Determinants of timely management of acute bacterial meningitis in the ED

Purpose

The purpose was to study the emergency management of patients with suspected meningitis to identify potential areas for improvement.

Methods

All patients who underwent cerebrospinal fluid puncture at the emergency department of the University Hospital of Bern from January 31, 2004, to October 30, 2008, were included. A total of 396 patients were included in the study. For each patient, we analyzed the sequence and timing for the following management steps: first contact with medical staff, administration of the first antibiotic dose, lumbar puncture (LP), head imaging, and blood cultures. The results were analyzed in relation to clinical characteristics and the referral diagnosis on admission.

Results

Of the 396 patient analyzed, 15 (3.7%) had a discharge diagnosis of bacterial meningitis, 119 (30%) had nonbacterial meningitis, and 262 (66.3%) had no evidence of meningitis. Suspicion of meningitis led to earlier antibiotic therapy than suspicion of an acute cerebral event or nonacute cerebral event (P < .0001). In patients with bacterial meningitis, the average time to antibiotics was 136 minutes, with a range of 0 to 340 minutes. Most patients (60.1%) had brain imaging studies performed before LP. On the other hand, half of the patients with a referral diagnosis of meningitis (50%) received antibiotics before performance of an LP.

Conclusions

Few patients with suspected meningitis received antimicrobial therapy within the first 30 minutes after arrival, but most patients with pneumococcal meningitis and typical symptoms were treated early; patients with bacterial meningitis who received treatment late had complex medical histories or atypical presentations.     

Acute meningitis prognosis using cerebrospinal fluid interleukin-6 levels

Background

Improved diagnostic tests would aid in diagnosing and treating community-acquired meningitis.

Objective

To analyze the diagnostic value of interleukin-6 (IL-6) in the cerebrospinal fluid (CSF) of patients presenting with symptoms of acute meningitis.

Material and Methods

In a 6-month prospective, observational, cross-sectional emergency department (ED) study, serum and CSF samples were obtained from all patients with a headache and fever in whom the physician suspected meningitis. Patients were excluded if computed tomography findings contraindicated a lumbar puncture, if they had bleeding disorders, or if their serum indicated bleeding. IL-6 levels were measured and compared in patients with (Group A) and without (Group B) bacterial meningitis.

Results

Samples were obtained from 53 patients, of whom 40 were ultimately found to have meningitis. These 40 patients averaged 49.6 ± 21.9 years, with number of men 18 (45%), hospitalizations 21 (52%), mortality 3 (.07%), and IL-6 average rating 491 (median: 14.5; range 0000–6000). Findings in the two groups were: Group A (with meningitis): n = 13, average IL-6 level: 1495 (median: 604; 25/75 percentiles: 232.5–2030; 95% confidence interval [CI] 371.7–2618.6; range 64–6000). Group B (with aseptic meningitis): n = 27, average IL-6 level: 7.34 (median: 5; 25/75 percentiles: 0.0/15.1; 95% CI 3.94–10.73; range 0–23.6). Mann-Whitney rank sum test: p < 0.0001.

Conclusions

In patients with acute bacterial meningitis, CSF cytokine concentrations are elevated. Measuring CSF inflammatory cytokine levels in patients with acute meningitis could be a valuable ED diagnostic tool. Using this tool could improve the prognosis of patients with bacterial meningitis by allowing more rapid initiation of antibiotic treatment.     

Viral Meningitis: Which Patients Can Be Discharged from the Emergency Department?

Background

Even in an era when cases of viral meningitis outnumber bacterial meningitis by at least 25:1, most patients with clinical meningitis are hospitalized.

Objective

We describe the clinical characteristics of an unusual outbreak of viral meningitis that featured markedly elevated cerebrospinal fluid white blood cell counts (CSF WBC). A validated prediction model for viral meningitis was applied to determine which hospital admissions could have been avoided.

Methods

Data were collected retrospectively from patients presenting to our tertiary care center. Charts were reviewed in patients with CSF pleocytosis (CSF WBC > 7 cells/mm³) and a clinical diagnosis of meningitis between March 1, 2003 and July 1, 2003. Cases were identified through hospital infection control and by surveying all CSF specimens submitted to the microbiology laboratory during the outbreak.

