Measures of acute physiology, comorbidity and functional status to differentiate illness severity and length of stay among acute general medical admissions: a prospective cohort study.

BACKGROUND: Simple measures of acute physiologic compromise, functional status and comorbidity may help clinicians to make decisions relating to clinical care and resource utilisation. AIMS: To explore the usefulness of common assessment tools in predicting outcomes of (i) death or intensive care unit (ICU) admission and (ii) length of hospital stay at a busy tertiary hospital in Singapore. METHODS: Three hundred and ninety-eight consecutive admissions to two general medicine teams were prospectively assessed during 2 months in 2011. Patients were followed until discharge or transfer to ICU/high dependency unit (HDU). Data collected included routine demographic data, final diagnosis, comorbid conditions including a weighted prognostic comorbidity index (the updated Charlson index) and the modified Early Warning Score (MEWS) at presentation to the emergency department. The admission modified Barthel Index was recorded for patients aged 65 and over. Death and total length of hospital stay were recorded in all cases. RESULTS: Of 398 patients, 16 (4 %) died or were transferred to ICU and 99 (25%) stayed for more than 7 days. Medical early warning (MEW) scores of ≥5 were significantly associated with death or ICU admission (hazard ratio 5.50, 95% confidence interval 1.77-17.07, P = 0.003). There was no independent association between this outcome and the Charlson score or admission Barthel Index. Excess length of stay was associated with a modified Barthel Index ≤17 and altered mental status at presentation. CONCLUSION: Among unselected general medical patients, MEW scores of ≥5 were significantly associated with death or ICU admissions and only functional status and altered mental status were independent predictors of excess length of stay.

Severe sepsis: take care, take part.

Severe sepsis is defined as organ dysfunction in the setting of systemic inflammatory response due to infection. With changes in population age, comorbidity and the delivery of medical care, severe sepsis is increasingly common, and can present in every area of the hospital. The major obstacles to improved outcomes in severe sepsis are deficiencies in healthcare staffing and education, haphazard recognition and response to early clinical deterioration and deviation from optimal management as defined by international guidelines. Major treatment errors were identified in 30% of patients with bacteraemia in one recent investigation. Against this, substantial reductions in mortality can be achieved by improving recognition, urgent care and resuscitation. With a view to improving survival in sepsis, collaborative efforts are required to measure outcomes, implement guidelines and secure adequate funding for ongoing practice improvement, education and research.

Population-based epidemiology of Staphylococcus aureus bloodstream infection in Canterbury, New Zealand.

BACKGROUND: Few contemporary reports describe population-based incidence of Staphylcoccus aureus bloodstream infection (SABSI). AIM: To describe longitudinal incidence of SABSI in a region of New Zealand with low MRSA prevalence. METHODS: Blood cultures growing S. aureus were identified from hospital laboratories between 1 July 1998 and 30 June 2006. Record linkage was used to combine information from local and national databases into a single patient event record. Information from the New Zealand census was used to determine regional incidence of disease. An address-based measure of deprivation was used to analyse the relationship between incidence and socioeconomic status. Morbidity data were not collected. RESULTS: 779 patients with SABSI were identified (482/779 (62%) male, 297/779 (38%) female). The crude incidence of S. aureus bacteraemia varied between 18.5-27.3/100 000 per annum. Three of 779 isolates (0.4%) were MRSA. Two hundred and seventy-seven of 776 (36%) patients with complete records had hospital-acquired SABSI. One hundred and forty-one of 778 patients (18%) died within 30 days and 235/778 (30%) died within a year. Proportional hazards survival models significantly associated age, male sex and more than 14 days of hospitalization in the year prior to index culture with adverse outcome. Higher socioeconomic status was associated with lower rates of SABSI (adjusted rate ratio 0.74, 95% confidence interval: 0.56-0.98, P= 0.007 after adjustment for age and sex, and comparing the highest and lowest deprivation quintiles). CONCLUSION: Population factors significantly influence SABSI incidence and survival. Further research is required to determine whether these have the potential to invalidate inter-hospital comparison of SABSI incidence as a measure of health-care quality.

Concomitant Staphylococcus aureus bacteriuria is associated with poor clinical outcome in adults with S. aureus bacteraemia.

A retrospective cohort study was undertaken to determine the prognostic significance of Staphylococcus aureus bacteriuria in patients presenting to our hospital with S. aureus bacteraemia between January 2000 and December 2003. A total of 378 patients had at least one positive blood culture for S. aureus, of whom 221 had urine cultured within 24h of presentation. For this group, 206 case records could be retrieved for review. Of these patients, all had meticillin-susceptible S. aureus bacteraemia and 35 (17%) had S. aureus cultured in urine. Logistic regression analysis was used to control for age, genitourinary tract status and comorbidity. Concomitant S. aureus bacteriuria persisted as a significant risk factor for ICU admission [risk ratio (RR): 2.5; 95% confidence interval (CI): 1.06-4.36; P=0.04] and in-hospital mortality (RR: 2.18; 95% CI: 1.05-3.57; P=0.04). Other findings were that cerebrovascular disease in males and increasing age in both sexes were associated with in-hospital and one-year mortality. Prospective studies are warranted exploring the link between S. aureus bacteriuria and clinical outcome in patients with S. aureus bacteraemia.

Health effects of war are devastating: pre-emptive war demands pre-emptive criticism by the medical profession.

The negative health effects of the 2003 invasion of Iraq should act as a watershed in the medical profession's approach to violent conflict.

Plasma glycocalicin levels are not elevated in patients with a history of transient ischaemic event and are normal in aspirinated normal volunteers.

Glycocalicin (GC) is the soluble portion of platelet membrane protein GP1b, and may be cleaved from the platelet surface during platelet activation. Previous study has indicated that plasma glycocalicin/platelet (GC/plt) levels are elevated in patients presenting with acute stroke. The present study was undertaken to determine the GC/plt levels in patients being treated for transient ischaemic episodes, to assess whether the elevated GC/plt level in acute stroke is due to a detectable, constitutive premorbid state of platelet activation. In sixteen consecutive patients attending a vascular surgery clinic, GC levels were measured on a citrated plasma sample, and corrected for circulating platelet count. Since 15 of 16 patients were taking aspirin when seen at clinic, a control study was undertaken to assess the effect of aspirin on sequential plasma GC/plt levels measured over 10 days--5 pre and post daily aspirin for 5 days, 4 acting as non-aspirinated controls. Plasma GC/plt levels in normal plasma were 21.6 +/- 8.0 fg; mean +/- SD. In the 16 patients the GC/plt levels were 13.1 fg/plt; SD 5.4, range 2.9-24.3. All platelet counts were in the normal range in all patients involved. While a masking effect due to aspirin cannot be completely ruled out, these studies indicate that plasma GC/plt level is not useful as a predictor of acute stroke in the premorbid population.