Spontaneous hypothermia on intensive care unit admission is a predictor of unfavorable neurological outcome in patients after resuscitation: an observational cohort study

Introduction  

A large number of patients resuscitated for primary cardiac arrest arrive in the intensive care unit (ICU) with a body temperature < 35.0°C. The aim of this observational cohort study was to determine the association between ICU admission temperature and neurological outcome in this patient group.     

An international survey of EEG use in the neonatal intensive care unit

Objective: To examine the extent of EEG monitoring in neonatal intensive care units (NICUs), and to survey the level of experience and training of those using it. Study design: A web‐based survey, the link to which was circulated via e‐mail, personal contact, specialist societies and professional groups. Survey data were exported to SPSS for analysis. Results: In total 210 surveys were analysed; 124 from Europe, 54 from the US. Ninety percent of respondents had access to either EEG or aEEG monitoring; 51% had both. EEG was mainly interpreted by neurophysiologists (72%) whereas aEEG was usually interpreted by neonatologists (80%). Only 9% of respondents reported that they felt ‘very confident’ in their ability to interpret aEEG/EEG with 31% reporting that they were ‘not confident’. Half had received no formal training in EEG. Conclusion: Both aEEG and conventional EEG were used extensively in the NICUs surveyed for this study. Most of the survey respondents were not confident in their ability to interpret EEGs despite the fact that they used monitoring routinely. There is an urgent need for a structured and appropriately targeted training programme in EEG methodologies and EEG interpretation for neonatal intensive care unit staff.     

An abnormal screening ultrasound: concordance with a tertiary obstetrical ultrasound unit

Objective: To determine concordance of ultrasound diagnosis in referrals to a tertiary obstetrical ultrasound unit (TOU) for suspected abnormalities.

Study design: Consecutive referrals for ‘abnormal outside ultrasound’ during a 6-month period were compared with the TOU ultrasound diagnosis. Concordance of diagnosis was compared on the basis of organ system involved and referral for single or multiple suspected abnormalities. χ² analysis was used; p?<?0.05 was considered significant.

Results: Of 104 consecutive referrals reviewed, 42 (40.4%) had no abnormality documented at the TOU. Of the 62 abnormal ultrasound scans at the TOU, 78.3% were concordant. Concordance based on organ system involvement was central nervous system, 30.3%; cardiothoracic, 66.7%; gastrointestinal, 63.6%; genitourinary, 50%. Referrals for a single suspected anomaly were statistically no more likely to have a normal TOU ultrasound scan (40.4%) than those referred for multiple suspected anomalies (36.4%, p?>?0.05).

Conclusions: Most referrals to a tertiary center for ‘abnormal outside ultrasound’ will be diagnosed with an abnormality.     

Central or local incident reporting? A comparative study in Dutch GP out-of-hours services

Background

Centralised incident reporting in a Dutch collaboration of nine out-of-hours services yielded very few incident reports. To improve incident reporting and the awareness of primary caregivers about patient safety issues, a local incident-reporting procedure was implemented.

Aim

To compare the number and nature of incident reports collected in a local incident-reporting procedure (intervention) versus the currently used centralised incident-reporting procedure.

Design of study

Quasi experiment.

Setting

Three GPs'' out-of-hours services (OHSs) in the centre of the Netherlands participated over 2 years before and 2 years after the intervention.

Method

A local incident-reporting procedure was implemented in OHS1, in which participants were encouraged to report all occurring incidents. A local committee with peers analysed the reported incidents fortnightly in order to initiate improvements if necessary. In OHS2 and OHS3, the current centralised incident-reporting procedure was continued, where incidents were reported to an advisory committee of the board of directors of the OHSs collaboration and were assessed every 2 months. The main outcome measures were the number and nature of incidents reported.

Results

At baseline, participants reported fewer than 10 incidents per year each. In the follow-up period, the number of incidents reported in OHS1 increased 16-fold compared with the controls. The type of incidents reported did not alter. In the local incident-reporting procedure, improvements were implemented in a shorter time frame, but reports in the centralised incident-reporting procedure led to a more systematic addressing of general and recurring safety problems.

Conclusion

It is likely that a local incident-reporting procedure increases the willingness to report and facilitates faster implementation of improvements. In contrast, the central procedure, by collating reports from many settings, seems better at addressing generic and recurring safety issues. The advantages of both approaches should be combined.     

Serotonin receptor 3A polymorphism c.-42C &gt; T is associated with severe dyspepsia

Background

The association between anxiety and depression related traits and dyspepsia may reflect a common genetic predisposition. Furthermore, genetic factors may contribute to the risk of having increased visceral sensitivity, which has been implicated in dyspeptic symptom generation. Serotonin (5-HT) modulates visceral sensitivity by its action on 5-HT₃ receptors. Interestingly, a functional polymorphism in HTR3A, encoding the 5-HT₃ receptor A subunit, has been reported to be associated with depression and anxiety related traits. A functional polymorphism in the serotonin transporter (5-HTT), which terminates serotonergic signalling, was also found associated with these psychiatric comorbidities and increased visceral sensitivity in irritable bowel syndrome, which coexistence is associated with higher dyspeptic symptom severity. We investigated the association between these functional polymorphisms and dyspeptic symptom severity.

