Comparison of Intensive Care and Trauma-specific Scoring Systems in Critically Ill Patients.

INTRODUCTION: Amongst critically ill trauma patients admitted to ICU and still alive and in ICU after 24 hours, it is unclear which trauma scoring system offers the best performance in predicting in-hospital mortality. METHODS: The Australia and New Zealand Intensive Care Society Adult Patient Database and Victorian State Trauma Registry were linked using a unique patient identification number. Six scoring systems were evaluated: the Australian and New Zealand Risk of Death (ANZROD), Acute Physiology and Chronic Health Evaluation III (APACHE III) score and associated APACHE III Risk of Death (ROD), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and the Revised Trauma Score (RTS). Patients who were admitted to ICU for longer than 24 hours were analysed. Performance of each scoring system was assessed primarily by examining the area under the receiver operating characteristic curve (AUROC) and in addition using standardised mortality ratios, Brier score and Hosmer-Lemeshow C statistics where appropriate. Subgroup assessments were made for patients aged 65 years and older, patients between 18 and 40 years of age, major trauma centre and head injury. RESULTS: Overall, 5,237 major trauma patients who were still alive and in ICU after 24 hours were studied from 25 ICUs in Victoria, Australia between July 2008 and January 2018. Hospital mortality was 10.7%. ANZROD (AUROC 0.91; 95% CI 0.90-0.92), APACHE III ROD (AUROC 0.88; 95% CI 0.87-0.90), and APACHE III (AUROC 0.88; 95% CI 0.87-0.89) were the best performing tools for predicting hospital mortality. TRISS had acceptable overall performance (AUROC 0.78; 95% CI 0.76-0.80) while ISS (AUROC 0.61; 95% CI 0.59-0.64), NISS (AUROC 0.68; 95% CI 0.65-0.70) and RTS (AUROC 0.69; 95% CI 0.67-0.72) performed poorly. The performance of each scoring system was highest in younger adults and poorest in older adults. CONCLUSION: In ICU patients admitted with a trauma diagnosis and still alive and in ICU after 24 hours, ANZROD and APACHE III had a superior performance when compared with traditional trauma-specific scoring systems in predicting hospital mortality. This was observed both overall and in each of the subgroup analyses. The anatomical scoring systems all performed poorly in the ICU population of Victoria, Australia.

Tackling the problem of blood culture contamination in the intensive care unit using an educational intervention.

Blood culture contamination (BCC) has been associated with unnecessary antibiotic use, additional laboratory tests and increased length of hospital stay thus incurring significant extra hospital costs. We set out to assess the impact of a staff educational intervention programme on decreasing intensive care unit (ICU) BCC rates to <3% (American Society for Microbiology standard). BCC rates during the pre-intervention period (January 2006-May 2011) were compared with the intervention period (June 2011-December 2012) using run chart and regression analysis. Monthly ICU BCC rates during the intervention period were reduced to a mean of 3.7%, compared to 9.5% during the baseline period (P < 0.001) with an estimated potential annual cost savings of about £250,100. The approach used was simple in design, flexible in delivery and efficient in outcomes, and may encourage its translation into clinical practice in different healthcare settings.

Impact of an enhanced antibiotic stewardship on reducing methicillin-resistant Staphylococcus aureus in primary and secondary healthcare settings.

The objective of this study was to evaluate the impact of restricting high-risk antibiotics on methicillin-resistant Staphylococcus aureus (MRSA) incidence rates in a hospital setting. A secondary objective was to assess the impact of reducing fluoroquinolone use in the primary-care setting on MRSA incidence in the community. This was an interventional, retrospective, ecological investigation in both hospital and community (January 2006 to June 2010). Segmented regression analysis of interrupted time-series was employed to evaluate the intervention. The restriction of high-risk antibiotics was associated with a significant change in hospital MRSA incidence trend (coefficient=-0·00561, P=0·0057). Analysis showed that the intervention relating to reducing fluoroquinolone use in the community was associated with a significant trend change in MRSA incidence in community (coefficient=-0·00004, P=0·0299). The reduction in high-risk antibiotic use and fluoroquinolone use contributed to both a reduction in incidence rates of MRSA in hospital and community (primary-care) settings.

