Hypothermia or Machine Perfusion in Kidney Donors.

BACKGROUND: Therapeutic hypothermia in brain-dead organ donors has been shown to reduce delayed graft function in kidney recipients after transplantation. Data are needed on the effect of hypothermia as compared with machine perfusion on outcomes after kidney transplantation. METHODS: At six organ-procurement facilities in the United States, we randomly assigned brain-dead kidney donors to undergo therapeutic hypothermia (hypothermia group), ex situ kidney hypothermic machine perfusion (machine-perfusion group), or both (combination-therapy group). The primary outcome was delayed graft function in the kidney transplant recipients (defined as the initiation of dialysis during the first 7 days after transplantation). We also evaluated whether hypothermia alone was noninferior to machine perfusion alone and whether the combination of both methods was superior to each of the individual therapies. Secondary outcomes included graft survival at 1 year after transplantation. RESULTS: From 725 enrolled donors, 1349 kidneys were transplanted: 359 kidneys in the hypothermia group, 511 in the machine-perfusion group, and 479 in the combined-therapy group. Delayed graft function occurred in 109 patients (30%) in the hypothermia group, in 99 patients (19%) in the machine-perfusion group, and in 103 patients (22%) in the combination-therapy group. Adjusted risk ratios for delayed graft function were 1.72 (95% confidence interval [CI], 1.35 to 2.17) for hypothermia as compared with machine perfusion, 1.57 (95% CI, 1.26 to 1.96) for hypothermia as compared with combination therapy, and 1.09 (95% CI, 0.85 to 1.40) for combination therapy as compared with machine perfusion. At 1 year, the frequency of graft survival was similar in the three groups. A total of 10 adverse events were reported, including cardiovascular instability in 9 donors and organ loss in 1 donor owing to perfusion malfunction. CONCLUSIONS: Among brain-dead organ donors, therapeutic hypothermia was inferior to machine perfusion of the kidney in reducing delayed graft function after transplantation. The combination of hypothermia and machine perfusion did not provide additional protection. (Funded by Arnold Ventures; ClinicalTrials.gov number, NCT02525510.).

The impact of distance on post-ICU disability.

BACKGROUND: Nonurban residential living is associated with adverse outcomes for a number of chronic health conditions. However, it is unclear what effect it has amongst survivors of critical illness. OBJECTIVES: The purpose of this study is to determine whether patients living greater than 50 km from the treating intensive care unit (ICU) have disability outcomes at 6 months that differ from people living within 50 km. METHODS: This was a multicentre, prospective cohort study conducted in five metropolitan ICUs. Participants were adults admitted to the ICU, who received >24 h of mechanical ventilation and survived to hospital discharge. In a secondary analysis of these data, the cohort was dichotomised based on residential distance from the treating ICU: <50 km and ≥50 km. The primary outcome was patient-reported disability using the 12-item World Health Organization's Disability Assessment Schedule (WHODAS 2.0). This was recorded at 6 months after ICU admission by telephone interview. Secondary outcomes included health status as measured by EQ-5D-5L return to work and psychological function as measured by the Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression was used to assess the association between distance from the ICU and moderate to severe disability, adjusted for potential confounders. Variables included in the multivariable model were deemed to be clinically relevant and had baseline imbalance between groups (p < 0.10). These included marital status and hours of mechanical ventilation. Sensitivity analysis was also conducted using distance in kilometres as a continuous variable. RESULTS: A total of 262 patients were enrolled, and 169 (65%) lived within 50 km of the treating ICU and 93 (35%) lived ≥50 km from the treating ICU (interquartile range [IQR] 10-664 km). There was no difference in patient-reported disability at 6 months between patients living <50 km and those living ≥50 km (WHODAS total disability % [IQR] 10.4 [2.08-25] v 14.6 [2.08-20.8], P = 0.74). There was also no difference between groups for the six major life domains of the WHODAS. There was no difference in rates of anxiety or depression as measured by HADS score (HADS anxiety median [IQR] 4 [1-7] v 3 [1-7], P = 0.60) (HADS depression median [IQR] 3 [1-6] v 3 [1-6], P = 0.62); health status as measured by EQ-5D (mean [SD] 66.7 [20] v 69.8 [22.2], P = 0.24); or health-related unemployment (% (N) 39 [26] v 25 [29.1], P = 0.61). After adjusting for confounders, living ≥50 km from the treating ICU was not associated with increased disability (odds ratio 0.61, 95% confidence interval: 0.33-1.16; P = 0.13) CONCLUSIONS: Survivors of intensive care in Victoria, Australia, who live at least 50 km from the treating ICU did not have greater disability than people living less than 50 km at 6 months after discharge. Living 50 km or more from the treating ICU was not associated with disability, nor was it associated with anxiety or depression, health status, or unemployment due to health.

