Out-of-hours intensive care unit admission and 90-day mortality: a Danish nationwide cohort study.

BACKGROUND: Mortality rates in critically ill adult patients admitted to the intensive care unit (ICU) remains high, and numerous patient- and disease-related adverse prognostic factors have been identified. In recent years, studies in a variety of emergency conditions suggested that outcome is dependent on the time of hospital admission. The importance of out-of-hours admission to the ICU has been sparsely evaluated and with ambiguous findings. We assessed the association between out-of-hours (16:00 to 07:00) and weekend admission to the ICU, respectively, and 90-day mortality in a nationwide cohort. METHODS: We included all Danish adult patients admitted to the ICU between 1 January 2011 and 30 June 2014, with an ICU stay > 24 h. The crude and adjusted association between out-of-hours and weekend admission and 90-day mortality was assessed (odds ratio (ORs) with 95% confidence intervals (CI)). RESULTS: A total of 44,797 patients were included, 53.3% were admitted out-of-hours, and 22.6% during weekends. Median age was 67 years (interquartile range (IQR) 55-76), and median SAPS II was 42 (IQR 30-54). Patients admitted in-hours vs. out-of-hours displayed a 90-day mortality rate of 41.0% vs. 44.2%. The adjusted association (OR with 95% CI) between out-of-hours admission and 90-day mortality was 1.07 (1.02-1.11), and the adjusted association (OR with 95% CI) between weekend admission and 90-day mortality was 1.10 (1.05-1.15). CONCLUSION: This nationwide study suggests that critically ill adult patients admitted to the ICU during weekends and out-of-hours, and with an ICU stay > 24 h are at slightly increased risk of mortality.

Influence of body mass index on mortality after surgery for perforated peptic ulcer.

BACKGROUND: Body mass index (BMI) is a strong predictor of mortality in the general population. In spite of the medical hazards of obesity, a protective effect on mortality has been suggested in surgical patients: the obesity paradox. The aim of the present nationwide cohort study was to examine the association between BMI and mortality in patients treated surgically for perforated peptic ulcer (PPU). METHODS: This was a national prospective cohort study of all Danish patients treated surgically for PPU between 1 February 2003 and 31 August 2009, for whom BMI was registered. Non-surgically treated patients and those with malignant ulcers were excluded. The primary outcome measure was 90-day mortality. The association between BMI and mortality was calculated as crude and adjusted relative risks (RRs) with 95 per cent confidence intervals (c.i.). RESULTS: Of 2668 patients who underwent surgical treatment for PPU, 1699 (63.7 per cent) had BMI recorded. Median age was 69.4 (range 17.6-100.9) years and 53.7 per cent of the patients were women. Some 1126 patients (66.3 per cent) had at least one of six co-morbid diseases; 728 (42.8 per cent) had an American Society of Anesthesiologists grade of III or more. A total of 471 patients (27.7 per cent) died within 90 days of surgery. Being underweight was associated with a more than twofold increased risk of death following surgery for PPU (adjusted RR 2.26, 95 per cent c.i. 1.37 to 3.71). No statistically significant association was found between obesity and mortality. CONCLUSION: Being underweight was associated with increased mortality in patients with PPU, whereas being overweight or obese was neither protective nor an adverse prognostic factor.

Surgical delay is a critical determinant of survival in perforated peptic ulcer.

BACKGROUND: Morbidity and mortality following perforated peptic ulcer (PPU) remain substantial. Surgical delay is a well established negative prognostic factor, but evidence derives from studies with a high risk of bias. The aim of the present nationwide cohort study was to evaluate the adjusted effect of hourly surgical delay on survival after PPU. METHODS: This was a cohort study including all Danish patients treated surgically for PPU between 1 February 2003 and 31 August 2009. Medically treated patients and those with a malignant ulcer were excluded. The associations between surgical delay and 30-day survival are presented as crude and adjusted relative risks (RRs) with 95 per cent confidence intervals (c.i.). RESULTS: A total of 2668 patients were included. Their median age was 70·9 (range 16·2-104·2) years and 55·4 per cent (1478 of 2668) were female. Some 67·5 per cent of the patients (1800 of 2668) had at least one of six co-morbid diseases and 45·6 per cent had an American Society of Anesthesiologists fitness grade of III or more. A total of 708 patients (26·5 per cent) died within 30 days of surgery. Every hour of delay from admission to surgery was associated with an adjusted 2·4 per cent decreased probability of survival compared with the previous hour (adjusted RR 1·024, 95 per cent c.i. 1·011 to 1·037). CONCLUSION: Limiting surgical delay in patients with PPU seems of paramount importance.

Conditioning-specific reflex modification of the rabbit (Oryctolagus cuniculus) nictitating membrane response: generality and nature of the phenomenon.

Conditioning-specific reflex modification (CRM) occurs when classical conditioning modifies responding to an unconditioned stimulus in the absence of a conditioned stimulus. This form of reflex modification suggests that learning modifies the unconditioned reflex pathway. Rabbit (Oryctolagus cuniculus) nictitating membrane responses to 5 intensities and 3 durations of airpuff (AP) or periorbital electrical stimulation (ES) were monitored before and after conditioning. AP tests detected strong CRM after conditioning with ES and modest levels of CRM after conditioning with AP. After conditioning with AP, ES tests failed to detect CRM. After conditioning with a stronger AP, CRM was again detected by AP tests. CRM is a general phenomenon but is more readily detected after training with a relatively aversive stimulus; thus, it may be a function of level of arousal.