Results

There were 78 cases of viral meningitis and 1 case of bacterial meningitis identified. Fifty-eight percent of the viral meningitis cases were confirmed by culture or polymerase chain reaction to be due to Enterovirus. Mean CSF WBC count was 571 cells/mm³, including 20 patients with a CSF WBC count > 750 cells/mm³ (25%) and 11 patients with values > 1000 cells/mm³ (14%). Sixty-four of 78 patients (82%) were hospitalized. Rates of headache, photophobia, nuchal rigidity, vomiting, and administration of intravenous fluids in the Emergency Department were no different between admitted and discharged patients. Only 26/78 (33%) patients with viral meningitis would have been admitted if the prediction model had been used.

Conclusions

Although not all cases of viral meningitis are necessarily suitable for outpatient management, use of a prediction model for viral meningitis may have helped decrease hospitalization by nearly 60%, even though this outbreak was characterized by unusually high levels of CSF pleocytosis.     

Usefulness of interleukin 6 levels in the cerebrospinal fluid for the diagnosis of bacterial meningitis

Purpose

Interleukin 6 (IL-6) is a proinflammatory cytokine produced during infections. We hypothesized that IL-6 levels in the cerebrospinal fluid (CSF) would be elevated in bacterial meningitis and useful for diagnosing and predicting neurologic outcomes.

Materials and methods

For the differentiation of bacterial meningitis, serum and CSF samples were obtained from patients with an altered level of consciousness. Patients were classified into 3 groups: bacterial meningitis, nonbacterial central nervous system disease, and other site sepsis.

Results

Of the 70 patients included in this study, there were 13 in the bacterial meningitis group, 21 in the nonbacterial central nervous system disease group, and 36 in the other site sepsis group. The CSF IL-6 level was significantly higher in the bacterial meningitis group than in the other 2 groups (P < .0001). Of the 5 CSF parameters assessed, CSF IL-6 level exhibited the largest area under the receiver operating characteristic curve (0.962), with a cut-off value of 644 pg/mL (sensitivity, 92.3%; specificity, 89.5%). To examine a potential association between a high CSF level and neurologic outcome, CSF IL-6 levels were divided into 4 quartiles, and each level was compared with the frequency of a good neurologic outcome. The frequency of a good neurologic outcome was significantly lower in the highest CSF IL-6 quartile than in the other 3 quartiles (odds ratio, 0.18; 95% confidence interval, 0.05-0.69; P = .013).

Conclusions

Measurement of the CSF IL-6 level is useful for diagnosing bacterial meningitis.     

Does This Child Have Bacterial Meningitis? A Systematic Review of Clinical Prediction Rules for Children with Suspected Bacterial Meningitis

Background

Acute meningitis is a relatively common phenomenon in children. Identifying which children are most likely to have bacterial meningitis vs. self-limiting aseptic meningitis is important, as these children require investigation and antibiotic treatment.

Objective

Our aim was to systematically identify and review the quality and performance of published clinical prediction rules (CPRs) for children with suspected bacterial meningitis.

Methods

Medline and Embase were searched for CPRs involving children 0–18 years of age with suspected bacterial meningitis, with cerebral spinal fluid (CSF) culture used as the reference diagnostic standard. CPR quality was assessed using 17 previously published items. CPR performance was evaluated using sensitivity, negative likelihood ratio, and the treatment frequency that would result if the rule was used.

Results

Eleven studies involving 6675 children with acute meningitis fulfilled all inclusion criteria and were entered in the study. They all describe the derivation or validation of six unique CPRs. A rigorously developed, high-performing, and well-validated CPR ready for clinical use to guide which children with suspected bacterial meningitis should be hospitalized and treated with intravenous antibiotics and which can be safely discharged home was not identified. Areas for quality improvement for future CPR studies include prospective validation using standardized inclusion criteria, adequate blinding, predictor reproducibility assessment, and meticulous follow-up of outcomes. The Bacterial Meningitis Score had the highest quality and performance and is the best candidate for prospective validation.