A universal drug delivery catheter for the treatment of infrapopliteal arterial disease using liquid therapy.

OBJECTIVE: The objective of this study was to investigate the safety and feasibility of treating infrapopliteal lesions using a novel drug delivery catheter locally delivering liquid paclitaxel. BACKGROUND: Balloon angioplasty is currently the Gold Standard to treat below-the-knee disease; however, restenosis continues to be a great challenge following these percutaneous revascularization procedures. METHODS: The Occlusion Perfusion Catheter for Optimal Delivery of Paclitaxel for the Prevention of Endovascular Restenosis (COPPER-A) study-Below-the-Knee Cohort was a prospective, nonrandomized, multicenter, feasibility, and safety study that enrolled 35 patients at 11 participating sites. The safety endpoints at 1, 3, and 6 months were freedom from thrombosis, major amputation in the target limb and target limb related death. The efficacy endpoints were primary patency and freedom from clinically driven target lesion revascularization at 6 months. RESULTS: All patients tolerated the procedure well with no reports of adverse procedural events. Thirty-five patients were treated with a mean lesion length of 112 ± 81.2 mm with the lesion length range of 20-286 mm. At 6-month follow-up, primary patency was 89.3% and freedom from clinically driven target lesion revascularization was 96.4%. No patients demonstrated thrombosis, major amputation in the target limb and target limb related death at the 1-, 3- and 6-months follow-up intervals. CONCLUSIONS: The results of this multi-center study demonstrated that infrapopliteal arteries can be safely and effectively treated with liquid paclitaxel using the occlusion perfusion catheter.

Impact of Simulated Patients on Physiotherapy Students' Skill Performance in Cardiorespiratory Practice Classes: A Pilot Study.

Purpose: To date, no evidence exists that high-fidelity simulation improves skill development among physiotherapy students in the university setting. With pressures to reduce costs and maintain or improve the quality of the learning experience, and with pressures on clinical placement, it is essential to investigate methods that might improve students' skill performance before they undertake clinical practice. Our study set out to investigate (1) the impact of using simulated patients (SPs) in a practical class on physiotherapy students' skill acquisition and (2) the students' reflections on the intervention. Method: We devised a pilot study using a single-centre randomized controlled trial. A total of 28 undergraduate physiotherapy students, matched using previous practical examination grades, undertook a 2-hour practical class in which they practised their core cardiorespiratory skills. Pre-session resources were identical. The control group practised on peers; the intervention group practised on SPs. The students' skill performance was assessed 2 weeks later using the Mini-Clinical Evaluation Exercise (MiniCEX), including gathering qualitative data from the students' reflections. Twenty-eight students undertook the practical class and subsequent MiniCEX assessment. Results: A statistically significant difference was found for all aspects of the MiniCEX except medical interview (p = 0.07) and physical interview (p = 0.69), and a large effect size was found for all areas except physical interview (0.154) and medical interview (0.378). The students' reflections focused on three key themes: behaviours and attitudes, teaching the active cycle of breathing technique, and feedback. Conclusions: Our findings suggest that interacting with SPs improves student skill performance, but further research using a larger sample size and an outcome measure validated for this population is required to confirm this.

