Neurological intensive care admissions: identifying candidates for intermediate care and the services they receive.

OBJECTIVE: The high cost and scarcity of intensive care unit (ICU) beds has resulted in a need for improved utilization. This study describes the characteristics of patients who are admitted to the ICU for neurosurgical and neurological care, identifies patients who might receive all or most of their care in an intermediate care unit, and describes the services the patients would receive in an intermediate care unit. METHODS: We describe patients who received neurological care and who were part of a prospective study of 17,440 patients admitted to 42 ICUs at 40 United States hospitals. We identified patients who received only monitoring during ICU Day 1 and then used a previously validated equation to distinguish which patients were at low risk (< 10%) for subsequent active life-supporting therapy. We also describe the services these patients received during their ICU stay. RESULTS: Among 3000 patients admitted to the ICU for neurological care, 1350 received active therapy and 1650 (55%) underwent monitoring and received concentrated nursing care on ICU Day 1. After excluding those patients who received active therapy at admission, 1288 (78%) of the 1650 patients who underwent monitoring at admission were at low risk (< 10%) for subsequent active therapy; 95.8% received no active therapy. These patients who were at low risk for subsequent active therapy were significantly (P < 0.001) more often admitted postoperatively, were younger and less severely ill, and had lower ICU and hospital mortality rates (0.9 and 3.9%, respectively) than patients who received active treatment at admission. CONCLUSIONS: Patients receiving neurological care at an ICU who receive only monitoring during their 1st ICU day and have a less than 10% predicted risk of active treatment can be safely transferred to an intermediate care unit. Some of these patients may not require ICU admission. We suggest guidelines for equipping and staffing neurological intermediate care units based on the type and amount of therapy received by these patients.

A patient with acquired immunodeficiency syndrome and untreated Encephalitozoon (Septata) intestinalis microsporidiosis leading to small bowel perforation. Response to albendazole.

BACKGROUND: Encephalitozoon (Septata) intestinalis is a common disseminating opportunistic intestinal microsporidian affecting patients with acquired immunodeficiency syndrome. This microsporidian does respond to albendazole therapy. A patient with acquired immunodeficiency syndrome and chronic diarrhea presented to George Washington University Hospital in January of 1996. Despite appropriate surgical specimens, no etiology had been found to explain his cholecystitis, cystitis, and enteritis 3 months previously at another hospital. DESIGN: Tissue specimens were analyzed by light microscopy, using hematoxylin-eosin and the Armed Forces Institute of Pathology Brown-Brenn microsporidia stain, and by transmission electron microscopy. Urine and stool specimens were analyzed by modified chromotrope 2R trichrome and chitin fluorochrome stains and by transmission electron microscopy. RESULTS: At George Washington University Hospital, disseminated E intestinalis was diagnosed from duodenal biopsy, urine, and stool specimens. On the 14th day of oral albendazole therapy, a partial small bowel resection was performed to correct a perforation (air under the diaphragm). There was no enterocyte microsporidian infection at that time, only spores undergoing macrophage digestion. Review of previous specimens showed severe E intestinalis cholecystitis, cystitis, and enteritis. Albendazole was restarted and, after 2 weeks, the patient had negative stool and urine specimens. CONCLUSIONS: Encephalitozoon intestinalis symptomatically targets many organs, including the urinary bladder. To our knowledge, this is the first tissue-documented case of cystitis. Left untreated with albendazole, small bowel infection can lead to perforation and peritonitis.

ICU scoring systems allow prediction of patient outcomes and comparison of ICU performance.

Too much time and effort are wasted in attempts to pass final judgment on whether systems for ICU prognostication are "good or bad" and whether they "do or do not" provide a simple answer to the complex and often unpredictable question of individual mortality in the ICU. A substantial amount of data supports the usefulness of general ICU prognostic systems in comparing ICU performance with respect to a wide variety of endpoints, including ICU and hospital mortality, duration of stay, and efficiency of resource use. Work in progress is analyzing both general resource use and specific therapeutic interventions. It also is time to fully acknowledge that statistics never can predict whether a patient will die with 100% accuracy. There always will be exceptions to the rule, and physicians frequently will have information that is not included in prognostic models. In addition, the values of both physicians and patients frequently lead to differences in how a probability in interpreted; for some, a 95% probability estimate means that death is near and, for others, this estimate represents a tangible 5% chance for survival. This means that physicians must learn how to integrate such estimates into their medical decisions. In doing so, it is our hope that prognostic systems are not viewed as oversimplifying or automating clinical decisions. Rather, such systems provide objective data on which physicians may ground a spectrum of decisions regarding either escalation or withdrawal of therapy in critically ill patients. These systems do not dehumanize our decision-making process but, rather, help eliminate physician reliance on emotional, heuristic, poorly calibrated, or overly pessimistic subjective estimates. No decision regarding patient care can be considered best if the facts upon which it is based on imprecise or biased. Future research will improve the accuracy of individual patient predictions but, even with the highest degree of precision, such predictions are useful only in support of, and not as a substitute for, good clinical judgment.

