Emergency responses for clinical deterioration within and beyond 24 hours of emergency admission: Patient outcomes and ICU implications

Introduction: The National Emergency Access Target was implemented to ensure 90% of patients leave emergency departments (EDs) within 4h. The impact of time driven performance on the number of physiologically unstable ward-based patients is unknown. An increase in clinical deterioration episodes potentially leading to adverse events will have resource implications for intensive care units (ICUs).
Objectives: To compare the characteristics and outcomes of patients who required an emergency response for clinical deterioration (cardiac arrest team or rapid response system activation) within and beyond 24 h of emergency admission to general medical and surgical units.
Methods: A retrospective exploratory design was used. The study site was a 365 bed urban hospital in Melbourne. Emergency responses for clinical deterioration during 2012 were examined.
Results: Of 819 emergency responses for clinical deterioration, 587 patients were admitted via ED. The median time to first responsewas59h, 28.4% of patients required this <24 h after admission. One in eight patients required ICU admission. Comparison of patients requiring a response within and beyond 24h of admission showed no significant differences in age, gender, waiting times, ED length of stay or in-hospital mortality rates. Patients in whom first emergency response occurred <24h after admission were less likely to be admitted to ICU immediately following the emergency response (7.6% vs 13.9%, p-0.039), less likely to have recurrent emergency responses during their hospitalisation (9.7% vs 34.0%, p<0.001), and had shorter median hospital length of stay (7 vs 11 days, p<0.001).
Conclusions: Considerable ICU resources were utilised given one in eight patients required ICU admission following emergency response, and patients admitted via the ED constituted 55% of all rapid response system activations. Exploring potential antecedents to clinical deterioration in this cohort may assist in establishing risk management strategies to reduce utilisation of ICU resources.

Structured type 1 diabetes education delivered in routine care in Australia reduces diabetes-related emergencies and severe diabetes-related distress: the OzDAFNE program

AIMS: To evaluate structured type 1 diabetes education delivered in routine practice throughout Australia.

METHODS: Participants attended a five-day training program in insulin dose adjustment and carbohydrate counting between April 2007 and February 2012. Using an uncontrolled before-and-after study design, we investigated: HbA1c (% and mmol/mol); severe hypoglycaemia; diabetes ketoacidosis (DKA) requiring hospitalisation, and diabetes-related distress (Problem Areas in Diabetes scale; PAID), weight (kg); body mass index. Data were collected pre-training and 6-18 months post-training. Change in outcome scores were examined overall as well as between groups stratified by baseline HbA1c quartiles. Data are mean±SD or % (n).

RESULTS: 506 participants had data eligible for analysis. From baseline to follow-up, significant reductions were observed in the proportion of participants reporting at least one severe hypoglycaemic event (24.7% (n=123) vs 12.1% (n=59), p<0.001); and severe diabetes-related distress (29.3% (n=145) vs 12.6% (n=60), p<0.001). DKA requiring hospitalisation in the past year reduced from 4.1% (n=20) to 1.2% (n=6). For those with above target baseline HbA1c there was a small, statistically significant improvement (n=418, 8.4±1.1% (69±12mmol/mol) to 8.2±1.1% (66±12mmol/mol). HbA1c improvement was clinically significant among those in the highest baseline quartile (n=122, 9.7±1.1% (82±11mmol/mol) to 9.0±1.2% (75±13mmol/mol), p<0.001).

CONCLUSIONS: The proportion of participants reporting severe hypoglycaemia, DKA and severe diabetes-related distress was at least halved, and HbA1c reduced by 0.7% (7mmol/mol) among those with highest baseline levels. Structured type 1 diabetes education delivered in routine practice offers clinically important benefits for those with greatest clinical need.

Pro-inflammatory dietary intake as a risk factor for CVD in men: a 5-year longitudinal study