Objectif : jusqu'à présent, aucune donnée probante n'indique que la simulation haute-fidélité améliore les compétences des étudiants universitaires en physiothérapie. Compte tenu des pressions pour réduire les coûts, maintenir ou améliorer la qualité de l'expérience d'apprentissage et participer à des stages, il est essentiel d'explorer des méthodes pour améliorer le rendement des compétences avant d'entreprendre la pratique clinique. Dans la présente étude, les chercheurs ont exploré 1) les répercussions du recours à des patients simulés (PS) dans un cours pratique d'acquisition des compétences des étudiants en physiothérapie et 2) les réflexions des étudiants à l'égard de l'intervention. Méthodologie : les chercheurs ont conçu un projet pilote dans le cadre d'un essai aléatoire et contrôlé monocentrique. Au total, 28 étudiants au premier cycle en physiothérapie, jumelés d'après leurs notes antérieures aux examens pratiques, ont suivi un cours pratique de deux heures pendant lequel ils ont exercé leurs compétences de base en santé cardiorespiratoire. Ils ont tous reçu les mêmes ressources avant le cours. Les membres du groupe témoin se sont exercés sur leurs homologues, et ceux du groupe d'intervention, sur des PS. Les chercheurs ont évalué le rendement des compétences des étudiants deux semaines plus tard à l'aide du mini-exercice d'évaluation clinique (MiniCEX), qui incluait une collecte de données qualitatives sur les réflexions des étudiants. Les 28 étudiants ont suivi le cours pratique et rempli l'évaluation MiniCEX subséquente. Résultats : les chercheurs ont constaté une différence statistiquement significative dans tous les aspects du MiniCEX, sauf l'entrevue médicale (p = 0,07) et l'entrevue physique (p = 0,69), et une taille d'effet importante dans tous les secteurs sauf l'entrevue physique (0,154) et l'entrevue médicale (0,378). Les réflexions des étudiants ont porté sur trois grands thèmes : comportements et attitudes, enseignement du cycle actif de la technique respiratoire et rétroaction. Conclusion : d'après les résultats, l'interaction avec des PS améliore le rendement des compétences des étudiants, mais il faudra réaliser d'autres recherches auprès d'un plus gros échantillon et valider les résultats dans cette population pour confirmer ces observations.

STOP5: a hot debrief model for resuscitation cases in the emergency department.

OBJECTIVE: Team-based resuscitation in emergency departments (EDs) is an excellent opportunity for hot debriefs (HDBs). In creating a bespoke HDB model for emergency medicine resuscitations, we sought to optimize learning from clinical experience, identify team strengths, challenges, encourage honest reflection and focus on ways of improving future performance. METHODS: Multidisciplinary ED focus groups reviewed existing models, identified benefits/barriers and created new frame works, testing and adapting further using fottage of a simulated complex resuscitation case. The new HDB tool was coined: "STOP5" (STOP for 5 minutes). Cases targeted were prehospital retrievals, major trauma, cardiac arrests, deaths in resuscitation, and staff-triggered. The framework details included a specifically scripted introduction followed by core elements that were S: summarize the case; T: things that went well; O: opportunities to improve; P: points to action and responsibilities. Staffs were surveyed at 1 month prior then 6 and 18 months post-introduction. Data collection forms were used to identify and track hard outcomes/system improvements resulting directly from HDBs. RESULTS: Potential benefits identified by respondents included: improved staff morale; team cohesion; improved care for future patients; promoting a culture for learning, patient safety and quality improvement. Ten process and equipment changes resulted directly from STOP5 over 12 months. CONCLUSION: We anticipate the STOP5 framework to be globally generalizable and effective for many ED teams.

Multidisciplinary Care for Critical Limb Ischemia: Current Gaps and Opportunities for Improvement.

Critical limb ischemia (CLI), defined as ischemic rest pain or nonhealing ulceration due to arterial insufficiency, represents the most severe and limb-threatening manifestation of peripheral artery disease. A major challenge in the optimal treatment of CLI is that multiple specialties participate in the care of this complex patient population. As a result, the care of patients with CLI is often fragmented, and multidisciplinary societal guidelines have not focused specifically on the care of patients with CLI. Furthermore, multidisciplinary care has the potential to improve patient outcomes, as no single medical specialty addresses all the facets of care necessary to reduce cardiovascular and limb-related morbidity in this complex patient population. This review identifies current gaps in the multidisciplinary care of patients with CLI, with a goal toward increasing disease recognition and timely referral, defining important components of CLI treatment teams, establishing options for revascularization strategies, and identifying best practices for wound care post-revascularization.

Predictors of return to work in survivors of critical illness.

PURPOSE: To determine predictors of inability to return to work due to health six-months after intensive care admission; and compare functional recovery between patients who had not returned to work and employed patients. METHODS: Participants were working adults admitted to ICU who received >24 h of mechanical ventilation. Outcomes included inability to return to work due to health at six-months post-ICU admission, disability, health status, anxiety, depression and post-traumatic stress. RESULTS: Of 107 patients, 31 (29%) were unable to return to work due to health at six-months after ICU admission. Predictors of inability to return to work included longer hospital stay (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.08; P = .004); lower Glasgow Coma Scale (GCS) at admission (OR, 0.86; CI, 0.75-0.99; P = .03); and admission due to major trauma (OR, 8.83; CI, 2.57-30.38; P < .001). Compared to employed patients, those who had not returned to work reported higher levels of disability and psychological distress, and poorer health-related quality of life. CONCLUSION: Major trauma, lower GCS and increased hospital length of stay predicted inability to return to work due to health at six-months post-ICU admission. Compared to employed patients, those who had not returned to work reported poorer functional recovery.

