0.93) and better fluid output (multivariable OR 1.12 (1.07–1.18)) associated with enhanced change of resolution of AKI.ConclusionsAKI patients received more fluids albeit having lower fluid output compared to matched critically ill non-AKI patients. Smaller volumes of fluid input and higher fluid output were associated with better AKI recovery.     

Review: Can we identify how programmes aimed at promoting self‐management in musculoskeletal pain work and who benefits? A systematic review of sub‐group analysis within RCTs

Background: There are now several systematic reviews of RCTs testing self‐management for those with chronic musculoskeletal pain. Evidence for the effectiveness of self‐management interventions in chronic musculoskeletal pain is equivocal and it is not clear for which sub‐groups of patients SM is optimally effective. Aims: To systematically review randomized controlled trials of self‐management for chronic musculoskeletal pain that reported predictors, i.e., ‘baseline factors that predict outcome independent of any treatment effect’; moderators, i.e., ‘baseline factors which predict benefit from a particular treatment’; or mediators i.e., ‘factors measured during treatment that impact on outcome’ of outcome. Method: We searched relevant electronic databases. We assessed the evidence according to the methodological strengths of the studies. We did meta‐regression analyses for age and gender, as potential moderators. Results: Although the methodological quality of primary trials was good, there were few relevant studies; most were compromised by lack of power for moderator and mediator analyses. We found strong evidence that self‐efficacy and depression at baseline predict outcome and strong evidence that pain catastrophizing and physical activity can mediate outcome from self‐management. There was insufficient data on moderators of treatment. Conclusions: The current evidence suggests four factors that relate to outcome as predictors/mediators, but there is no evidence for effect moderators. Future studies of mediation and moderation should be designed with ‘a priori’ hypotheses and adequate statistical power.     

Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs

Background

There are now several systematic reviews of RCTs testing self-management for those with chronic musculoskeletal pain. Evidence for the effectiveness of self-management interventions in chronic musculoskeletal pain is equivocal and it is not clear for which sub-groups of patients SM is optimally effective.

Aims

To systematically review randomized controlled trials of self-management for chronic musculoskeletal pain that reported predictors, i.e., ‘baseline factors that predict outcome independent of any treatment effect’; moderators, i.e., ‘baseline factors which predict benefit from a particular treatment’; or mediators i.e., ‘factors measured during treatment that impact on outcome’ of outcome.

Method

We searched relevant electronic databases. We assessed the evidence according to the methodological strengths of the studies. We did meta-regression analyses for age and gender, as potential moderators.

Results

Although the methodological quality of primary trials was good, there were few relevant studies; most were compromised by lack of power for moderator and mediator analyses. We found strong evidence that self-efficacy and depression at baseline predict outcome and strong evidence that pain catastrophizing and physical activity can mediate outcome from self-management. There was insufficient data on moderators of treatment.

Conclusions

The current evidence suggests four factors that relate to outcome as predictors/mediators, but there is no evidence for effect moderators. Future studies of mediation and moderation should be designed with ‘a priori’ hypotheses and adequate statistical power.     

Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza?A infection

Introduction

Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza?A infection, although relatively common, remains controversial.

Methods

Prospective, observational, multicenter study from 23 June 2009 through 11 February 2010, reported in the European Society of Intensive Care Medicine (ESICM) H1N1 registry.

Results

Two hundred twenty patients admitted to an intensive care unit (ICU) with completed outcome data were analyzed. Invasive mechanical ventilation was used in 155 (70.5%). Sixty-seven (30.5%) of the patients died in ICU and 75 (34.1%) whilst in hospital. One hundred twenty-six (57.3%) patients received corticosteroid therapy on admission to ICU. Patients who received corticosteroids were significantly older and were more likely to have coexisting asthma, chronic obstructive pulmonary disease (COPD), and chronic steroid use. These patients receiving corticosteroids had increased likelihood of developing hospital-acquired pneumonia (HAP) [26.2% versus 13.8%, p?p?p?=?0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0?C4.8, p?Conclusions Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza?A infection did not result in better outcomes and was associated with increased risk of superinfections.     

