ORCID Profile
0000-0002-6705-6004
Current Organisations
Murdoch University
,
Fiona Stanley Hospital
,
The University of Western Australia Medical School
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Publisher: BMJ
Date: 11-2007
Publisher: Elsevier BV
Date: 08-2010
DOI: 10.1093/BJA/AEQ156
Abstract: Recent evidence suggests that neuraxial and regional anaesthesia may influence the progression of the underlying malignant disease after surgery. This retrospective cohort study assessed whether neuraxial anaesthesia would affect the progression of cervical cancer in 132 consecutive patients who were treated with brachytherapy in a tertiary cancer centre in Australia. Age, American Society of Anesthesiologists status, International Federation of Gynecologists and Obstetricians (FIGO) cancer staging, invasion into the uterus, tumour volume, and tumour cell types were not significantly different between patients who received neuraxial and general anaesthesia during their first brachytherapy treatment. The use of neuraxial anaesthesia during the first brachytherapy was not associated with a reduced risk of local or systemic recurrence [hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.54-1.67 P=0.863], long-term mortality from tumour recurrence (HR 1.46, 95% CI 0.75-2.84 P=0.265), or all-cause mortality (HR 1.46, 95% CI 0.81-2.61 P=0.209), after adjusting for other prognostic factors. Tumour recurrence and long-term survival were only significantly associated with the tumour cell type, tumour volume, and FIGO tumour staging. Sensitivity analyses using proportions of all brachytherapy sessions performed under neuraxial anaesthesia also did not show any beneficial effects of neuraxial anaesthesia on tumour recurrence and long-term survival. Using neuraxial anaesthesia during brachytherapy for patients with cervical cancer was not associated with a reduced risk of tumour recurrence and mortality when compared with general anaesthesia.
Publisher: Elsevier BV
Date: 12-2013
Publisher: Elsevier BV
Date: 02-2021
DOI: 10.1016/J.INJURY.2020.09.056
Abstract: Using three patient characteristics, including age, Injury Severity Score (ISS) and transfusion within 24 h of admission (yes vs. no), the Geriatric Trauma Outcome Score (GTOS) and Geriatric Trauma Outcome Score II (GTOS II) have been developed to predict mortality and unfavourable discharge (to a nursing home or hospice facility), of those who were ≥65 years old, respectively. This study aimed to validate the GTOS and GTOS II models. For the nested-cohort requiring intensive care, we compared the GTOS scores with two ICU prognostic scores - the Acute Physiology and Chronic Health Evaluation (APACHE) III and Australian and New Zealand Risk of Death (ANZROD). All elderly trauma patients admitted to the State Trauma Unit between 2009 and 2019 were included. The discrimination ability and calibration of the GTOS and GTOS II scores were assessed by the area under the receiver-operating-characteristic (AUROC) curve and a calibration plot, respectively. Of the 57,473 trauma admissions during the study period, 15,034 (26.2%) were ≥65 years-old. The median age and ISS of the cohort were 80 (interquartile range [IQR] 72-87) and 6 (IQR 2-9), respectively and the average observed mortality was 4.3%. The ability of the GTOS to predict mortality was good (AUROC 0.838, 95% confidence interval [CI] 0.821-0.855), and better than either age (AUROC 0.603, 95%CI 0.581-0.624) or ISS (AUROC 0.799, 95%CI 0.779-0.819) alone. The GTOS II's ability to predict unfavourable discharge was satisfactory (AUROC 0.707, 95%CI 0.696-0.719) but no better than age alone. Both GTOS and GTOS II scores over-estimated risks of the adverse outcome when the predicted risks were high. The GTOS score (AUROC 0.683, 95%CI 0.591-0.775) was also inferior to the APACHE III (AUROC 0.783, 95%CI 0.699-0.867) or ANZROD (AUROC 0.788, 95%CI 0.705-0.870) in predicting mortality for those requiring intensive care. The GTOS scores had a good ability to discriminate between survivors and non-survivors in the elderly trauma patients, but GTOS II scores were no better than age alone in predicting unfavourable discharge. Both GTOS and GTOS II scores were not well-calibrated when the predicted risks of adverse outcome were high.