Conditioning the unconditioned response: modification of the rabbit's (Oryctolagus cuniculus) unconditioned nictitating membrane response.

Conditioning-specific reflex modification (CRM) occurs when classical conditioning modifies responding to an unconditioned stimulus (US) in the absence of a conditioned stimulus (CS). Three experiments monitored rabbit nictitating (Oryctolagus cuniculus) membrane unconditioned responses to 5 intensities and 4 durations of periorbital electrical stimulation before and after CS or US manipulation. CRM occurred after 12 days of CS-US pairings but not following unpaired CS/US presentations or restraint. CRM survived CS-alone and CS/US-unpaired extinction of the conditioned response (CR) but not presentations of the US alone, although CRs remained intact. Thus, CRs could be weakened without eliminating CRM and CRM could be weakened without eliminating CRs. Data indicate CRM is a reliable, associative effect that is more than a generalized CR and may not be explained by habituation, stimulus generalization, contextual conditioning, or bidirectional conditioning.

Comparison of right ventricular outflow tract and apical lead permanent pacing on cardiac output.

Cardiac output was measured in 89 patients using transthoracic continuous-wave echo Doppler comparing right ventricular outflow tract pacing with the right ventricular apex at the time of permanent pacemaker implantation. Overall, cardiac output improved 18.8% (p <0.0001) and cardiac index 21.0% (p <0.0001) with outflow tract placement; patients with a lower baseline cardiac index had a greater percent improvement with outflow tract placement.

Effect of tetrahydroaminoacridine, a cholinesterase inhibitor, on cognitive performance following experimental brain injury.

An emerging literature exists in support of deficits in cholinergic neurotransmission days to weeks following experimental traumatic brain injury (TBI). In addition, novel cholinomimetic therapeutics have been demonstrated to improve cognitive outcome following TBI in rats. We examined the effects of repeated postinjury administration of a cholinesterase inhibitor, tetrahydroaminoacridine (THA), on cognitive performance following experimental TBI. Rats were either injured at a moderate level of central fluid percussion TBI (2.1+/-0.1 atm) or were surgically prepared but not delivered a fluid pulse (sham injury). Beginning 24 h after TBI or sham injury, rats were injected (IP) daily for 15 days with an equal volume (1.0 ml/kg) of either 0.0, 1.0, 3.0, or 9.0 mg/kg THA (TBI: n = 8, 8, 10, and 7, respectively, and Sham: n = 5, 7, 8, 7, respectively). Cognitive performance was assessed on Days 11-15 after injury in a Morris water maze (MWM). Analysis of maze latencies over days indicated that chronic administration of THA produced a dose-related impairment in MWM performance in both the injured and sham groups, with the 9.0 mg/kg dose producing the largest deficit. The 1.0 and 3.0 mg/kg doses of THA impaired MWM performance without affecting swimming speeds. Thus, the results of this investigation do not support the use of THA as a cholinomimetic therapeutic for the treatment of cognitive deficits following TBI.

Working memory deficits following traumatic brain injury in the rat.

This study was designed to examine working memory following fluid-percussion traumatic brain injury (TBI) using the Morris water maze (MWM). Rats were injured (n = 9) at a moderate level of central fluid percussion injury (2.1 atm) or were prepared for injury but did not receive a fluid pulse (sham injury) (n = 10). On days 11-15 postinjury, working memory was assessed using the MWM. Each animal received 8 pairs of trials per day. For each pair of trials, animals were randomly assigned to one of four possible starting points and one of four possible escape platform positions. On the first trial of each pair, rats were placed in the maze facing the wall and were given 120 sec to locate the hidden escape platform. After remaining on the goal platform for 10 sec, they were placed back into the maze for the second trial of the pair. The platform position and the start position remained unchanged on this trial. After the second trial, the animal was given a 4 min intertrial rest. Between pairs of trials, both the start position and the goal location were changed. Analyses of the latency to reach the goal platform indicated that sham-injured animals performed significantly better on the second trial than on the first trial of each pair. However, injured animals did not significantly differ between first and second trial goal latencies on any day. These results indicate that injured animals have a profound and enduring deficit in spatial working memory function on days 11-15 after TBI.

A longitudinal study of nose growth from ages 6 to 18.

The purpose of this study was to investigate nose maturation by cephalometric sagittal surface area methodology longitudinally in males and females. Both males and females exhibited a statistically significant continuum of nose growth from ages 6 to 18. Growth ceased in both sexes at age 18. Correlation coefficients indicated that males' noses tended to be either large or small in all dimensions from ages 6 to 18. The same was not true for females. A major finding of possible clinical importance was that maturity is reached at age 12 in girls with 84% of adult area, and in boys at age 15 with 87% of adult size.

Force production decay rate in Alastik modules.

The production and decay of forces produced by Alastik modules was studied under conditions simulating clinical usage over time period of 2 hr to 4 weeks. Force decay was moderate and all Kx modules tested produced approximately 1 lb of force at the end of the 4-week test period. Therefore, from a clinical standpoint, modules need not be changed more frequently than once every 4 weeks.

Paranasal aspergilloma caused by an albino variant of Aspergillus fumigatus.

An unusual case of aspergilloma in the maxillary sinus caused by an albino variant of Aspergillus fumigatus var ellipticus is presented. Removal of the fungus ball by a left Caldwell-Luc procedure resulted in complete recovery for the patient. This case is the 17th culturally proven case of paranasal aspergilloma caused by A fumigatus, the third case reported from the United States, the first case due to aspergillosis caused by an albino strain of A fumigatus.