Outcomes of second-tier rapid response activations in a tertiary referral hospital: A prospective observational study

INTRODUCTION@#A second-tier rapid response team (RRT) is activated for patients who do not respond to first-tier measures. The premise of a tiered response is that first-tier responses by a ward team may identify and correct early states of deterioration or establish goals of care, thereby reducing unnecessary escalation of care to the RRT. Currently, utilisation and outcomes of tiered RRTs remain poorly described.@*METHODS@#A prospective observational study of adult patients (age ≥18 years) who required RRT activations was conducted from February 2018 to December 2019.@*RESULTS@#There were 951 consecutive RRT activations from 869 patients and 76.0% patients had a National Early Warning Score (NEWS) ≥5 at the time of RRT activation. The majority (79.8%) of patients required RRT interventions that included endotracheal intubation (12.7%), point-of-care ultrasound (17.0%), discussing goals of care (14.7%) and intensive care unit (ICU) admission (24.2%). Approximately 1 in 3 (36.6%) patients died during hospitalisation or within 30 days of RRT activation. In multivariate analysis, age ≥65 years, NEWS ≥7, ICU admission, longer hospitalisation days at RRT activation, Eastern Cooperative Oncology Group performance scores ≥3 (OR [odds ratio] 2.24, 95% CI [confidence interval] 1.45-3.46), metastatic cancer (OR 2.64, 95% CI 1.71-4.08) and haematological cancer (OR 2.78, 95% CI 1.84-4.19) were independently associated with mortality.@*CONCLUSION@#Critical care interventions and escalation of care are common with second-tier RRTs. This supports the need for dedicated teams with specialised critical care services. Poor functional status, metastatic and haematological cancer are significantly associated with mortality, independent of age, NEWS and ICU admission. These factors should be considered during triage and goals of care discussion.

Zero Tolerance Towards Asthma Deaths in Singapore: Role of the Family Doctor

@#Asthma is a common chronic respiratory disease in Singapore and it is the primary cause of chronic respiratory disease burden in childhood and early adulthood. Despite having one of the best healthcare systems in the world, our asthma mortality rates are several folds higher than other first world countries. Most asthma deaths are preventable. We illustrate a case of fatal asthma and highlight some learning points from this case.

Therapeutic Observation of Needle Knife and Governor-Vessel Moxibustion plus Medication for Ankylosing Spondylitis / 上海针灸杂志

Objective To observe the clinical efficacy of needle knife, Governor-Vessel moxibustion plus medication in treating ankylosing spondylitis (AS).Method Forty AS patients were randomized into a treatment group and a control group, 20 cases in each group. The control group was intervened by intravenous administration of Ossotide injection, while the treatment group was by needle knife and Governor-Vessel moxibustion in addition to Ossotide injection. Before and after the intervention, the symptoms and body signs, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Bath Ankylosing Spondylitis Functional Index (BASFI) were observed in the two groups, and the clinical efficacies were compared between the two groups.Result The total effective rate was 90.0% in the treatment group versus 75.0% in the control group, and the between-group difference was statistically significant (P<0.05). After the intervention, the symptoms and body signs (spinal pain score, Schober test, morning stiffness duration, chest expansion degree, and occiput-wall distance) were changed significantly in both groups (P<0.05). The BASDAI and BASFI scores were significantly changed after the intervention in both groups (P<0.05). The BASDAI and BASFI scores in the treatment group were significantly different from those in the control group after the intervention (P<0.05).Conclusion Needle knife plus Governor-Vessel moxibustion and medication is an effective approach in treating AS.

A simplified approach to haemoptysis

Haemoptysis is commonly seen in the healthcare setting. It can lead to life-threatening complications and therefore requires careful evaluation of the severity and status of the patient. Common causes of haemoptysis can be broadly grouped into five main categories: infective, neoplastic, vascular, autoimmune and drug-related. Detailed history-taking and careful physical examination are necessary to provide a diagnosis and assess the patient's haemodynamic status. Physicians must have a clear understanding of the criteria for further investigations and the need for a specialist or inpatient referral for management.