Publisher: Wiley
Date: 23-08-2010
DOI: 10.1111/J.1537-2995.2010.02855.X
Abstract: Electrolyte disturbances are common in patients with critical bleeding requiring massive transfusion. The risk factors and outcome associated with the occurrence of hypomagnesemia in massive transfusion remain uncertain. A cohort of 353 consecutive patients who required massive transfusion, defined as 10 or more units of allogeneic red blood cells or whole blood transfusion within 24 hours, between 2002 and 2008 in a quaternary health care center in Western Australia was considered. Logistic regression was used to identify risk factors and outcome associated with hypomagnesemia during massive transfusion (<0.7 mmol/L or 1.7 mg/dL). Of the 353 patients requiring massive transfusion during the study period, 298 patients (84%) had serum magnesium concentrations available for analysis. Hypomagnesemia was common (172 patients, 58%), and the mean magnesium concentration was 0.68 mmol/L (1.65 mg/dL standard deviation, 0.15 mmol/L) in these patients. The risk factors for hypomagnesemia were hypocalcemia (odds ratio [OR], 1.67 per 0.1 mmol/L decrement 95% confidence interval [CI], 1.36-2.01 p = 0.001) and hypofibrinogenemia (OR, 1.05 per 0.1 g/L decrement 95% CI, 1.01-1.09 p = 0.009). The lowest serum magnesium concentrations were associated with the lowest ionized calcium concentrations (Spearman correlation coefficient, 0.377 p = 0.001). Both magnesium concentrations (OR, 0.91 per 0.1 mmol/L increment 95% CI 0.31-2.69 p = 0.863) and the interaction term between magnesium and calcium concentrations were not associated with an increased risk of mortality after adjusting for other covariates. Hypomagnesemia was common and associated with hypocalcemia in massive transfusion, but serum magnesium concentrations had no independent effect or interactive effect with hypocalcemia on mortality of patients requiring massive transfusion.
Publisher: Springer Science and Business Media LLC
Date: 13-01-2017
DOI: 10.1007/S12630-017-0818-Z
Abstract: During cancer surgery, prostaglandin-mediated inflammation may promote and activate micrometastatic disease with a consequent increase in long-term cancer recurrence. Cyclooxygenase-2 inhibitors, known to have anti-proliferative properties, may offset such perioperative perturbation. We investigated the effectiveness of these agents to minimize inflammatory changes during cancer surgery. Following ethics approval, 32 patients who were to undergo major intracavity cancer surgery were enrolled in this prospective, randomized, clinical trial. The treatment group received 400 mg celecoxib preoperatively followed by five 200 mg 12-hourly doses. The control group received no anti-inflammatory agents. Inflammatory and immunomodulatory end points were measured serially. The primary end points were the measured plasma and urinary prostaglandin E metabolite (PGE No differences in the 48-hr plasma or urinary PGE Standard dosing of the cyclooxygenase-2 inhibitor celecoxib slightly reduced perioperative cyclooxygenase activity during cancer surgery. Given cyclooxygenase's role in cancer pathways, we recommend dose-finding studies be undertaken before prospective clinical trials are conducted testing the currently unsubstantiated hypothesis that perioperative anti-inflammatory administration improves long-term cancer outcomes. This trial was registered at: Australian New Zealand Clinical Trial Registry: ACTRN12615000041550 www.anzctr.org.au.