A point prevalence survey of antibiotic use in four acute-care teaching hospitals utilizing the European Surveillance of Antimicrobial Consumption (ESAC) audit tool.

The objective of this research was to assess current patterns of hospital antibiotic prescribing in Northern Ireland and to determine targets for improving the quality of antibiotic prescribing. A point prevalence survey was conducted in four acute teaching hospitals. The most commonly used antibiotics were combinations of penicillins including ß-lactamase inhibitors (33·6%), metronidazole (9·1%), and macrolides (8·1%). The indication for treatment was recorded in 84·3% of the prescribing episodes. A small fraction (3·9%) of the surgical prophylactic antibiotic prescriptions was for >24 h. The results showed that overall 52·4% of the prescribed antibiotics were in compliance with the hospital antibiotic guidelines. The findings identified the following indicators as targets for quality improvement: indication recorded in patient notes, the duration of surgical prophylaxis and compliance with hospital antibiotic guidelines. The results strongly suggest that antibiotic use could be improved by taking steps to address the identified targets for quality improvement.

Clinical and economic impact of contaminated blood cultures within the hospital setting.

Blood cultures have an important role in the diagnosis of serious infections, although contamination of blood cultures (i.e. false-positive blood cultures) is a common problem within the hospital setting. The objective of the present investigation was to determine the impact of the false-positive blood culture results on the following outcomes: length of stay, hotel costs, antimicrobial costs, and costs of laboratory and radiological investigation. A retrospective case-control study design was used in which 142 false-positive blood culture cases were matched with suitable controls (patients for whom cultures were reported as true negatives). The matching criteria included age, comorbidity score and month of admission to the hospital. The research covered a 13-month period (July 2007 to July 2008). The findings indicated that differences in means, between cases and controls, for the length of hospital stay and the total costs were 5.4 days [95% CI (confidence interval): 2.8-8.1 days; P<0.001] and £5,001.5 [$7,502.2; 95% CI: £3,283.9 ($4,925.8) to £6,719.1 ($10,078.6); P<0.001], respectively. Consequently, and considering that 254 false-positive blood cultures had occurred in the study site hospital over a one-year period, patients with false-positive blood cultures added 1372 extra hospital days and incurred detrimental additional hospital costs of £1,270,381 ($1,905,572) per year. The findings therefore demonstrate that false-positive blood cultures have a significant impact on increasing hospital length of stay, laboratory and pharmacy costs. These findings highlight the need to intervene to raise the standard of blood-culture-taking technique, thus improving both the quality of patient care and resource use.

The extent of unlicensed and off-label drug use in the paediatric ward of a district general hospital in Northern Ireland.

Children receive many drugs which are either unlicensed or used outside the licensing terms (off-label prescribing). Children are thereby at greater risk of side-effects. We sought to determine non-licensed drug usage in a non-specialised paediatric unit because previous studies had examined only specialised centres. Drug charts were examined prospectively over two months. Items were compared with product licenses and determined as licensed, unlicensed or off-label usage. Seventy four charts (237 prescriptions) were examined in which 183 (77.2%) drug courses were licensed. The commonest drugs were antipyretics and antibiotics. In 32 children, 8 items (3.4%) were unlicensed and 46 items (19.4%) were off-label prescriptions. The unlicensed prescriptions were mostly anti-emetics and pro-motility drugs. The three commonest off-label prescriptions were bronchodilators, antibiotics and laxatives. Non-licensed drug usage is common in non-specialised wards and therefore probably all levels of paediatric healthcare provision. Governments must re-examine paediatric drug licensing.

Multiple pulmonary chemodectomas in a child: results of four different therapeutic regimens.

PURPOSE: Chemodectomas (or paragangliomas) are rare tumors of neuroendocrine chemoreceptors, such as the carotid body. This report describes a case of multiple pulmonary chemodectomas in an adolescent and discusses the results of four therapeutic regimens. PATIENTS: At 15 years of age, the patient had cough and fatigue. Investigation revealed numerous 1- to 2-cm diameter nodules throughout both lungs. Biopsy revealed multiple pulmonary chemodectomas of uncertain malignant potential. No extrapulmonary primary site could be found. RESULTS: Because of deteriorating pulmonary function, she was treated with courses of etoposide-cisplatin and subsequently somatostatin without effect. She finally responded to a course of doxorubicin and streptozocin. She is currently maintained on interferon-alpha 2B but her measured vital capacity continues to fall slowly, reflecting increased tumor growth. Because there is still no evidence of extrapulmonary spread, she is considered to be a candidate for lung transplantation. CONCLUSIONS: A doxorubicin-streptozocin combination produced a temporary remission of this patient's multiple pulmonary chemodectomas.