Intensive care unit admissions with cirrhosis: risk-stratifying patient groups and predicting individual survival.

Prognosis for acutely ill patients with cirrhosis is influenced by the severity of hepatic abnormalities and by dysfunction of other organ systems. The purpose of this study was to examine the usefulness of the Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) prognostic system for risk-stratifying groups of intensive care unit (ICU) patients with cirrhosis and in predicting individual survival. We used data for 17,440 ICU admissions at 40 American hospitals to select 117 of the 537 patients with a history of cirrhosis who were ventilated on ICU day 1, a group known to have a high mortality rate. We then calculated each patient's probability of hospital death on ICU days 1 through 7, using seven previously validated multivariate equations. Hospital mortality was 63% for the 117 study patients. The most important determinants of risk for hospital death on ICU day 1 were the acute physiology score of APACHE III, ICU admission diagnosis, and operative status. Daily changes in the acute physiology score caused a rise or fall in the probability of hospital mortality and was useful in assessing individual response to therapy. APACHE III accurately risk stratifies critically ill patients with cirrhosis because it accounts for many of the factors known to influence prognosis. This capability can be used to assess severity of illness and risk-stratify patients with cirrhosis during clinical trials. Daily prognostic estimates based on physiological changes over time reflect patient response and can help physicians to assess the incremental benefit of therapy.

The use of APACHE III to evaluate ICU length of stay, resource use, and mortality after coronary artery by-pass surgery.

OBJECTIVE: To identify patient characteristics that are associated with increased ICU length of stay, resource use, and hospital mortality after coronary artery bypass surgery. DESIGN: Prospective, multicenter study. SETTING: Six tertiary care hospitals. PARTICIPANTS: A consecutive sample of 2,435 unselected ICU admissions following coronary artery by-pass surgery. MATERIALS AND METHODS: Demographic, operative characteristics and APACHE III score were collected during the first postoperative day; and APACHE III scores and therapeutic interventions during the first three postoperative days. Hospital survival and ICU length of stay were also recorded. Multivariate equations were derived and cross-validated to predict hospital mortality, ICU length of stay, and ICU resource use. RESULTS: Unadjusted hospital mortality rate was 3.9% (range 1.0% to 6.0%), mean ICU length of stay was 3.7 days (range 3.2 to 4.7 days), and first 3-day ICU resource use (TISS points) was 99 (range 68 to 116). The range of actual to predicted ICU length of stay varied from 0.86 to 1.26; and resource use from 0.71 to 1.16. CONCLUSIONS: A limited number of operative characteristics, the post-operative acute physiology score (APS) of APACHE III and patient demographic data can predict hospital death rate, ICU length of stay, and resource use immediately following coronary by-pass surgery. These estimates may compliment assessments based on pre-operative risk factors in order to more precisely evaluate and improve the efficacy and efficiency of cardiovascular surgery.

Facilitation of internal jugular venous cannulation using an audio-guided Doppler ultrasound vascular access device: results from a prospective, dual-center, randomized, crossover clinical study.

OBJECTIVE: To determine the utility of an audio-guided Doppler ultrasound device in improving success and decreasing complications in cannulation of the internal jugular vein in high-risk patients. DESIGN: Prospective, randomized, crossover clinical study. SETTING: Two major university medical centers in critical care environments. PATIENTS: Seventy-six consecutive, consenting adult patients with preexisting obesity or coagulopathy requiring central venous access. INTERVENTIONS: Subjects enrolled in the study were randomized to receive either the traditional "blind" (control) technique or the ultrasonic technique. A maximum of three cannulation attempts were allowed before crossover to three attempts with the alternative technique. All cannulations were attempted via the internal jugular vein through a high/central approach. RESULTS: Patient and operator characteristics were similar between groups. The initial use of an audio-guided ultrasound device was associated with increased success of cannulation (84.4% vs. 61.4%; p < .05) and decreased need to crossover to the alternative technique. Success on the first needle pass was more likely with the ultrasound technique (56.3% vs. 29.5%; p < .05). Significant complications were greater with the control technique (carotid artery puncture 16.3% vs. 2.0% [p < .02]; any significant complication 26.5% vs. 6.1% [p < .01]). CONCLUSIONS: The use of an audio-guided Doppler ultrasound vascular access device was associated with increased success of cannulation and a decreased frequency of significant complications in a population of high-risk patients with obesity or coagulopathy.