Convincing evidence has identified inflammation as an initiator of atherosclerosis, underpinning CVD. We investigated (i) whether dietary inflammation, as measured by the 'dietary inflammatory index (DII)', was predictive of 5-year CVD in men and (ii) its predictive ability compared with that of SFA intake alone. The sample consisted of 1363 men enrolled in the Geelong Osteoporosis Study who completed an FFQ at baseline (2001-2006) (excluding participants who were identified as having previous CVD). DII scores were computed from participants' reported intakes of carbohydrate, micronutrients and glycaemic load. DII scores were dichotomised into a pro-inflammatory diet (positive values) or an anti-inflammatory diet (negative values). The primary outcome was a formal diagnosis of CVD resulting in hospitalisation over the 5-year study period. In total, seventy-six events were observed during the 5-year follow-up period. Men with a pro-inflammatory diet at baseline were twice as likely to experience a CVD event over the study period (OR 2·07; 95 % CI 1·20, 3·55). This association held following adjustment for traditional CVD risk factors and total energy intake (adjusted OR 2·00; 95 % CI 1·03, 3·96). This effect appeared to be stronger with the inclusion of an age-by-DII score interaction. In contrast, SFA intake alone did not predict 5-year CVD events after adjustment for covariates (adjusted OR 1·40; 95 % CI 0·73, 2·70). We conclude that an association exists between a pro-inflammatory diet and CVD in Australian men. CVD clinical guidelines and public health recommendations may have to expand to include dietary patterns in the context of vascular inflammation.

Patient engagement in clinical communication: an exploratory study

AIM: Existing practice strategies for actively involving patients in care during hospitalisation are poorly understood. The aim of this study was to explore how healthcare professionals engaged patients in communication associated with care transitions.

METHOD: An instrumental, collective case study approach was used to generate empirical data about patient transitions in care. A purposive sample of key stakeholders representing (i) patients and their families; (ii) hospital discharge planning team members; and (iii) healthcare professionals was recruited in five Australian health services. Individual and group semi-structured interviews were conducted to elicit detailed explanations of patient engagement in transition planning. Interviews lasted between 30 and 60 minutes and were digitally recorded and transcribed verbatim. Data collection and analysis were conducted simultaneously and continued until saturation was achieved. Thematic analysis was undertaken.

RESULTS: Five themes emerged as follows: (i) organisational commitment to patient engagement; (ii) the influence of hierarchical culture and professional norms on patient engagement; (iii) condoning individual healthcare professionals' orientations and actions; (iv) understanding and negotiating patient preferences; and (v) enacting information sharing and communication strategies. Most themes illustrated how patient engagement was enabled; however, barriers also existed.

CONCLUSION: Our findings show that strong organisational and professional commitment to patient-centred care throughout the organisation was a consistent feature of health services that actively engaged patients in clinical communication. Understanding patients' needs and preferences and having both formal and informal strategies to engage patients in clinical communication were important in how this involvement occurred.

Incident delirium in the acute general medical setting

 Delirium is a serious neuro‐cognitive disorder that affects many people admitted to hospital. Results of this research have contributed valuable knowledge regarding the risk factors, health outcomes and management of medical patients with who developed incident delirium during hospitalisation.

Eficácia da fisioterapia respiratória em pacientes pediátricos hospitalizados com pneumonia adquirida na comunidade : um ensaio clínico randomizado

Objetivo: Avaliar a eficácia da fisioterapia respiratória como tratamento adjuvante em pacientes pediátricos com pneumonia adquirida na comunidade. Delineamento: Ensaio clínico randomizado Local do estudo: Hospital da Criança Santo Antônio – Complexo Hospitalar Santa Casa, Porto Alegre, Brasil. Participantes e métodos: Foram arroladas crianças com idade entre 1 e 12 anos, com diagnóstico clínico e radiológico confirmado de pneumonia, hospitalizadas no período de setembro de 2001 a setembro de 2002. Os pacientes que preencheram os critérios de inclusão foram randomizados para receber fisioterapia respiratória três vezes ao dia (grupo intervenção) ou para receber, uma vez ao dia, orientações para respirar profundamente, expectorar a secreção e manter preferencialmente o decúbito lateral (grupo controle). As variáveis analisadas na linha de base, no primeiro e no segundo períodos de seguimento e no dia da alta hospitalar foram: escore de gravidade (composto pela freqüência respiratória anormal para a idade, tiragem supra-esternal, intercostal, e subcostal, febre, saturação de oxigênio da hemoglobina e raio-x de tórax), duração da hospitalização, freqüência respiratória, temperatura e saturação do oxigênio. Resultados: Setenta e dois pacientes foram randomizados para os grupos intervenção ou controle. Destes, sete foram retirados devido a complicações como atelectasia ou drenagem pleural. Dentre os 65 pacientes estudados no primeiro seguimento (terceiro dia), a febre foi mais prevalente no grupo intervenção (34,4%) do que no grupo controle (12,5%), bem como o escore de gravidade 9,63 ± 1,62 e 8,71 ± 0,86 pontos, respectivamente. No segundo seguimento, entre o quarto e sexto dia, a diferença entre os grupos teve tendência à significância apenas para febre, 31,6% no grupo intervenção e 6,7% no grupo controle (P= 0,07). A duração média da hospitalização foi de 7,41 ± 6,58 dias para o grupo intervenção e 4,52 ± 2,21 dias para o controle. Conclusão: Neste ensaio clínico, a fisioterapia prolongou a hospitalização e a duração da febre nos pacientes pediátricos com pneumonia adquirida na comunidade. Nestes pacientes, a fisioterapia é prejudicial e não deveria ser prescrita até que evidências de benefício estejam disponíveis.