Bronchial casts in children: a proposed classification based on nine cases and a review of the literature.

Bronchial casts are characterized by the formation of obstructive airway plugs that may be large enough to fill the branching pattern of an entire lung. The condition is rare but can occur at any age. Casts may be secondary to underlying diseases such as asthma and cystic fibrosis, but there are often no predisposing factors. There is no accepted classification system for bronchial casts; but only a confusion of descriptive terms such as mucoid impaction, fibrinous bronchitis, and pseudomembranous bronchitis. Based on a review of nine well-documented cases and the available literature, we have separated bronchial casts into two well-defined groups: Type 1 (inflammatory), consisting of casts composed mainly of fibrin with a dense eosinophilic inflammatory infiltrate; and Type 2 (acellular), consisting of casts composed mainly of mucin with little or no cellular infiltrate and occurring only in children with congenital cyanotic heart disease. Acute mortality was high in both groups. Survivors of Type 1 casts seem to be well controlled with inhaled steroids. Optimal therapy for patients with Type 2 casts is not clear; the prognosis probably depends on underlying cardiac status. We hope that this simple classification will provide a framework for further study of this obscure condition.

Influence of marrow on ultrasonic velocity and attenuation in bovine trabecular bone.

Measurements of ultrasonic velocity and specific differential attenuation (SDA) were obtained on 24 bovine trabecular bone specimens from the femoral condyles. The measurements were obtained using two pairs of ultrasonic transducers, one with a low nominal center frequency (500 kHz) and the other pair with a high nominal center frequency (1 MHz). The ultrasonic velocity and specific differential attenuation associated with the bone samples were determined both with and without marrow, i.e., replacing the marrow with water in the pores of the trabecular bone. Significant increases (2.1% and 2.9%) in the velocity of ultrasound were observed after removal of the marrow, for the low and high frequency transducer pairs, respectively. In contrast, significant decreases (-6.5% and -8.8%) in SDA were observed after removal of the marrow, for the low and high frequency transducer pairs, respectively. The bone densities (BD) of the samples were also determined using single photon absorptiometry (SPA). Correlations between ultrasonic parameters and bone densities for samples both with and without marrow were found to be similar. For example, for the 1 MHz transducer pair, the correlation between BD and velocity was r = 0. 86 with marrow, and r = 0.89 without marrow. This study also compared the results obtained using a contact (no water bath) technique and an insertion (with a water bath) technique of ultrasonic measurements. For the high frequency transducer pair, the correlation coefficients between the two methods were r = 0.99 and r = 0.93, for the velocity and specific differential attenuation, respectively. Similar results were found for the low frequency transducer pair as well. In addition, approximately equal correlations between BD and ultrasonic velocity and SDA were also found, indicating that contact and insertion measurements provide essentially equivalent information.

Uma nova e simplificada técnica ultra-sônica clínica para a caracterizaçäo de tecido ósseo / A new and simplified clinical ultrasound technical for bone tissue caracterization

A atenuação (BUA), medida pela técnica ultra-sônica de caracterização de tecido ósseo, pode ser substituída pela frequência instantânea média (MIF), que é um parâmetro mais simples de ser medido e sem perda de informação, utilizando-se a técnica de inserção por contato no calcanhar do paciente. Uma nova forma de classificação da osteoporose poderá ser criada baseada neste novo parâmetro.

An easy to measure ultrasonic feature namely mean instantanaeous frequency (MJF) has been demonstrated to provide about the sarne information as attenuation (BUA) in a new contact clinical ultrasonic system. A new classification of osteoporosis may be achieved using this new parameter.

Long-term electrical stimulation of rabbit skeletal muscle increases growth of paired arteries and veins.