Conclusions

Until consistently high methodological quality and diagnostic performance are demonstrated through prospective validation, caution is warranted in the routine clinical use of existing CPRs for children with suspected bacterial meningitis.     

Acute bacterial meningitis in the intensive care unit and risk factors for adverse clinical outcomes: Retrospective study

Background

Bacterial meningitis constitutes a medical emergency. Its burden has driven from childhood to the elderly and the immunocompromised population. However, the admission of patients with bacterial meningitis to the intensive care unit (ICU) has been sparsely approached, as have the prognostic factors associated with an adverse clinical outcome.

Methods

We performed a retrospective analysis during a 7-year period of patients older than 18 years admitted to 2 polyvalent ICUs. Clinical, demographic, and outcome data were collected to evaluate its clinical impact on the outcome of patients with acute bacterial meningitis.

Results

We identified 65 patients with the diagnosis of acute bacterial meningitis (mean Acute Physiology and Chronic Health Evaluation II, 23; hospital mortality, 40%). Upon clinical presentation, their most frequent signs were fever (84%), seizures (21.5%), and a low Glasgow Coma Scale (GCS) score (GCS < 8; 58.4%). Fifty-five patients (85%) required organ support. A definite microbiological diagnosis was achieved in 45 patients. An adverse clinical outcome was noted in 46 patients (71%). These patients were older (P = .005), had higher Physiology and Chronic Health Evaluation II score (P = .022), and had lower GCS (P = .022). In the multivariate analysis, older age (per year; adjusted odds ratio [aOR], 1.059) was associated with an adverse outcome, whereas a higher GCS (per point; aOR, 0.826) and presence of fever upon admission (aOR, 0.142) increase the chance of a good recovery.

Conclusions

Patients with acute bacterial meningitis admitted to ICU had substantial morbidity and mortality. Those with low GCS or absence of fever have a particularly high risk of an adverse outcome.     

Hypotension is Uncommon in Patients Presenting to the Emergency Department with Non-traumatic Cardiac Tamponade

Background

Cardiac tamponade is a life-threatening disease in which hypotension is believed to be a common finding. Prior inpatient studies have described normotensive or hypertensive cases of tamponade; however, because the data were not collected from the Emergency Department (ED), the hemodynamic spectrum may differ from those presenting to the ED.

Objectives

We hypothesized that hypotension is uncommon in patients presenting to the ED with non-traumatic tamponade.

Methods

A retrospective chart review was conducted between January 2002 and December 2007 of patients presenting to our ED who were subsequently diagnosed with cardiac tamponade.

Results

A total of 34 patients were identified with a diagnosis of tamponade. The mean blood pressure on ED arrival was 131/79 mm Hg. Upon initial presentation to the ED, 35% (n = 12) of patients were hypertensive, 50% (n = 17) were normotensive, and 15% (n = 5) were hypotensive. Of the 5 patients who were hypotensive on ED arrival, only 2 (6% of all patients) remained hypotensive upon admission to the hospital and before a pericardiocentesis. An average of 995 mL of fluid was removed from the pericardium. The chief complaint for the majority of patients in tamponade was shortness of breath (70%); 59% were tachycardic in the ED, and 72% had cardiomegaly on chest X-ray study.

Conclusions

Hypotension is uncommon in patients presenting to the ED with non-traumatic cardiac tamponade. The majority of patients are normotensive or even hypertensive. Thus, the emergency physician should not exclude the diagnosis of tamponade even in light of normotension or hypertension.     

Cerebrospinal creatinine kinase level in children with meningitis

Background

The aim of this study is to evaluate the diagnostic value of the enzyme creatine kinase (CK) in the cerebrospinal fluid (CSF) of children with meningitis.

Method

CSF samples were collected from seventy one children suspected of having meningitis. The levels of total CK, CK-BB, Glucose, total protein, WBC counts, and culture were determined in the CSF. The cutoff value for total CK in the CSF was defined as 18 U/L.

