Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study

IntroductionSystolic blood pressure is a widely used tool to assess circulatory function in acutely ill patients. The systolic blood pressure limit where a given patient should be considered hypotensive is the subject of debate and recent studies have advocated higher systolic blood pressure thresholds than the traditional 90 mmHg. The aim of this study was to identify the best performing systolic blood pressure thresholds with regards to predicting 7-day mortality and to evaluate the applicability of these in the emergency department as well as in the prehospital setting.MethodsA retrospective, hospital-based cohort study was performed at Odense University Hospital that included all adult patients in the emergency department between 1995 and 2011, all patients transported to the emergency department in ambulances in the period 2012 to 2013, and all patients serviced by the physician-staffed mobile emergency care unit (MECU) in Odense between 2007 and 2013. We used the first recorded systolic blood pressure and the main outcome was 7-day mortality. Best performing thresholds were identified with methods based on receiver operating characteristics (ROC) and multivariate regression. The performance of systolic blood pressure thresholds was evaluated with standard summary statistics for diagnostic tests.ResultsSeven-day mortality rates varied from 1.8 % (95 % CI (1.7, 1.9)) of 112,727 patients in the emergency department to 2.2 % (95 % CI (2.0, 2.5)) of 15,862 patients in the ambulance and 5.7 % (95 % CI (5.3, 6.2)) of 12,270 patients in the mobile emergency care units. Best performing thresholds ranged from 95 to 119 mmHg in the emergency department, 103 to 120 mmHg in the ambulance, and 101 to 115 mmHg in the MECU but area under the ROC curve indicated poor overall discriminatory performance of SBP thresholds in all cohorts.ConclusionsSystolic blood pressure alone is not sufficient to identify patients at risk regardless of the defined threshold for hypotension. If, however, a threshold is to be defined, a systolic blood pressure threshold of 100 to 110 mmHg is probably more relevant than the traditional 90 mmHg.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0884-y) contains supplementary material, which is available to authorized users.     

Podocyte-specific loss of cdc42 leads to congenital nephropathy

Rho family GTPases are molecular switches best known for their pivotal role in dynamic regulation of the actin cytoskeleton. The prototypic members of this family are Cdc42, Rac1, and RhoA; these GTPases contribute to the breakdown of glomerular filtration and the resultant proteinuria, but their functions in normal podocyte physiology remain poorly understood. Here, mice lacking Cdc42 in podocytes developed congenital nephropathy and died as a result of renal failure within 2 weeks after birth. In contrast, mice lacking Rac1 or RhoA in podocytes were overtly normal and lived to adulthood. Kidneys from Cdc42-mutant mice exhibited protein-filled microcysts with hallmarks of collapsing glomerulopathy, as well as extensive effacement of podocyte foot processes with abnormal junctional complexes. Furthermore, we observed aberrant expression of several podocyte markers and cell polarity proteins in the absence of Cdc42, indicating a disruption of the slit diaphragm. Kidneys from Rac1- and RhoA-mutant mice, however, had normal glomerular morphology and intact foot processes. A nephrin clustering assay suggested that Cdc42 deficiency, but not Rac1 or RhoA deficiency, impairs the polymerization of actin at sites of nephrin aggregates. Taken together, these data highlight the physiological importance of Cdc42, but not Rac1 or RhoA, in establishing podocyte architecture and glomerular function.     

The dynamic allocation of attention to emotion: Simultaneous and independent evidence from the late positive potential and steady state visual evoked potentials