We tested whether chronic stimulation of skeletal muscle can increase the growth of paired arteries and veins in rabbit extensor digitorum longus muscle (EDL). The right EDL of female New Zealand White rabbits was stimulated via the common peroneal nerve at 10 Hz using 300 microseconds square waves at 3-4 V. Two-hour periods of stimulation was alternated with 4-h periods of rest, 7 days/wk for approximately 60 days. The left EDL served as control. The hindlimb vascular system was maximally dilated and perfuse-fixed with 3% glutaraldehyde and 2% paraformaldehyde at arterial and venous pressures of 80-100 and 15-20 mmHg, respectively. Muscles were postfixed in OsO4 and embedded in EPOX 812 resin. One millimeter-thick transverse sections were cut at uniform locations through the entire breadth of the muscle and analyzed using videomicroscopy along with computerized morphometric and stereological techniques. All paired arteries and veins on each full muscle section were analyzed. Chronic muscle stimulation caused the wall volume of paired arteries and veins to increase by an average of approximately twofold and the lumen volume to increase by an average of approximately threefold compared with the contralateral muscles. The wall-to-lumen area ratio of the arteries and veins was not affected. Muscle stimulation also caused the numerical density of arteries having a diameter > 100 microns to increase by approximately fourfold and the density of veins having a perimeter > 500 microns to increase by approximately 10-fold.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined magnetic fields increase insulin-like growth factor-II in TE-85 human osteosarcoma bone cell cultures.

In vitro exposure to low-energy, combined magnetic fields (CMF) increased the release of insulin-like growth factor (IGF)-II from human TE-85 osteosarcoma cells. Short-term CMF exposure of only 10 min increased IGF-II levels in conditioned medium 1 h post CMF exposure. IGF-II levels were measured with a radioreceptor assay using H-35 cells that contain abundant IGF-II but not IGF-I receptors. This assay also uses a recently validated BioGel P-10 acid gel filtration method to remove IGF binding protein before quantitation of either IGF-I or IGF-II. In addition to an increase in IGF-II levels, DNA synthesis, as an index of cell proliferation, was increased during the 24-h period post CMF exposure. A monoclonal antibody against IGF-II blocked the increase in cell proliferation following CMF exposure, whereas a control monoclonal antibody against osteocalcin did not attenuate the mitogenic action of CMF exposure. The effect of CMF exposure to increase both cell proliferation and IGF-II was cell-density dependent with greater stimulation by CMF observed at lower densities. Together, these data are consistent with the hypothesis that CMF exposure stimulates release/production of IGF-II from bone cells and that increased IGF-II then promotes an increase in cell proliferation.

IGF-II receptor number is increased in TE-85 osteosarcoma cells by combined magnetic fields.

Human osteosarcoma-derived osteoblast-like cells, TE-85, were used to assess the effect of a low frequency alternating magnetic field in combination with a controlled static magnetic field (combined magnetic fields, CMF) on insulin-like growth factor receptor regulation. In our culture system, application of a 15.3 Hz CMF induces a calculated maximum electrical potential in the culture media of 10(-5) V/m. Initial characterization of TE-85 cells demonstrated that (a) TE-85 cells contain both type I insulin-like growth factor (IGF-I) and IGF-II receptors and (b) dose dependence for IGF-stimulated cell proliferation were comparable to the affinities of the IGF's binding to membrane binding sites (i.e., receptors had dissociation constants in the low nanomolar concentration range). The studies with CMF exposure revealed that CMF treatment for 30 minutes increased the number of IGF-II receptors in a frequency-dependent manner without affecting the number of IGF-I receptors. The CMF-dependent increase in IGF-II receptor number was associated with a significant increase in the IGF-II dissociation constant. These results indicate that a membrane receptor levels can be altered by short-term exposure to low-energy, low-frequency electromagnetic fields and suggest a potential biochemical mechanism for electromagnetic effects on bone formation and remodeling.

Combined magnetic fields increased net calcium flux in bone cells.

Low energy electromagnetic fields (EMF) exhibit a large number of biological effects. A major issue to be determined is "What is the lowest threshold of detection in which cells can respond to an EMF?" In these studies we demonstrate that a low-amplitude combined magnetic field (CMF) which induces a maximum potential gradient of 10(-5) V/m is capable of increasing net calcium flux in human osteoblast-like cells. The increase in net calcium flux was frequency dependent, with a peak in the 15.3-16.3 Hz range with an apparent bandwidth of approximately 1 Hz. A model that characterizes the thermal noise limit indicates that non-spherical cell shape, resonant type dynamics, and signal averaging may all play a role in the transduction of low-amplitude EMF effects in biological systems.