Results

Three cases (4%) of bacterial meningitis and 11 cases (15%) of aseptic meningitis were confirmed by culture. The sensitivity and specificity of total CK CSF level alone to diagnose bacterial meningitis were found to be 33% and 91% respectively. The positive and negative predictive values were found to be 14% and 98% respectively. On the other hand, the sensitivity and specificity of total CK level in aseptic meningitis were found to be 40% and 98% respectively and the positive and negative predictive values were 86% and 94% respectively. The sensitivity and specificity of total protein and glucose in CSF were also calculated. Streptococcus pneumonia and homophiles influenza were the main types identified in our cases.

Discussion and conclusion

Measuring the total CK level in the CSF may be very useful in diagnosis of meningitis if only combined with other CSF markers. It is not of any much benefit if it is used solely.     

Factors associated with ambulatory status 6 months after total hip arthroplasty

Objective

To identify an assessment tool and its cut-off point for indicating ambulatory status 6 months after total hip arthroplasty (THA).

Design

Cross-sectional study.

Setting

Kyoto University Hospital.

Participants

Eighty-eight patients who underwent unilateral THA.

Main outcome measure

Lower-extremity muscle strength, hip range of motion and hip pain were measured 6 months after THA. The patients were divided into two groups according to their ability to walk 6 months after THA: an independent ambulation group and a cane-assisted ambulation group.

Results

A stepwise multiple logistic regression analysis indicated that age and lower-extremity maximal load were significant variables affecting mid-term ambulatory status following THA. Receiver operating characteristic curve analyses revealed that ambulatory status following THA was indicated more accurately by leg extension strength (cut-off point = 8.24 N/kg, sensitivity = 92%, specificity = 82%, area under the curve = 0.93) than age.

Conclusion

Lower-limb load force with a cut-off point of 8.24 N/kg is a reliable assessment tool for indicating ambulatory status 6 months after primary THA.     

Nurse facilitated Self-management support for people with heart failure and their family carers (SEMAPHFOR): a randomised controlled trial

Objective

To compare the clinical effectiveness of a newly developed cognitive behavioural self-management manual delivered by specialist heart failure nurses or the same programme followed by the patient on their own, in terms of readmissions/admissions to hospital for any reason within a 12 month period, patient health related quality of life, self-management and carer quality of life.

Design

Pragmatic, open parallel group, randomised controlled trial.

Setting

Open access heart failure diagnostic clinics and primary care.

Participants

260 patients with a definitive diagnosis of symptomatic heart failure (LVSD) as defined by ECHO, clinical diagnosis or coronary angiography were eligible for the study.

Intervention

A newly developed nurse facilitated, cognitive behavioural self-management programme was developed and was delivered either by a heart failure nurse or by the patient on their own.

Main outcome measures

Patient admission/readmission to hospital for any reason within a 12 month period following randomisation. Secondary outcomes were: participant health related quality of life as measured by the Minnesota Living with Heart Failure questionnaire, the Hospital, Anxiety and Depression Scale, the European self-care form.

Results

There was no evidence of a difference between the groups in whether or not a patient was re-admitted to hospital during the 12 month follow-up period (p = 0.66). There was no evidence of a difference between the treatment groups in the mean MLHF scores over time (p = 0.768), the European self-care questionnaire (p = 0.340) or the mean HAD anxiety score (p = 0.786). However, when adjusted for baseline scores the self-management group had a statistically significant higher HADS depression score at 12 months (p = 0.003).

Conclusion

There was no evidence of a difference in admissions/readmission to hospital between patients who undertook a brief heart failure self-management programme facilitated by a specialist heart failure nurse and those also receiving care from a specialist nurse who followed the programme on their own.

Trial registration

This trial is registered as ISRCTN84692046.     

Low vacuum and discard tubes reduce hemolysis in samples drawn from intravenous catheters

Objectives

In-vitro hemolysis is a great challenge to emergency departments where blood is drawn from intravenous catheters (IVCs). Although high quality samples can be obtained by straight needle venipuncture, IVCs are preferred for various reasons. The aim of this study was to identify blood collection practices that reduce hemolysis while using IVC.

