Relevance of presenting risks of frailty, sarcopaenia and osteopaenia to outcomes from aneurysmal subarachnoid haemorrhage.

INTRODUCTION: Aneurysmal subarachnoid haemorrhage (aSAH) is a condition with significant morbidity and mortality. Traditional markers of aSAH have established their utility in the prediction of aSAH outcomes while frailty markers have been validated in other surgical specialties. We aimed to compare the predictive value of frailty indices and markers of sarcopaenia and osteopaenia, against the traditional markers for aSAH outcomes. METHODS: An observational study in a tertiary neurosurgical unit on 51 consecutive patients with ruptured aSAH was performed. The best performing marker in predicting the modified Rankin scale (mRS) on discharge was selected and an appropriate threshold for the definition of frail and non-frail was derived. We compared various frailty indices (modified frailty index 11, and 5, and the National Surgical Quality Improvement Program score [NSQIP]) and markers of sarcopaenia and osteopaenia (temporalis [TMT] and zygoma thickness), against traditional markers (age, World Federation of Neurological Surgery and modified Fisher scale [MFS]) for aSAH outcomes. Univariable and multivariable analysis was then performed for various inpatient and long-term outcomes. RESULTS: TMT was the best performing marker in our cohort with an AUC of 0.82, Somers' D statistic of 0.63 and Tau statistic 0.25. Of the frailty scores, the NSQIP performed the best (AUC 0.69), at levels comparable to traditional markers of aSAH, such as MFS (AUC 0.68). The threshold of 5.5 mm in TMT thickness was found to have a specificity of 0.93, sensitivity of 0.51, positive predictive value of 0.95 and negative predictive value of 0.42. After multivariate analysis, patients with TMT ≥ 5.5 mm (defined as non-frail), were less likely to experience delayed cerebral ischaemia (OR 0.11 [0.01 - 0.93], p = 0.042), any complications (OR 0.20 [0.06 - 0.069], p = 0.011), and had a larger proportion of favourable mRS on discharge (95.0% vs. 58.1%, p = 0.024) and at 3-months (95.0% vs. 64.5%, p = 0.048). However, the gap between unfavourable and favourable mRS was insignificant at the comparison of 1-year outcomes. CONCLUSION: TMT, as a marker of sarcopaenia, correlated well with the presenting status, and outcomes of aSAH. Frailty, as defined by NSQIP, performed at levels equivalent to aSAH scores of clinical relevance, suggesting that, in patients presenting with acute brain injury, both non-neurological and neurological factors were complementary in the determination of eventual clinical outcomes. Further validation of these markers, in addition to exploration of other relevant frailty indices, may help to better prognosticate aSAH outcomes and allow for a precision medicine approach to decision making and optimization of best outcomes.

Development of a heart rate variability and complexity model in predicting the need for life-saving interventions amongst trauma patients.

BACKGROUND: Triage trauma scores are utilised to determine patient disposition, interventions and prognostication in the care of trauma patients. Heart rate variability (HRV) and heart rate complexity (HRC) reflect the autonomic nervous system and are derived from electrocardiogram (ECG) analysis. In this study, we aimed to develop a model incorporating HRV and HRC, to predict the need for life-saving interventions (LSI) in trauma patients, within 24 h of emergency department presentation. METHODS: We included adult trauma patients (≥ 18 years of age) presenting at the emergency department of Singapore General Hospital between October 2014 and October 2015. We excluded patients who had non-sinus rhythms and larger proportions of artefacts and/or ectopics in ECG analysis. We obtained patient demographics, laboratory results, vital signs and outcomes from electronic health records. We conducted univariate and multivariate analyses for predictive model building. RESULTS: Two hundred and twenty-five patients met inclusion criteria, in which 49 patients required LSIs. The LSI group had a higher proportion of deaths (10, 20.41% vs 1, 0.57%, p < 0.001). In the LSI group, the mean of detrended fluctuation analysis (DFA)-α1 (1.24 vs 1.12, p = 0.045) and the median of DFA-α2 (1.09 vs 1.00, p = 0.027) were significantly higher. Multivariate stepwise logistic regression analysis determined that a lower Glasgow Coma Scale, a higher DFA-α1 and higher DFA-α2 were independent predictors of requiring LSIs. The area under the curve (AUC) for our model (0.75, 95% confidence interval, 0.66-0.83) was higher than other scoring systems and selected vital signs. CONCLUSIONS: An HRV/HRC model outperforms other triage trauma scores and selected vital signs in predicting the need for LSIs but needs to be validated in larger patient populations.

Treatment preferences for decompression illness amongst Singapore dive physicians.

INTRODUCTION: Owing to the scarcity of randomized controlled trials to guide treatment for decompression illness (DCI), there are many unanswered questions about its management. Apart from reviews and expert opinion, surveys that report practice patterns provide information about useful management strategies. Hence, this study aimed to identify current treatment preferences for DCI amongst diving physicians in Singapore. METHODS: An anonymous web-based questionnaire was sent to known diving physicians in Singapore. The demographics of the respondents were captured. Respondents were asked about their preferred management for five different DCI scenarios. RESULTS: The response rate was 74% (17 of 23 responses). All respondents chose to recompress patients described in the five scenarios. Regarding the number of recompression sessions, "one additional session after no further improvement in signs and symptoms" was the most common end point of treatment across all the scenarios (47 of 85 responses). Analgesics would be used by five physicians, three would use lidocaine and two steroids as adjuvant therapies. CONCLUSIONS: Apart from the general agreement that recompression is indicated for DCI, there was no strong consensus regarding other aspects of management. This survey reinforces the need for robust RCTs to validate the existing recommendations for DCI treatment.