Emotional stimuli capture and hold attention without explicit instruction. The late positive potential (LPP) component of the event related potential can be used to track motivated attention toward emotional stimuli, and is larger for emotional compared to neutral pictures. In the frequency domain, the steady state visual evoked potential (ssVEP) has also been used to track attention to stimuli flickering at a particular frequency. Like the LPP, the ssVEP is also larger for emotional compared to neutral pictures. Prior work suggests that both the LPP and ssVEP are sensitive to “top-down” manipulations of attention, however the LPP and ssVEP have not previously been examined using the same attentional manipulation in the same participants. In the present study, LPP and ssVEP amplitudes were simultaneously elicited by unpleasant and neutral pictures. Partway through picture presentation, participants’ attention was directed toward an arousing or non-arousing region of unpleasant pictures. In line with prior work, the LPP was reduced when attention was directed toward non-arousing compared to arousing regions of unpleasant pictures; similar results were observed for the ssVEP. Thus, both electrocortical measures index affective salience and are sensitive to directed (here: spatial) attention. Variation in the LPP and ssVEP was unrelated, suggesting that these measures are not redundant with each other and may capture different neurophysiological aspects of affective stimulus processing and attention.     

Forensic mental health nurses' experiences of rebuilding the therapeutic relationship after an episode of physical restraint in forensic services in Ireland: A qualitative study

Few studies have explored how forensic mental health nurses can rebuild the therapeutic relationship following an episode of physical restraint in the acute forensic setting. In this study, we aimed to redress this gap in the literature by exploring with forensic mental health nurses the factors that enable or hinder the rebuilding of the therapeutic relationship following an episode of physical restraint. A qualitative study design was used to capture participants' experiences, views and perceptions of the therapeutic relationship following an episode of physical restraint in the acute forensic setting. Data were collected through individual interviews with forensic mental health nurses (n = 10) working in an acute forensic setting. Interviews were audio recorded, and transcribed verbatim and accounts were analysed using thematic analysis. Four themes were identified: ‘Building a Recovery Focused Therapeutic Relationship’; ‘Authoritarian Role’; ‘Inevitable Imbalance’; ‘Rebuilding the Therapeutic Relationship’; plus two sub-themes ‘Facilitators to rebuilding’ and ‘Barriers to rebuilding’. Findings suggest that an inevitable imbalance exists in building a recovery-focused therapeutic relationship and at times, is hindered by the authoritarian role of the forensic mental health nurse. Recommendations for changes in clinical practice and in upcoming policies should incorporate a dedicated debrief room and protected time for staff to debrief effectively following restraint. Routine post-restraint-focused clinical supervision would also be beneficial to mental health nursing staff.     

Current trends in modern orthokeratology

The present article describes the basic concepts and principles of modern orthokeratology. Early investigators postulated a variety of theories. However, controlled clinical studies have shown these methods to be both unpredictable and also modest in their ability to correct myopia. These traditional techniques involved fitting lenses according to a `rule-of-thumb' and clinicians had no means of accurately evaluating corneal topography. More recently, with the significant advances in corneal topography systems and the application of reverse geometry lenses (lenses where the secondary curve steepens) certain investigators have concluded that the technique can rapidly reduce greater levels of myopia with greater predictability. The procedure involves a more scientific sagitta based fitting philosophy and predictability is defined according to corneal asphericity.     

Intraperitoneal bupivacaine for the reduction of postoperative pain following operative laparoscopy: a pilot study and review of the literature.

This pilot case-control study was carried out to determine the value of intraperitoneal irrigation with a long-acting local anaesthetic agent in reducing postoperative analgesic requirements following gynaecological operative laparoscopy. Twenty women undergoing gynaecological laparoscopic surgery were recruited to receive dilute bupivacaine instilled into the peritoneal cavity at the completion of surgery. Analgesic requirements were assessed during the first 10 hours, and pain scores at 4 and 24 hours. Analgesic requirements were then compared with historical controls. Our results revealed that the total parenteral opioid requirement after bupivacaine was significantly less than in the control group (0.50 mg vs. 7.17 mg, P=0.006). Oral analgesic requirements were not significantly different between the two groups. Pain scores in the bupivacaine group showed no difference at 4 and 24 hours postoperatively. Intraperitoneal irrigation with dilute bupivacaine at the end of gynaecological laparoscopic surgery appears to reduce early postoperative analgesic requirements in this pilot study.