Design and methods

The study was conducted at an emergency department where blood is drawn in ≥ 90% of patients from IVC. Hemolysis, measured spectrophotometrically, was compared between syringe and vacuum tubes. The following practices were tested in combination with vacuum collection; a Luer-slip adapter, a Luer-lock adapter, discard tubes and low vacuum tubes. Each intervention lasted 1 week and retrieved 154 to 297 samples. As reference, hemolysis was also measured in vacuum tubes retrieved from departments where only straight needle venipuncture is performed.

Results

Vacuum collection led to more hemolytic samples compared with syringe tubes (24% versus 16% respectively, p = 0.008). No difference in hemolysis was observed between the Luer-slip and the Luer-lock adapter. The use of discard (17% hemolytic, p = 0.045) and low vacuum tubes (12% hemolytic, p < 0.001) substantially decreased hemolysis. None of the interventions reduced the hemolysis rate to the level observed when drawing blood by straight needle venipuncture (3%, p < 0.02).

Conclusions

In summary, both discard and low vacuum tubes reduce hemolysis while drawing blood from IVC. Of these practices the use of a low vacuum tube is preferred considering the less volume of blood and the amount of tubes drawn.     

A suction laryngoscope facilitates intubation for physicians with occasional emergency medical service experience—A manikin study with severe simulated airway haemorrhage

Introduction

We developed a suction laryngoscope, which enables simultaneous suction and laryngoscopy in cases of airway haemorrhage and evaluated its potential benefits in physicians with varying emergency medical service experience.

Methods

Eighteen physicians with regular and 24 physicians with occasional emergency medical service experience intubated the trachea of a manikin with severe simulated airway haemorrhage using the suction laryngoscope and the Macintosh laryngoscope in random order.

Results

In physicians with regular emergency medical service experience, there was neither a difference in time needed for intubation [median (IQR, CI 95%)]: 34 (18, 30–46) vs. 34 (22, 30–52) s; P = 0.52, nor in the number of oesophageal intubations [0/18 (0%) vs. 3/18 (16.7%); P = NS] when using the suction vs. the Macintosh laryngoscope. In physicians with occasional emergency medical service experience, there was no difference in time needed for intubation [median (IQR, CI 95%)]: 42 (25, 41–57) vs. 45 (33, 41–65) s; P = 0.56, but the number of oesophageal intubations was significantly lower when using the suction laryngoscope [4/24 (16.7%) vs. 12/24 (50.0%); P = 0.04].

Conclusions

In a model of severe simulated airway haemorrhage, employing a suction laryngoscope significantly decreased the likelihood of oesophageal intubations in physicians with occasional emergency medical service experience.     

Emergency medical helicopter operations for avalanche accidents

Background

In the European Alps emergency medical helicopter services are regularly involved in avalanche rescue missions. How the helicopter emergency medical system best supports avalanche rescue missions is controversial.

Aim of the study

To study advantages and limitations of the early dispatch of emergency medical helicopters after avalanche accidents.

Methods

Data on rescue mission characteristics and patterns and severity of medical emergencies were obtained for 221 helicopter avalanche rescue missions performed in the Austrian province of Tyrol between October 2008 and June 2011.

Results

A buried avalanche victim had to be searched for in only 12 (5.5%) of the 221 rescue missions, whereas medical emergencies were encountered at the scene in 24 missions (11%). Survival rate for totally buried victims extricated after helicopter arrival was significantly lower than for victims extricated before helicopter arrival (19% versus 74%, p = 0.0002). In 124 missions (56%) no victim was present at the scene when the helicopter arrived. Medical emergencies involved normothermic cardiac arrest (n = 11), severe accidental hypothermia (n = 6), critical trauma (n = 7) and hypothermia combined with critical trauma (n = 1). Survival rate at hospital discharge was 27% for arrested normothermic patients and 50% for trauma and hypothermia patients.

Conclusions

Medical emergencies are encountered at avalanche scenes twice as often as there is need to search for totally buried victims, clearly supporting the immediate dispatch of medical crew members to the accident site. The high rate of emergency medical helicopter operations to avalanche incidents where no victim is injured or buried may be characteristic for densely populated mountainous regions and can be reduced by a restrictive dispatch policy after avalanche accidents without clear information about human involvement.     