Factors affecting days open, gestation length, and calving interval in Florida dairy cattle.

Effects of several factors on reproductive performance were evaluated. Mean performance and number of observations were for days from parturition to first service, 93 and 7730; days from first to successful service, 35 and 11,751; days open, 123 and 8571; gestation length, 280 and 13,612; and calving interval, 400 and 8524. Data covered 52 yr during which no detectable trends in calving interval occurred; other variables changed slightly. Jerseys had 8 fewer d from parturition to first service, 16 fewer d from first service to conception, 8 fewer d open, and 8-d shorter calving intervals than did Guernseys and Holsteins, which did not differ. Cows freshening in warm rather than cool weather suffered by 7, 7, 12, and 13 d for these variables. Repeatabilities ranged from .05 to .12; heritabilities were .05 and .06. Nonmaternal estimate of heritability of gestation length was .22. Phenotypic and genetic correlations between days from parturition to first service and calving interval were .48 and .87; for days open and calving interval, they were .97 and .96. Although days from first to successful service were essentially uncorrelated with days open and calving interval phenotypically (.05), genetic correlations were greater than 1.0 and estimated as unity. Results show no discrepancy between estimates for measures of reproductive performance in a subtropical environment and numerous studies in temperate areas. Large studies from subtropical areas are sparse; essentially none concerns long-term trends.

Fetuin inhibits zona pellucida hardening and conversion of ZP2 to ZP2f during spontaneous mouse oocyte maturation in vitro in the absence of serum.

The zona pellucida of mouse oocytes becomes resistant to chymotrypsin digestion, or "hardened", when spontaneous maturation occurs in serum-free medium (De Felici and Siracusa, Gam Res 1982; 6:107). The hardened zona pellucida is refractory to sperm penetration, thus preventing fertilization. Conversion of the zona pellucida glycoprotein ZP2 to ZP2f by a protease from precociously released oocyte cortical granules appears to be a major contributory factor of zona pellucida hardening (Ducibella et al., Dev Biol 1990; 137:46). Fetal bovine serum (FBS) prevents zona hardening and the ZP2 to ZP2f conversion during oocyte maturation in vitro (Downs et al., Gam Res 1986; 15:115; Ducibella et al., Dev Biol 1990; 137:46). This study was conducted to determine whether fetuin, a major glycoprotein constituent of FBS and a protease inhibitor, could prevent zona pellucida hardening during murine oocyte maturation in serum-free medium. Commercially available preparations of fetuin purified by three different methods were all active in inhibiting zona pellucida hardening in a concentration-dependent manner. Further chromatographic purification of one of these preparations indicated that the activity preventing zona pellucida hardening was associated specifically with fetuin. Fetuin also inhibited the conversion of ZP2 to ZP2f in a concentration-dependent manner during oocyte maturation in serum-free medium. Moreover, oocytes that matured in serum-free medium containing fetuin could be fertilized and could undergo preimplantation development to the blastocyst stage. These results indicate that fetuin, a component of FBS, inhibits zona pellucida hardening during oocyte maturation, and suggest that fetuin acts by preventing the proteolytic conversion of ZP2 to ZP2f by precociously released cortical granules.

Vital statistics and reasons for disposal of United States and Canadian artificial insemination dairy sires.

Vital statistics were evaluated for artificial insemination sires leaving service during 1939 through 1974. Data consisted of 11,704 sires of six breeds. The major cause for leaving service was reproductive failure at a frequency of 32.5%; next ranked was undesirable characteristics of offspring with a frequency of 20.7%. Overall culling rate for low yields of daughters was 14.8%, but after 1965 this cause accounted for about 30%. Mean life span was 3.4 yr with small differences among years. Breed differences were detected for service life and causes for leaving service. Modifications of classic life table techniques are needed to reflect entry of sires into service at various ages and evaluation of vital statistics subsequent to 1974.

Development of the conceptus in the bovine.

Growth of fetuses, fetal membranes, and fetal fluids was characterized by least squares analysis for 254 conceptuses ranging from 25 to 278 days of gestation. Prior to 100 days of gestation, increases in allantoic fluid volume and chorio-allantoic membrane weight preceded those of fetal weight, amnio-allantoic membrane weight, and amniotic fluid volume. The relative rate of growth of components suggests a prerequisite of chorio-allantoic membrane expansion for subsequent fetal growth. Male fetuses were heavier than female fetuses as early as 100 days of gestation. Rate of growth of all fetuses was maximal at 230 days of gestation with a peak rate of greater than 200 g/day. Growth rate then declined to less than 100 g/day by term.