Lactate - Arterial and Venous Agreement in Sepsis: a prospective observational study.

BACKGROUND: Sepsis is a common condition in the emergency department (ED). Lactate measurement is an important part of management: arterial lactate (A-LACT) measurement is the gold standard. There is increasing use of peripheral venous lactate (PV-LACT); however, there is little research supporting the interchangeability of the two measures.If PV-LACT has good agreement with A-LACT, it would significantly reduce patient discomfort and the risks of arterial sampling for a large group of acutely unwell patients, while allowing faster and wider screening, with potential reduced costs to the healthcare system. OBJECTIVE: The aim of this study is to determine the agreement between PV-LACT and A-LACT in septic patients attending the ED. METHODS: We carried out a prospective observational cohort study of 304 consented patients presenting with sepsis to a single UK NHS ED (110 000 adult attendances annually) taking paired PV-LACT and A-LACT. Bland-Altman analysis was carried out to determine agreement. Receiver operating characteristic curves and 2×2 tables were constructed to explore the predictive value of PV-LACT for A-LACT. RESULTS: The mean difference (PV-LACT-A-LACT) is 0.4 mmol/l [95% confidence interval (CI): 0.37-0.45], with 95% limits of agreement from -0.4 (95% CI: -0.45 to -0.32) to 1.2 (95% CI: 1.14-1.27). A PV-LACT of at least 2 mmol/l predicts an A-LACT of at least 2 with 100% sensitivity (95% CI: 89-100%) and 83% specificity (95% CI: 77-87%). CONCLUSION: This study is the largest comparing the two measurements, and shows good clinical agreement. We recommend using PV-LACT in the routine screening of septic patients. A PV-LACT less than 2 mmol/l is predictive of an A-LACT less than 2 mmol/l.

A universal drug delivery catheter for the treatment of infrapopliteal arterial disease: Results from the multi-center first-in-human study.

OBJECTIVE: The objective of this study was to assess the feasibility, safety and initial efficacy of paclitaxel administration using a novel drug delivery catheter for the prevention of restenosis in infrapopliteal de novo and restenotic lesions. BACKGROUND: Restenosis continues to be a great challenge after percutaneous revascularization procedures for peripheral arterial disease, particularly for below-the-knee applications. METHODS: A prospective, multicenter first-in-human registry of a novel delivery catheter delivering liquid paclitaxel was conducted in 10 patients. The primary efficacy endpoint at 6 months was freedom from clinically driven target lesion revascularization (CD-TLR) and the primary safety endpoint at 1, 3, and 6 months were thrombosis, major amputation in the target limb and target limb related death. RESULTS: All patients tolerated the procedure well with no reports of adverse procedural events. Twelve (n = 12) lesions in ten patients were treated with a mean lesion length of 83.3 ± 49.2 mm, with the lesion length range of 30mm to 182 mm. At 6-month follow-up, the rate of CD-TLR was 30% (3 of 10 patients). Zero patients (0 out of 10) demonstrated thrombosis, major amputation in the target limb and target limb related death at the 1, 3, and 6 month follow-up intervals. CONCLUSIONS: This first in-human experience obtained in a multicenter study of real-world de novo and restenotic lesions demonstrates a favorable safety and efficacy profile at 6 months. Randomized comparison to current drug coated balloons should be performed to further validate this approach and positive experience.

Erratum to: The impact of disability in survivors of critical illness.

In the Results section, under the subheading "Return to work or usual activities", the second sentence should read.

Bilateral pneumothoraces following acupuncture.

A 50-year-old woman was brought to the emergency department with shortness of breath and chest tightness following acupuncture to her upper back for a chronically painful left shoulder. She had symptoms of respiratory distress and chest X-ray revealed bilateral pneumothoraces. Symptoms resolved after insertion of bilateral Seldinger chest drains. She was admitted to the Cardiothoracic Surgery ward, chest drains were removed on the second and third days and the patient was discharged from hospital after 3 days. Clinicians and acupuncturists should be aware of this adverse event following acupuncture.