Pediatric Lumbar Puncture and Cerebrospinal Fluid Analysis

Background

Lumbar puncture (LP) is a commonly performed procedure in pediatrics. Accurate analysis of cerebrospinal fluid (CSF) profile is essential in diagnosing and managing a variety of infectious and inflammatory conditions involving the brain, meninges, and spinal cord. It can also provide useful diagnostic information in the evaluation of possible subarachnoid hemorrhage and demyelinating syndromes, and aid in the diagnosis and management of pseudotumor cerebri.

Objectives

To review anatomic, physiologic, and pathologic aspects of performing pediatric lumbar puncture and CSF analysis.

Discussion

Although still a commonly performed procedure in the outpatient setting, effective vaccines to prevent invasive infection due to Streptococcus pneumoniae and Haemophilus influenzae type b have greatly reduced pediatric bacterial meningitis rates due to these pathogens, resulting in decreased opportunity for physician-trainees to perfect this important skill (among nonneonates) during the 3 years of supervised residency training. Success in performing pediatric LP is augmented by a thorough understanding of medical aspects related to this procedure. This article discusses technical aspects involved in successfully performing a lumbar puncture to obtain CSF, and interpreting a CSF profile in children.

Conclusion

A thorough understanding of anatomic, physiologic, and pathologic considerations regarding performing lumbar puncture and CSF analysis can augment success in diagnosing a variety of potentially serious pediatric conditions.     

The effectiveness of a self-efficacy-enhancing intervention for Chinese patients with colorectal cancer: A randomized controlled trial with 6-month follow up

Background

Colorectal cancer is a major public health problem. There is growing support for colorectal cancer survivors who are experiencing problems after cancer treatment to engage in self-management programs to reduce symptom distress. However, there is inconclusive evidence as to the effectiveness of such program especially in Asian region.

Objectives

This study tested the effects of a six-month nurse-led self-efficacy-enhancing intervention for patients with colorectal cancer, compared with routine care over a six-month follow up.

Design

A randomized controlled trial with repeated measures, two-group design.

Setting

Three teaching hospitals in Guangzhou, China.

Participants:

One hundred and fifty-two Chinese adult patients with a diagnosis of colorectal cancer were recruited. The intervention group (n = 76) received self-efficacy-enhancing intervention and the control group (n = 76) received standard care.

Method

The participants were randomized into either intervention or control group after baseline measures. The outcomes of the study (self-efficacy, symptom distress, anxiety, depression and quality of life) were compared at baseline, three and six months after the intervention.

Results

Sixty-eight participants in the intervention group and 53 in the control group completed the study. Their mean age was 53 (SD = 11.3). Repeated measure MANOVA found that the patients in the intervention group had significant improvement in their self-efficacy (F = 7.26, p = 0.003) and a reduction of symptom severity (F = 5.30, p = 0.01), symptom interference (F = 4.06, p = 0.025), anxiety (F = 6.04, p = 0.006) and depression (F = 6.96, p = 0.003) at three and six months, compared with the control group. However, no statistically significant main effect was observed in quality of life perception between the two groups.

Conclusions

The nurse-led self-efficacy enhancing intervention was effective in promoting self-efficacy and psychological well-being in patients with colorectal cancer, compared with standard care. The intervention can be incorporated into routine care. Future empirical work is required to determine the longer term effects of the intervention.     

Effect of RAS inhibition on TGF-β, renal function and structure in experimentally induced diabetic hypertensive nephropathy rats

Objective

Transforming growth factor-β (TGF-β) implicated in the pathogenesis of diabetic nephropathy. Hence, developing agents that antagonize fibrogenic signals is a critical issue facing researchers.

Material and methods

Fifty rats were allocated to five groups: 1 = control rats, 2 = diabetic hypertensive rats 3 = diabetic hypertensive rats treated with spironolactone, 4 = diabetic hypertensive rats treated with moexpril, 5 = diabetic hypertensive rats treated with both spironolactone and moexpril. Measurement of TGF-β, aldosterone, creatinine and ACE. Degree of fibrosis was calculated.

Results

Serum creatinine, mean arterial blood pressure (MAP), aldosterone, ACE, TGF-β and renal fibrosis increased significantly in untreated diabetic hypertensive rats compared with control rats. Administration of spironolactone, moexpril, or both decreased these changes.