Methods

Data from 592 unrelated, Caucasian, primary care patients with dyspepsia participating in a randomised clinical trial comparing step-up and step-down antacid drug treatment (The DIAMOND trial) were analysed. Patients were genotyped for HTR3A c.-42C > T SNP and the 44 bp insertion/deletion polymorphism in the 5-HTT promoter (5-HTTLPR). Intensity of 8 dyspeptic symptoms at baseline was assessed using a validated questionnaire (0 = none; 6 = very severe). Sum score ≥20 was defined severe dyspepsia.

Results

HTR3A c.-42T allele carriers were more prevalent in patients with severe dyspepsia (OR 1.50, 95% CI 1.06-2.20). This association appeared to be stronger in females (OR 2.05, 95% CI 1.25-3.39) and patients homozygous for the long (L) variant of the 5-HTTLPR genotype (OR 2.00, 95% CI 1.01-3.94). Females with 5-HTTLPR LL genotype showed the strongest association (OR = 3.50, 95% CI = 1.37-8.90).

Conclusions

The HTR3A c.-42T allele is associated with severe dyspeptic symptoms. The stronger association among patients carrying the 5-HTTLPR L allele suggests an additive effect of the two polymorphisms. These results support the hypothesis that diminished 5-HT₃ mediated antinociception predisposes to increased visceral sensitivity of the gastrointestinal tract. Moreover, the HTR3A c.-42C > T and 5-HTTLPR polymorphisms likely represent predisposing genetic variants in common to psychiatric morbidity and dyspepsia.

     

Assessing the information desire of patients with advanced cancer by providing information with a decision aid,which is evaluated in a randomized trial: a study protocol

Background  

There is a continuing debate on the desirability of informing patients with cancer and thereby involving them in treatment decisions. On the one hand, information uptake may be hampered, and additional stress could be inflicted by involving these patients. On the other hand, even patients with advanced cancer desire information on risks and prognosis. To settle the debate, a decision aid will be developed and presented to patients with advanced disease at the point of decision making. The aid is used to assess the amount of information desired. Factors related to information desire are explored, as well as the ability of the medical oncologist to judge the patient's information desire. The effects of the information on patient well-being are assessed by comparing the decision aid group with a usual care group.     

Prevalence and risk indicators of oral mucosal lesions in an urban population from South Brazil

Oral Diseases (2011) 17 , 171–179 Objective: The objective of the study was to assess the prevalence of oral mucosal lesions (OML) and to perform a multivariable risk assessment of demographic, socioeconomic, behavioral, and oral risk indicators for its occurrence in an urban population in South Brazil. Methods: This cross‐sectional study selected 1586 subjects (719M/867F, age: 14–104 years) using a multistage probability sampling strategy (65.1% response rate). Prevalence, odds ratios (OR), and confidence intervals (95% CI) were calculated accounting for the survey design. Results: Leukoplakia and lichen planus were observed in 1.01% and 1.02% of subjects, respectively. In the multivariable analysis, these lesions were significantly associated with moderate/heavy smoking (OR = 9.0, 95% CI = 2.1–39.1) and heavy drinking (OR = 2.0, 95% CI = 1.1–3.7). Candidiasis and proliferative lesions were observed in 14.09% and 3.80% of the subjects, respectively. These lesions were significantly associated with female gender (OR = 2.2, 95% CI = 1.5–3.2 and OR = 1.7, 95% CI = 1.0–2.8), older age (OR = 22, 95% CI = 8.0–60.8 and OR = 8.9, 95% CI = 3.4–23.7), and low socioeconomic status (OR = 1.9, 95% CI = 1.0–3.5 and OR = 3.0, 95% CI = 1.2–7.2). Conclusions: This population is in need of OML prevention and treatment. Future studies should validate the findings that premalignant lesions are causally related to smoking and alcohol consumption, and that other OML are associated with socioeconomic‐demographic disparities in this and similar populations.     

Pulmonary flow profile and distensibility following acute pulmonary embolism

Objective

Proof of concept study evaluating CMR as screening tool for chronic thromboembolic pulmonary hypertension (CTEPH) in patients treated for acute pulmonary embolism (PE).

Materials and methods

Right and left ventricular function of 15 consecutive patients treated for PE and 10 consecutive patients in whom PE was excluded was estimated at baseline by cardiac CT and at 6 months follow-up by CMR. Additionally, during the follow-up visit, pulmonary artery (PA) hemodynamics were studied by CMR and the presence of pulmonary hypertension by echocardiography.

Results

CT measured right ventricular ejection fraction (RVEF) was lower in patients with PE compared to patients without PE at time of diagnosis (median 47%, interquartile range 39-53 vs. 55%, 52-58; p = 0.014). After 6 months follow up, the RVEF between patients treated for PE and patients without PE were not statistically significant different (55%, 52-60 versus 54%, 51-57; p = 0.57), as were distensibility index (0.18 ± 0.18 versus 0.25 ± 0.18, p = 0.20), mean velocity (14.1 ± 3.9 cm/s versus 14.0 ± 2.5 cm/s, p = 0.81), peak velocity (86.5 ± 22 cm/s versus 89.6 ± 13 cm/s, p = 0.43) and time to peak PA blood flow velocity (142 ± 49 ms versus 161 ± 29 ms, p = 0.14). One patient was diagnosed with CTEPH and CMR revealed poor right systolic function, decreased PA distensibility and flow velocity, and a systolic notch in the PA flow profile consistent with persistent PA obstruction.

Conclusion

In this small series, right ventricular performance and PA flow profiles of patients treated for 6 months after PE are equivalent to those parameters in normal patients.