The impact of disability in survivors of critical illness.

PURPOSE: To use the World Health Organisation's International Classification of Functioning to measure disability following critical illness using patient-reported outcomes. METHODS: A prospective, multicentre cohort study conducted in five metropolitan intensive care units (ICU). Participants were adults who had been admitted to the ICU, received more than 24 h of mechanical ventilation and survived to hospital discharge. The primary outcome was measurement of disability using the World Health Organisation's Disability Assessment Schedule 2.0. The secondary outcomes included the limitation of activities and changes to health-related quality of life comparing survivors with and without disability at 6 months after ICU. RESULTS: We followed 262 patients to 6 months, with a mean age of 59 ± 16 years, and of whom 175 (67%) were men. Moderate or severe disability was reported in 65 of 262 (25%). Predictors of disability included a history of anxiety/depression [odds ratio (OR) 1.65 (95% confidence interval (CI) 1.22, 2.23), P = 0.001]; being separated or divorced [OR 2.87 (CI 1.35, 6.08), P = 0.006]; increased duration of mechanical ventilation [OR 1.04 (CI 1.01, 1.08), P = 0.03 per day]; and not being discharged to home from the acute hospital [OR 1.96 (CI 1.01, 3.70) P = 0.04]. Moderate or severe disability at 6 months was associated with limitation in activities, e.g. not returning to work or studies due to health (P < 0.002), and reduced health-related quality of life (P < 0.001). CONCLUSION: Disability measured using patient-reported outcomes was prevalent at 6 months after critical illness in survivors and was associated with reduced health-related quality of life. Predictors of moderate or severe disability included a prior history of anxiety or depression, separation or divorce and a longer duration of mechanical ventilation. TRIAL REGISTRATION: NCT02225938.

Dedifferentiated liposarcoma of the lower extremity with low-grade dedifferentiation and low-grade osteosarcomatous component.

Dedifferentiated liposarcoma can arise de novo or as a complication of a preexisting well-differentiated liposarcoma. We describe the radiologic and pathologic features of a long-standing liposarcoma with multiple recurrences in a 59-year-old male. Imaging demonstrated a heterogeneous fat-containing mass in the anterior thigh. The adjacent proximal femur showed irregular cortical new bone, eventually followed by intramedullary osteoblastic involvement and pathologic fracture. Histologic assessment at resection revealed dedifferentiated liposarcoma with low-grade osteosarcomatous component. The patient subsequently developed metastatic lesions in the lungs containing osteoid and osteoblastic bone metastases. We discuss the radiologic and pathologic features of this rare entity that, to our knowledge, has previously been reported to directly involve osseous structures in only one other case and discuss the potential pitfalls in diagnosis.

Tibiopedal Access for Crossing of Infrainguinal Artery Occlusions: A Prospective Multicenter Observational Study.

PURPOSE: To report a prospective, multicenter, observational study (ClinicalTrials.gov identifier NCT01609621) of the safety and effectiveness of tibiopedal access and retrograde crossing in the treatment of infrainguinal chronic total occlusions (CTOs). METHODS: Twelve sites around the world prospectively enrolled 197 patients (mean age 71±11 years, range 41-93; 129 men) from May 2012 to July 2013 who met the inclusion criterion of at least one CTO for which a retrograde crossing procedure was planned or became necessary. The population consisted of 64 (32.5%) claudicants (Rutherford categories 2/3) and 133 (67.5%) patients with critical limb ischemia (Rutherford category ≥4). A primary antegrade attempt to cross had been made prior to the tibiopedal attempt in 132 (67.0%) cases. Techniques used for access, retrograde lesion crossing, and treatment were at the operator's discretion. Follow-up data were obtained 30 days after the procedure. RESULTS: Technical tibiopedal access success was achieved in 184 (93.4%) of 197 patients and technical occlusion crossing success in 157 (85.3%) of the 184 successful tibial accesses. Failed access attempts were more common in women (9 of 13 failures). The rate of successful crossing was roughly equivalent between sexes [84.7% (50/59) women compared to 85.6% (107/125) men]. Technical success did not differ significantly based on a prior failed antegrade attempt: the access success rate was 92.4% (122/132) after a failed antegrade access vs 95.4% (62/65) in those with a primary tibiopedal attempt (p=0.55). Similarly, crossing success was achieved in 82.8% (101/122) after a failed antegrade access vs 90.3% (56/62) for patients with no prior antegrade attempt (p=0.19). Minor complications related to the access site occurred in 11 (5.6%) cases; no patient had access vessel thrombosis, compartment syndrome, or surgical revascularization. CONCLUSION: Tibiopedal access appears to be safe and can be used effectively for the crossing of infrainguinal lesions in patients with severe lower limb ischemia.