Omentalisation as a treatment for prostatic cysts and abscesses

Seven dogs with prostatic retention cysts and three with prostatic abscess were referred for prostatic omentalisation and were discharged 72 hours later. Eight dogs had an uneventful recovery while one dog had a minor incontinence for two days. One dog died due to a previous long-term sepsis. The low incidence of post-operative complications and brief hospitalisation period make omentalisation the surgery of choice for the treatment of prostatic cysts and abscess.

Eficácia e segurança de uma vacina oral de rotavírus humano atenuado contra gastroenterite grave por rotavírus, durante os primeiros dois anos de vida em crianças em Belém, Pará, Brasil

Os rotavírus se constituem nos principais agentes causadores de gastroenterite grave entre crianças com idades inferiores a 5 anos, tanto nos países desenvolvidos quanto naqueles em desenvolvimento, com pico de incidência entre 6 e 24 meses de vida. Em termos globais, estima-se que pelo menos 500.000 óbitos por ano se associem a esse enteropatógeno. Um extenso ensaio clínico de fase 111, randomizado na proporção de 1 :1, controlado por placebo e duplo-cego, envolvendo 11 países da América Latina e a Finlândia se levou a efeito objetivando-se avaliar a eficácia e segurança de uma vacina atenuada, de origem humana, contra rotavírus, denominada RIX4414. Na totalidade, recrutaram-se mais de 63.000 crianças. Em Belém, Pará, tais estudos envolveram 3.218 indivíduos aos quais se administraram duas doses de vacina ou placebo, no segundo e quarto meses de idade. Desse total avaliou-se um subgrupo de 653 crianças quanto à eficácia da vacina, com acompanhamento ao longo de 1 a 2 anos, quando se registraram 37 episódios de GE grave por rotavírus, 75,6% (28/37) dos quais no grupo placebo e 24,3% (9/37) entre os vacinados, daí se inferindo eficácia da vacina de 68,8% (IC95% 32.0-87,0) nos primeiros dois anos de vida. No que se refere à intensidade desses episódios, notou-se maior eficácia contra os classificados como muito graves (escore de Ruuska & Vesikari ≥ 15), alcançando níveis de 83% (IC95% 22-96). No grupo placebo observou-se risco cumulativo, quanto ao desenvolvimento de gastroenterite grave por rotavírus, 4 vezes superior em relação ao vacinado. Quanto aos sorotipos de rotavírus G1 e não-G1, evidenciou-se proteção de 51 % (IC95% -30 - 81) e 82% (IC95% 37-95), respectivamente, denotando-se proteção tanto homotípica quanto heterotípica. De particular relevância se constituiu a proteção frente ao G9 [93% (IC95% 47-99)], dado o caráter emergente global desse sorotipo, além do seu potencial quanto a desencadear quadros diarréicos rotineiramente mais graves. A eficácia da vacina contra episódios de GE de qualquer etiologia alcançou 35,3% (IC95% 11,6-52,9), do que se depreende o expressivo impacto em potencial da vacinação contra rotavírus em termos de saúde pública. No que se refere à segurança desse imunizante, não se observaram diferenças significativas do ponto de vista estatístico, entre os grupos vacina e placebo, no que concerne à ocorrência de eventos adversos graves. Não se registrou qualquer caso de intussuscepção entre os sujeitos participantes, mercê de extensiva vigilância ativa nos hospitais de referência. Os resultados encontrados nesse estudo corroboram os já descritos em ensaios multicêntricos como um todo, em vários continentes, consolidando os indicadores quanto à eficácia e segurança da vacina RIX4414 quando administrada em duas doses a crianças saudáveis.