A study of the physical rehabilitation and psychological state of patients who sustained limb loss as a result of terrorist activity in Northern Ireland 1969 – 2003

Objective.?To benchmark the psychological state and physical rehabilitation of patients who have sustained limb loss as a result of terrorist activity in Northern Ireland and to determine their satisfaction with the period of primary prosthetic rehabilitation and the artificial limb.

Method.?All patients who sustained limb loss as a result of the Troubles and were referred to our rehabilitation centre were sent a questionnaire. The main outcome measures were the SIGAM mobility grades, the General Health Questionnaire (GHQ12) and three screening questions for Post Traumatic Stress Disorder (PTSD).

Results.?Out of a 66% response rate, 52 (69%) patients felt that the period of primary prosthetic rehabilitation was adequate; 32 (54%) lower limb amputees graded themselves SIGAM C or D; 45 (60%) patients stated that they were still having significant stump pain. Significant stump pain was associated with poorer mobility. Nine (56%) upper limb amputees used their prosthetic limb in a functional way; 33 (44%) patients showed “psychiatric caseness” on the GHQ 12 and 50 (67%) had symptoms of PTSD.

Conclusions.?Most patients felt that the period of physical rehabilitation had been adequate; those who did not were more likely to be having ongoing psychological problems. A high percentage of patients continue to have psychological problems and stump pain.     

“Sedation is tricky”: A qualitative content analysis of nurses' perceptions of sedation administration in mechanically ventilated intensive care unit patients

Introduction

Critical care nurses are responsible for administering sedative medications to mechanically ventilated patients. With significant advancements in the understanding of the impact of sedative exposure on physiological and psychological outcomes of ventilated patients, updated practice guidelines for assessment and management of pain, agitation, and delirium in the intensive care unit were released in 2013. The primary aim of this qualitative study was to identify and describe themes derived from critical care nurses' comments regarding sedation administration practices with mechanically ventilated patients.

Evaluation of the effects of low temperature on performance of standard non-electric medical equipment at −21.5 °C (−6.7 °F) – A descriptive study on a real life challenge in the prehospital setting

Aim of the study

To our knowledge, there are no previous reports on the performance of medical equipment in cold conditions. The aim of this study was to evaluate the performance of several plastic, single-use medical equipment exposed to cold outdoor temperature.

Methods

Medical equipment such as endotracheal tubes, suction catheters and intravenous lines were exposed to outdoor temperature of −21.5 °C (−6.7 °F) for 15 min. After 15 min the equipment underwent a manual stress test resembling normal prehospital use.

Results

After 15 min in −21.5 °C (−6.7 °F) during the stress test several equipment exhibited significant changes in properties as compared to room temperature. Mainly, loss of flexibility and connectivity was observed. Examples of these were fractures of endotracheal tubes and suction catheters, and permanent airway adapter loosening from a respirator breathing circuit.

Conclusion

Plastic medical equipment has poor tolerance of cold conditions. Loss of equipment performance and properties could result in relevant harm to the patient. Retaining the equipment, e.g. in a closed backpack slows the rate of temperature decrease.     

Under (less) pressure – Facial pressure ulcer development in ventilated ICU patients: A prospective comparative study comparing two types of endotracheal tube fixations

IntroductionThe development of medical device-related pressure ulcers (MDR PUs) as a result of an endotracheal tube fixator (ETTF) use affects patients particularly in the intensive care unit (ICU).Study design and data collectionProspective comparative study followed two similar groups of ventilated ICU patients: Group A treated with cloth tape ETTF (CT-ETTF) and Group B treated with Anchorfast Hollister-ETTF (AH-ETTF). Data were collected regarding PU development, location, grade, time from intubation and hospitalisation.ResultsSignificant differences in PU development (p < 0.01), hospital LOS until PU development (p < 0.01), and ventilation days until PU development (p < 0.01) were found between the two groups all in favour of Group B.Linear regression conducted to identify the primary reason for these findings, revealed that the key factor responsible for more than 40% of the difference in ventilation days until ETT MDR PU formation between the groups was the usage of AH-ETTF (R² = 0.436, p = 0.000).ConclusionsThere was a significant advantage to AH-ETTF over CT-ETTF in pressure ulcer development. This should be taken into consideration when deciding which ETTF type to use.