Conclusions

Addition of the spironolactone to moexpril was more effective in reducing fibrosis and improvement of renal function than monotherapy with either drug, possibly due to a dual inhibitory effect on the RAS, and thus suppression of TGF-β.     

Procalcitonin as a diagnostic marker in differentiating parapneumonic effusion from tuberculous pleurisy or malignant effusion

Objectives

Differential diagnosis of exudative pleural effusions can be difficult, despite the use of several biomarkers. Serum procalcitonin (s-PCT) is a well-known biomarker for systemic bacterial infections. However, the usefulness of pleural fluid procalcitonin (pf-PCT) in clinical practice has not been established. This study evaluated the usefulness of PCT measurements in differentiating parapneumonic effusion (PPE) from tuberculous (TB) pleurisy or malignant effusion.

Design and methods

Ninety eight adult patients diagnosed with exudative pleural effusion were enrolled and allocated into the PPE group (n = 32), TB pleurisy group (n = 40), or malignant effusion group (n = 26). Both s-PCT and pf-PCT concentrations were measured at admission using an immunoluminometric assay.

Results

Both s-PCT and pf-PCT were significantly increased in the PPE group compared with the TB pleurisy or malignant effusion groups (p < 0.001). The optimal cut-off value for s-PCT in the diagnosis of PPE was 0.18 ng/mL (sensitivity 83.3%, specificity 81.0%). The pf-PCT cut-off value was 0.16 ng/mL (sensitivity 81.5%, specificity 72.1%). Serum PCT exhibited better diagnostic accuracy than pf-PCT, with areas under the receiver operating characteristic curves of 0.842 for s-PCT and 0.784 for pf-PCT (p = 0.015). In addition, s-PCT and pf-PCT showed better diagnostic accuracy than serum C-reactive protein (p = 0.005 and p = 0.023, respectively).

Conclusions

Measurement of s-PCT and pf-PCT is useful in differentiating PPE from TB pleurisy and malignant effusion. Both s-PCT and pf-PCT may be useful biomarkers in the differential diagnosis of exudative pleural effusions.     

The effects of sleep on the relationship between brain injury severity and recovery of cognitive function: A prospective study

Background

Disturbed sleep pattern is a common symptom after head trauma and its prevalence in acute traumatic brain injury (TBI) is less discussed. Sleep has a profound impact on cognitive function recovery and the mediating effect of disturbed sleep on cognitive function recovery has not been examined after acute TBI.

Objectives

To identify the prevalence of disturbed sleep in mild, moderate, and severe acute TBI patients, and to determine the mediating effects of sleep on the relationship between brain injury severity and the recovery of cognitive function.

Design

A prospective study design.

Setting

Neurosurgical wards in a medical center in northern Taiwan.

Participants

Fifty-two acute TBI patients between the ages of 18 and 65 years who had received a diagnosis of TBI for the first time, and were admitted to the neurosurgical ward.

Method

The severity of brain injury was initially determined using the Glasgow Coma Scale. Each patient wore an actigraphy instrument on a non-paralytic or non-dominated limb for 7 consecutive days. A 7-day sleep diary was used to facilitate data analysis. Cognitive function was assessed on the first and seventh day after admission based on the Rancho Los Amigos Levels of Cognitive Functioning.

Results

The mild (n = 35), moderate (n = 7) and severe (n = 10) TBI patients exhibited poorer sleep efficiency, and longer total sleep time (TST) and waking time after sleep onset, compared with the normative values for the sleep-related variables (P < .05 for all). The severe and moderate TBI patients had longer daytime TST than the mild TBI patients (P < .001), and the severe TBI patients had longer 24-h TST than the mild TBI patients (P = .001). The relationship between the severity of brain injury and the recovery of cognition function was mediated by daytime TST (t = −2.65, P = .004).

Conclusions

Poor sleep efficiency, prolonged periods of daytime sleep, and a high prevalence of hypersomnia are common symptoms in acute TBI patients. The duration of daytime sleep mediates the relationship between the severity of brain injury and the recovery of cognition function.