Haemodynamic effects of aliskiren in decompensated severe heart failure

Aim: The renin-angiotensin-aldosterone system (RAAS) has dual pathways to angiotensin II production; therefore, multiple blockages may be useful in heart failure. In this study, we evaluated the short-term haemodynamic effects of aliskiren, a direct renin inhibitor, in patients with decompensated severe heart failure who were also taking angiotensin-converting enzyme ( ACE) inhibitors. Materials and methods: A total of 16 patients (14 men, two women, mean age: 60.3 years) were enrolled in the study. The inclusion criteria included hospitalisation due to decompensated heart failure, ACE inhibitor use, and an ejection fraction < 40% (mean: 21.9 +/- 6.7%). The exclusion criteria were: creatinine > 2.0 mg/dl, cardiac pacemaker, serum K+ > 5.5 mEq/l, and systolic blood pressure < 70 mmHg. Patients either received 150 mg/d aliskiren for 7 days (aliskiren group, n = 10) or did not receive aliskiren (control group, n = 6). Primary end points were systemic vascular resistance and cardiac index values. Repeated-measures analysis of variance (ANOVA) was used to assess variables before and after intervention. A two-sided p-value < 0.05 was considered statistically significant. Results: Compared to pre-intervention levels, systemic vascular resistance was reduced by 20.4% in aliskiren patients, but it increased by 2.9% in control patients (p = 0.038). The cardiac index was not significantly increased by 19.0% in aliskiren patients, but decreased by 8.4% in control patients (p = 0.127). No differences in the pulmonary capillary or systolic blood pressure values were observed between the groups. Conclusion: Aliskiren use reduced systemic vascular resistance in patients with decompensated heart failure taking ACE inhibitors.

Hantavirus pulmonary syndrome: prognostic factors for death in reported cases in Brazil

Hantavirus pulmonary syndrome (HPS) was described for the first time in Brazil in 1993 and has occurred endemically throughout the country. This study analysed clinical and laboratory aspects as well as death-related factors for HPS cases in Brazil from 1993 to 2006. The investigation comprised a descriptive and exploratory study of the history of cases as well as an analytical retrospective cohort survey to identify prognostic factors for death due to HPS. A total of 855 Brazilian HPS cases were assessed. The majority of cases occurred during spring (33.5%) and winter (27.6%), mainly among young male adults working in rural areas. The global case fatality rate was 39.3%. The mean interval between the onset of symptoms and hospitalisation was 4 days and that between hospitalisation and death was 1 day. In the multiple regression analysis, adult respiratory distress syndrome and mechanical respiratory support were associated with risk of death; when these two variables were excluded from the model, dyspnoea and haemoconcentration were associated with a higher risk of death. (C) 2012 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.

Innovative analytical methods for Central Nervous System Drug analysis in biological fluids

During recent years a consistent number of central nervous system (CNS) drugs have been approved and introduced on the market for the treatment of many psychiatric and neurological disorders, including psychosis, depression, Parkinson disease and epilepsy. Despite the great advancements obtained in the treatment of CNS diseases/disorders, partial response to therapy or treatment failure are frequent, at least in part due to poor compliance, but also genetic variability in the metabolism of psychotropic agents or polypharmacy, which may lead to sub-therapeutic or toxic plasma levels of the drugs, and finally inefficacy of the treatment or adverse/toxic effects. With the aim of improving the treatment, reducing toxic/side effects and patient hospitalisation, Therapeutic Drug Monitoring (TDM) is certainly useful, allowing for a personalisation of the therapy. Reliable analytical methods are required to determine the plasma levels of psychotropic drugs, which are often present at low concentrations (tens or hundreds of nanograms per millilitre). The present PhD Thesis has focused on the development of analytical methods for the determination of CNS drugs in biological fluids, including antidepressants (sertraline and duloxetine), antipsychotics (aripiprazole), antiepileptics (vigabatrin and topiramate) and antiparkinsons (pramipexole). Innovative methods based on liquid chromatography or capillary electrophoresis coupled to diode-array or laser-induced fluorescence detectors have been developed, together with the suitable sample pre-treatment for interference removal and fluorescent labelling in case of LIF detection. All methods have been validated according to official guidelines and applied to the analysis of real samples obtained from patients, resulting suitable for the TDM of psychotropic drugs.

[Right-sided lower abdominal pain and diarrhea of a young diabetic woman]

We report the case of a 24-years old diabetic women hospitalised because of right-sided lower abdominal pain and diarrhea. She fulminantly developed shock before appendectomy could be performed and was transferred to intensive care unit. Hypotension remained and laparoscopy revealed primary peritonitis and toxic shock syndrome by Group A Streptococcus which was cultivated in blood and ascites. Therapy with penicilline and clindamycine resolved symptoms. During hospitalisation Clostridium difficile colitis occurred. This complication leaded to prolonged hospitalisation.