The association of incomplete glenoid component seating and periprosthetic glenoid radiolucencies after total shoulder arthroplasty.

BACKGROUND: Radiolucent lines surrounding prosthetic glenoid components are commonly seen after unconstrained total shoulder arthroplasty and can be a harbinger of subsequent glenoid component failure. Whether less than 100% glenoid seating is associated with the development of radiolucent lines around glenoid prostheses is unknown. This study investigated the association between incomplete glenoid component seating and periprosthetic glenoid radiolucencies. METHODS: Thirty-six unconstrained total shoulder arthroplasties were performed in 29 patients for primary glenohumeral osteoarthritis with a minimum 2-year follow-up. All were implanted with a partially cemented all-polyethylene glenoid prosthesis. Patients were evaluated with standardized plain films preoperatively and postoperatively and with thin-cut computed tomography (CT) scans at the latest follow-up. The Lazarus and Yian classifications were used to assess radiolucency and seating on radiographs and CT scans. Ratings were calculated for intraobserver and interobserver reliability and given κ, the Kendall coefficient, and interclass correlation coefficient values. RESULTS: At a mean of 43 months (range 24-26 months) after surgery, neither Lazarus plain film radiolucency scores (P = .78) nor Yian CT radiolucency scores (P = .68) were associated with Lazarus plain film seating scores. Neither Lazarus plain film radiolucency scores (P = .25) nor Yian CT radiolucency scores (P = .91) were associated with modified Lazarus CT scan seating scores. CT allowed for better intraobserver and interobserver reliability in all categories. CONCLUSION: Radiolucencies around a partially cemented glenoid component were not associated with the degree of component seating. Complete seating of the glenoid component is not necessary to achieve radiographic implant stability at a mean follow-up of 43 months.

Multidisciplinary approach to the diagnosis and management of patients with peripheral arterial disease.

Peripheral arterial disease (PAD) is frequently diagnosed after permanent damage has occurred, resulting in a high rate of morbidity, amputation, and loss of life. Early and ongoing diagnosis and treatment is required for this progressive disease. Lifestyle modifications can prevent or delay disease progression and improve symptoms. Limb-sparing endovascular interventions can restore circulation based on appropriate diagnostic testing to pinpoint vascular targets, and intervention must occur as early as possible to ensure optimal clinical outcomes. An algorithm for the diagnosis and management of PAD was developed to enable a collaborative approach between the family practice and primary care physician or internist and various specialists that may include a diabetologist, endocrinologist, smoking cessation expert, hypertension and lipid specialist, endovascular interventionalist, vascular surgeon, orthopedist, neurologist, nurse practitioner, podiatrist, wound healing expert, and/or others. A multidisciplinary team working together has the greatest chance of providing optimal care for the patient with PAD and ensuring ongoing surveillance of the patient's overall health, ultimately resulting in better quality of life and increased longevity for patients with PAD.

Arterial lactate levels in an emergency department are associated with mortality: a prospective observational cohort study.

OBJECTIVES: Lactate measurements are routinely carried out in emergency departments and are associated with increased mortality in septic patients. However, no definitive research has been carried out into whether lactate measurements can be used as a prognostic marker in a clinically unwell population in the emergency department. METHODS: We carried out a prospective observational cohort study in consecutive patients whose arterial lactate concentration was measured in the emergency department of a tertiary referral hospital assessing 110,000 patients per year between 11th May and 11th August 2011. The main outcome measure was 30-day mortality. RESULTS: There were 120 deaths (16.1%) at 30 days postattendance in our cohort of 747 patients. Multivariate logistic regression revealed lower lactate levels were associated with 30-day survival: ORs for 30-day death compared with lactate ≥4 were 0.125 (95% CI 0.068 to 0.229) for lactate <2 and 0.273 (95% CI 0.140 to 0.533) for lactate 2-<4. Kaplan-Meier analysis showed a survival difference when dividing lactate concentrations into strata (p<0.0001). This survival difference was maintained when septic diagnoses were taken into account. CONCLUSIONS: A single arterial lactate measurement on presentation to the emergency department predicts 30-day mortality independent of other measures of illness severity.