Bone remodeling and in vivo strain analysis of intact and implanted greyhound proximal femora.

Pre- and poststudy motion and gait analyses of eight size-matched male greyhounds confirmed uniform loading of their femora. Subminiature strain gages implanted on the intact inferior and anterior aspects of the femoral neck in six greyhounds indicated in vivo strain variations among test animals. Motion and gait analyses confirmed uniform loading of femora following unilateral hemiarthroplasty with cobalt-chromium hip implants. In vivo strain measurements adjacent to the implants indicated large variations among test animals. A consistent direction of strain change relative to the intact femur was noted, even though strain changes varied in magnitude. Image analysis of microradiographs indicated insignificant differences in the cortical areas of implanted and intact femora. Extensive new trabecular bone formation was noted along the implant in the endosteal cavity and correlated with a combination of implant placement and exercise level. Most of the bone was formed with centrally placed implants in exercised dogs, and the least with stems on the medial neck surface in rested dogs. Iliac crest biopsies indicated that bone formation rates slowed in rested animals and remained constant throughout the study in exercised animals. All implanted femora had a thin (< 1 mm thick) aligned fibrous tissue layer separating the implant from bone. It varied in thickness as a function of the aspect of the implant. Exercised dogs had a larger proportion of fibrous tissue on the anterior and posterior aspects, while rested dogs had a larger proportion of fibrous tissue on the medial and lateral aspects.

Strain redistribution in the canine femur resulting from hip implants of different stiffnesses.

Bone remodeling adjacent to orthopedic implants has been attributed to bone strain changes. Although many animal studies have assessed bone remodeling near implants, the altered bone strains and even the strains in the intact bone prior to implantation have not been mapped extensively. Instead, bone changes are often correlated with implant stiffnesses. In this study, a benchtop loading system was developed using measurements from in vivo strain analysis to simulate physiologic loading of a canine femur. The effect on bone strains of three different stiffness canine hip implants with the same anatomic shape were compared by taking measurements from the proximal greyhound femur during loading. Peak compressive and tensile strains of the order of 200 to 400 microstrain were measured in the intact and implanted femora. The measurements indicate that during simulated in vivo loading, none of the implants substantially alter the normal strain state of the bone. If initial axial strains significantly affect the remodeling response of bone, the similarity of measurements with the different implants in place suggests that the same remodeling response would be expected to both the stiffest and least stiff implant, as has been noted in animal studies adjacent to the intermediate stiffness implant. It also suggests that this implant shape and initial bone implant interface condition can compensate for strain reductions expected near stiff straight-stemmed implants.

Radiological and histological study of aseptic loosening using a cemented tibial hemiarthroplasty in the rabbit knee.

Fourteen mature New Zealand white female rabbits had a unilateral cemented, stemmed, titanium, condylar-type tibial hemiarthroplasty, using an anteromedial arthrotomy of the right knee. The articular cartilage and minimal bone were resected. There were two prosthetic groups of seven animals each: a well-fixed, non-loose group and a loose group. In the non-loose group, the implant was inserted into the cement bed and axially compressed until the PMMA had cured. In the loose group, the same volume of cement was allowed to cure on the implant ex vivo; the prosthesis was then implanted to ensure that it was loose fitting. Radiographs were performed at zero and 3 months and graded for new lucent lines. Histological analysis was performed using undecalcified coronal sections, surface stained with toluidine blue with the prosthesis in situ, and the cement mantle preserved. Back-scattered electron microscopy was also performed. The mean cumulative grading of new lucent lines was 0.3 +/- 0.1 for the non-loose group and 2.2 +/- 0.4 for the loose group (P < 0.005). Non-loose prostheses were surrounded by a thin fibrous membrane or bone. Loose prostheses were surrounded by a thicker, fibrous tissue layer, containing histiocytes and giant cells which were more prevalent around cement particles, especially near the prosthetic tip. These findings parallel the histology found at cemented prosthetic interfaces in humans. The results of this study suggest that the fibrohistiocytic membrane commonly found around loose cemented implants may be the result of, rather than the cause of, the loosening process.