Respiratory symptoms in preterm infants: burden of disease in the first year of life

Objective While respiratory symptoms in the first year of life are relatively well described for term infants, data for preterm infants are scarce. We aimed to describe the burden of respiratory disease in a group of preterm infants with and without bronchopulmonary dysplasia (BPD) and to assess the association of respiratory symptoms with perinatal, genetic and environmental risk factors. Methods Single centre birth cohort study: prospective recording of perinatal risk factors and retrospective assessment of respiratory symptoms during the first year of life by standardised questionnaires. Main outcome measures: Cough and wheeze (common symptoms), re-hospitalisation and need for inhalation therapy (severe outcomes). Patients: 126 preterms (median gestational age 28.7 weeks; 78 with, 48 without BPD) hospitalised at the University Children's Hospital of Bern, Switzerland 1999-2006. Results Cough occurred in 80%, wheeze in 44%, rehospitalisation in 25% and long term inhalation therapy in wheezers in 13% of the preterm infants. Using logistic regression, the main risk factor for common symptoms was frequent contact with other children. Severe outcomes were associated with maximal peak inspiratory pressure, arterial cord blood pH, APGAR and CRIB-Score. Conclusions Cough in preterm infants is as common as in term infants, whereas wheeze, inhalation therapy and re-hospitalisations occur more often. Severe outcomes are associated with perinatal risk factors. Preterm infants who did not qualify for BPD according to latest guidelines also showed a significant burden of respiratory disease in the first year of life.

Occurrence of systemic hypertension in dogs with acute kidney injury and treatment with amlodipine besylate

OBJECTIVES: To describe the occurrence of systemic hypertension in dogs with acute kidney injury and the efficacy of amlodipine besylate for its treatment. METHODS: This retrospective study included 52 dogs with acute kidney injury (2007 to 2008) grouped based on the use of amlodipine in their treatment. Systemic blood pressure was measured with an oscillometric device at admission, before, during, and after amlodipine therapy. RESULTS: Occurrence of systolic systemic hypertension (>/=160 mmHg) and severe systolic systemic hypertension (>/=180 mmHg) was 37% and 15% at admission and increased with hospitalisation to 81% and 62%, respectively. Twenty-two dogs were treated with amlodipine, at a median daily dosage of 0.38 mg/kg (interquartile range 0.28 to 0.49) divided in one to two applications per day. Amlodipine therapy was associated with a decrease in systolic systemic blood pressure of 24 mmHg (12 to 34) and a correction of severe systemic hypertension in 10 of 11 dogs within 24 hours. Overall, 73% of the dogs survived with a significantly lower proportion of survivors in treated compared to non-treated dogs (59% versus 83%, respectively, P=0.05). CLINICAL SIGNIFICANCE: Results of this study reveal that systemic hypertension is common in canine acute kidney injury and that treatment with amlodipine is beneficial in reducing systemic hypertension. The potential effect of amlodipine on global outcome requires prospective assessment.

Charakteristika schwer essgestörter Patientinnen in einer universitären Einrichtung und therapeutische Richtlinien

Patientinnen und Patienten mit einer schweren Essstörung (Anorexie, Bulimie, weitere) finden einerseits selten Eingang in systematische Studien, sind andererseits aber häufig auf ein stationäres Behandlungssetting in einem tertiären Zentrum angewiesen. Die kürzlich veröffentlichte S3-Leitlinie zur Behandlung von Essstörungen erlaubt eine klarere Einschätzung der Hospitalisationsbedürftigkeit schwer Essgestörter als bisher. In der vorliegenden Arbeit wurden 26 Patientinnen und Patienten mit einer schweren Essstörung, die konsekutiv auf einer spezialisierten psychosomatisch/internistischen universitären Einrichtung hospitalisiert wurden, retrospektiv hinsichtlich ihrer biologischen, psychologischen und sozialen Merkmale charakterisiert und in Bezug zur S3-Leitlinie gestellt. Die biopsychosozialen Charakteristika der untersuchten Population zeigen, dass die Hospitalisierung schwer Essgestörter im tertiärmedizinischen Setting mit einem multiprofessionellen Behandlungsteam evidenzbasiert erfolgt.