Dual regulation effect of somatostatin on immunity in patients with severe sepsis caused by abdominal diseases / 中华外科杂志

<p><b>OBJECTIVE</b>to investigate the effect of somatostatin on inflammatory immune disorders and prognosis in patients with severe sepsis caused by abdominal diseases.</p><p><b>METHODS</b>fifty-three patients with severe abdominal sepsis (age > 18 years, APACHE-II score > 15) from June 2005 to June 2009 were randomly divided into Somatostatin group (n = 23) and SSC Group (n = 30). Fifteen healthy volunteers of the same age range were chosen as Control group. The SSC group was treated with classical SSC therapy, and the Somatostatin Group was treated with the same regime plus 14-peptide somatostatin continuous infusion at the dose of 6 mg/24 h for 7 days. The serum levels of interleukin-10 (IL-10), tumor necrosis factor-α (TNF-α) were determined by using ELISA. CD(4)(+), CD(8)(+) T cell subsets were determined by fluorescence activated cell sorter(FACS) and CD(4)(+)/CD(8)(+) was calculated. APACHE-II score was observed on admission (d1) and day 3, 7 and 14 after treatment. Morality rates in 28 days in two groups were recorded.</p><p><b>RESULTS</b>compared with Control group, IL-10 and TNF-α levels were significantly elevated in patients with severe abdominal sepsis (P < 0.05), while CD(4)(+), CD(8)(+) T cell and CD(4)(+)/CD(8)(+) decreased significantly (P < 0.05). Compared with the Somatostatin group CD(4)(+), CD(8)(+) T cell and CD(4)(+)/CD(8)(+) on d7 and d14 in SSC Group were significantly increased (P < 0.05), while IL-10 and TNF-α decreased significantly(P < 0.05). APACHE-II scores on d3, d7, d14 of Somatostatin group were significantly lower than those of SSC group, and 28 d mortality rate also declined.</p><p><b>CONCLUSIONS</b>in patients with severe abdominal sepsis, systemic inflammatory response and immune suppression exist simultaneously. Somatostatin has a dual immunomodulatory activity in these patients.</p>

Effect of the whey basic protein on bone mineral density / 中华预防医学杂志

<p><b>OBJECTIVE</b>To examine the effects of the whey basic protein on bone metabolism of Sprague-Dawley (SD) rats and healthy mid-aged women.</p><p><b>METHODS</b>Forty-four female SD rats were randomized by weight into four groups of eleven rats each and fed 10 mg x kg BW(-1) x d(-1), 20 mg x kg BW(-1) x d(-1), 30 mg x kg BW(-1) x d(-1) of whey basic protein and control diet was given respectively by intragastrically injection for 90 days. Bone mineral density of femur was measured by dual-energy X-ray absorptiometry in vitro. Sixty-three health women [(37.9 +/- 4.3) years old] were randomly assigned to treatment with placebo, 30 mg whey basic protein per day or 60 mg whey basic protein per day for 24 weeks. The bone mineral density (BMD) of the lumbar vertebrae L2-LA, femoral neck and right calcaneus of each subject were measured by dual-energy X-ray absorptiometry (DXA) at 0 and the 24th week of treatment. Serum bone specific alkaline phosphatase and N-telopeptide (NTX) were measured at 0 and the 14th week.</p><p><b>RESULTS</b>The mean BMD value of the distal end of the femur in 10 mg x kg BW(-1) x d(-1) whey basic protein group was significantly higher than that of the control group at the end of the trail. But after treatment by doses of whey basic protein used in the study, there were no differences between the control group and others groups on bone mineral density in the human trail.</p><p><b>CONCLUSION</b>Whey basic protein should enhance the bone mineral density of the rats' femur and no obvious effect was detected in the human trail.</p>

The Parsternal Impulse

The left parasternal impulse was evaluated by inspection and palpation, and it's contour was confirmed with graphic display using a pilse pickup in 45 normal subjects and 33 patients with various cardiac disease.Using an upper limit of normal echocardiographic LV end-diastolic dimension insides, 3.7cm/m2, LV mass index, 80g/m2, RV dimension index, 2.9cm/m2, and RV free wall thickness, 0.4cm, the patients were subdivided into four groups. In 9 patients with pure RV hypertrophy or dilation, the hyperdynamic impulse or sustained heave was noticed in 7 cases(sensitivity 78%, specificity 76%). In 12 patients with pure LV hypertrophy or dilation, striking parasternal systolic retraction was noticed in 5 cases(sensitivity 42%, speccificity 86%). But in 7 patient with biventricular hypertrophy or dilation, either striking systolic retraction or hyperdynamic impulse was noticed in 4 cases. These findings suggest that the evaluation of the parasternal movement is helpful for the cardiac examination.