APACHE II score and abdominal sepsis. A prospective study

Therapeutic trials for intra-abdominal sepsis require pretreatment stratification; physiologic scoring has been recently proposed for this purpose. We have prospectively tested the validity of one such scoring system, namely, the Acute Physiology and Chronic Health Evaluation (APACHE II). As part of a larger database, we correlated APACHE II scores with mortality in 100 patients hospitalized for generalized peritonitis or abdominal abscess. Use of steroids was recorded because of our suspicion that steroids increase mortality but blunt the physiologic response to sepsis. Thirty-one patients died, including 12 of 19 patients receiving steroids. Stepwise discriminant analysis revealed that the APACHE II score and steroid use were each independently associated with the rate of mortality. We report a prospective validation of pretreatment APACHE II scoring in abdominal sepsis. Steroid use is an independent risk factor.     

C-reactive protein levels predict postoperative septic complications

We studied 108 patients undergoing clean-contaminated and dirty surgical procedures to determine whether daily C-reactive protein (CRP) measurements for 14 days postoperatively could predict the occurrence of septic complications prior to clinical diagnosis. Diagnostic criteria for septic complications and positive CRP response were defined in advance of the study. The CRP assays were carried out using an automated laser nephelometer system after the patient's discharge from the hospital. Forty-six septic complications were diagnosed in 40 patients. These complications consisted of wound infection (23), urinary tract infection (11), pneumonia (six), upper respiratory tract infection (three), intra-abdominal abscess (one), and other (two). The CRP testing was found to have a positive predictive value of 69% and a negative predictive value of 78%. We conclude that serial CRP measurements may be a valuable adjunct to surgical care in patients at high risk of postoperative septic complications.     

Development of an intravenous desferrioxamine mesylate treatment protocol for swine: monitoring of desferrioxamine and metabolites by high-performance liquid chromatography

Desferrioxamine (DFO) metabolism and its pharmacokinetics were studied in a swine model using high-performance liquid chromatography. DFO and three iron-binding metabolites occurred in plasma. Interindividual differences in pharmacokinetics and metabolism were observed. Urine analysis in 4 pigs showed three iron-binding metabolites. The mean percent dose excreted in urine in the form of the parent drug was 45 +/- 10% and 10 +/- 2% (means +/- SD) in the form of metabolites. Of the total amount of the parent drug infused, 3 h after initiation, 87% was in the form of DFO, whereas 13% was present as the DFO-iron III complex which represented 45 mg of urinary iron elimination. The described DFO infusion protocol provides for sufficient DFO to chelate significant amounts of ferric iron in excess of normal levels, thus allowing experimental studies of iron chelation in a variety of disease states.     

Percutaneous drainage of a tuberculous liver abscess

The authors describe the management by percutaneous drainage of a rare solitary tuberculous liver abscess in a 37-year-old woman. Open surgical drainage of such abscesses can be avoided using percutaneous drainage combined with transcatheter infusions of antituberculous agents. For the safe and successful use of this method three criteria must be met: the abscess should be unilocular, there must be a safe access route and a previously sterile compartment must not be contaminated. In addition a small (22 or 23 gauge) needle should be used for the initial puncture.     

PC-based system for collection and analysis of physiological data

A personal computer based system for data acquisition and analysis appropriate to physiological experiments is described in detail. The system is independent of the details of the analog signal generation. The software, written in C, is modular and easily portable to other PC systems. The system is capable of: (a) sampling many analog signals at an appropriate rate (100 Hz), (b) storing large quantities of digitized data, (c) analysing digitized waveforms to obtain signal parameters, and (d) storing signal parameters in a format suitable for statistical analysis. Computer processed cardiopulmonary data are compared with data derived from standard ICU equipment.     

Examining the relationship between the demand-control model and incident myocardial infarction and congestive heart failure in a representative sample of the employed women and men in Ontario,Canada, over a 15-year period

ObjectivesTo examine the relationship between job strain and incident myocardial infarction and congestive heart failure in a representative population of men and women in Ontario, Canada, over a 15-year period.MethodsA total of 14,508 respondents having provided responses to either the 2000/2001, 2002, or 2003 cycles of the Canadian Community Health Survey (CCHS) were aged 35 and older at the time and working. After removing respondents with pre-existing heart disease and missing data, our sample totaled 13,291 respondents. Responses were linked to administrative health care and hospitalization data to capture incident cases of myocardial infarction and congestive heart failure up to March 31, 2017. Job control and psychological demands were assessed using 5 items and 2 items respectively. A series of time-to-event regression models were run, adjusting sequentially for socio-demographic variables and health, other psychosocial work exposures, and health behaviours and body mass index.ResultsOver the study period, there were 199,583 person-years of follow-up (median follow-up: 15 years, 233 days). Higher incidence rates were observed for men (6.69 per 100 persons) than for women (2.77 per 100 persons). No clear relationship was observed for demand-control exposures and incidence of myocardial infarction and congestive heart failure in either men or women. After adjustment for socio-demographic factors, pre-existing health conditions, and other psychosocial exposures, the hazard ratio for high strain exposure (compared with low strain exposure) was 0.92 (0.46–1.84) for women and 0.75 (0.44–1.27) for men.ConclusionIn this large prospective cohort in Canada, we observed no relationship between components of the demand-control model and incident myocardial infarction and congestive heart failure over a 15-year period.     

Widening regional inequality in premature mortality rates in Manitoba

OBJECTIVE: To describe regional trends in premature mortality in Manitoba. DESIGN: Comparison of all-cause and cause-specific mortality of persons less than age 75 in 11 Regional Health Authority populations over two time periods: 1985-89 and 1990-94. RESULTS: The provincial premature mortality rate declined over the two time periods (4.00/1,000 to 3.72/1,000). Declines were also observed in 9 of 11 regional populations. Premature mortality increased, however, in the 2 regional populations with the highest mortality rates in the first observation period. CONCLUSION: Declining premature mortality in low mortality populations and rising premature mortality in high mortality populations has resulted in a widening of regional mortality rates in Manitoba. Recent policy initiatives in many provinces, including the devolution of authority for the management and delivery of health services and the implementation of population need-based funding formulas to share health care resources among regional health authorities, if implemented, have the potential to partially mitigate the processes producing these widening regional health inequalities.     

Predicting infection in localized intraabdominal fluid collections: value of pH and pO2 measurements

PURPOSE: To evaluate the use of pH, pO2, and the subjective opinion of the radiologist compared with bacterial culture in accurate diagnoses of bacterial infection in intraabdominal fluid collections. MATERIALS AND METHODS: Prospectively, 79 patients who were suspected of having an intraabdominal fluid collection underwent diagnostic fluid aspiration. The aspirate was cultured and measured for pH and pO2. A pH < or = 7.1 and a PO2 < or = 49 mm Hg were threshold values used to separate infected from sterile fluid collections. RESULTS: pH alone had a 92% sensitivity and 79% specificity, whereas PO2 alone had a 51% sensitivity and 79% specificity. pH or pO2 combined yielded a 92% sensitivity and 60% specificity. The radiologist's opinion produced a 83% sensitivity and 92% specificity. pH and the radiologist's opinion combined produced a 78% sensitivity and 96% specificity. pH or the radiologist's opinion combined had a 95% sensitivity and a 63% specificity. CONCLUSION: pH is the most sensitive indicator of infection and the radiologist's opinion is the most specific. We recommend proceeding to drainage if the radiologist believes the collection to be infected and performing pH analysis if not. If the pH < or = 7.04, proceed to drainage. If neither of the above criteria are met, drainage could be delayed, pending the results of culture.