Publisher: Elsevier BV
Date: 02-2016
DOI: 10.1016/J.JCRC.2015.10.019
Abstract: This study compared the performance of 3 admission prognostic scores in predicting hospital mortality. Patient admission characteristics and hospital outcome of 9549 patients were recorded prospectively. The discrimination and calibration of the predicted risks of death derived from the Simplified Acute Physiology Score (SAPS III), Admission Mortality Prediction Model (MPM0 III), and admission Acute Physiology and Chronic Health Evaluation (APACHE) II were assessed by the area under the receiver operating characteristic curve and a calibration plot, respectively. Of the 9549 patients included in the study, 1276 patients (13.3%) died after intensive care unit admission. Patient admission characteristics were significantly different between the survivors and nonsurvivors. All 3 prognostic scores had a reasonable ability to discriminate between the survivors and nonsurvivors (area under the receiver operating characteristic curve for SAPS III, 0.836 MPM0 III, 0.807 admission APACHE, 0.845), with best discrimination in emergency admissions. The SAPS III model had a slightly better calibration and overall performance (slope of calibration curve, 1.03 Brier score, 0.09 Nagelkerke R(2), 0.297) compared to the MPM0 III and admission APACHE II model. All 3 intensive care unit admission prognostic scores had a good ability to predict hospital mortality of critically ill patients, with best discrimination in emergency admissions.
Publisher: Elsevier BV
Date: 2013
DOI: 10.1016/J.WNEU.2012.08.012
Abstract: There has been a resurgence of interest in the use of decompressive craniectomy for severe traumatic brain injury (TBI). Numerous studies have shown that the procedure can consistently reduce intracranial pressure (ICP), and a significant number of patients achieve a good long-term functional recovery. However, there has been debate regarding clinical indications and patient selection. The DECRA (Decompressive Craniectomy in Patients with Severe Traumatic Brain Injury) study compared patients who underwent early decompressive craniectomy for diffuse TBI with patients who received standard medical therapy. Of patients, 70% in the craniectomy group had an unfavourable outcome versus 51% in the standard care group (odds ratio 2.21 [95% confidence interval 1.14-4.26] P=0.02). Based on these results, the authors concluded that decompressive craniectomy was associated with more unfavorable outcomes and that by adopting standard medical therapy rather than surgical decompression the health care system would save millions of dollars. These conclusions are not really supported by closer examination of the basic data. There were problems with randomization such that the patients in the surgical arm appeared to have sustained a more severe primary TBI, the ICP threshold of >20 mm Hg for >15 minutes did not reflect clinical practice, and there was a high crossover rate from the standard care arm to the surgical arm. Because of these problems, the DECRA trial has received a great deal of criticism, and some authorities have claimed that the results should have no influence on clinical practice. This claim is perhaps unfair, and an alternative interpretation is offered. Overall, the results of the DECRA study showed that a relatively transient and mild increase in ICP (>20 mm Hg for 15 minutes as recruitment criterion) does not imply that there is significant ongoing secondary brain injury, and any potential improvement obtained by surgical decompression may well be offset by surgical morbidity. The role of decompressive craniectomy when ICP continues to increase ≥20 mm Hg remains to be established. The ongoing RESCUEicp (Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intra-Cranial Pressure) study hopes to address this issue.
Publisher: SAGE Publications
Date: 07-12-2022
DOI: 10.1177/0310057X221105291
Abstract: The Royal College of Anaesthetists was commissioned by the United Kingdom Health Quality Partnership to conduct the National Emergency Laparotomy Audit of England and Wales (NELA), to compare outcomes of patients undergoing emergency laparotomy in order to promote quality improvement. Prior to 2016 there were minimal data for emergency laparotomy patients in Australia. The aim of this cohort study was to assess the utility and applicability of the NELA model in a tertiary centre in Western Australia. NELA-related data of patients who underwent emergency laparotomy, between June 2018 and May 2020, were merged with other administrative databases and clinical records. The discriminative ability and calibration of the model were assessed by the area under the receiver operating characteristic (AUROC) curve and calibration plot, respectively. Cox proportional hazards regression was used to assess whether the NELA-predicted risks were an independent predictor of hospital mortality. Of the 502 patients included, 168 (33.5%) patients had a NELA-predicted risk %, and of these, 93 (55.4%) were admitted to a critical care unit in a planned fashion immediately after surgery. The NELA model had a good ability to discriminate between survivors and non-survivors (AUROC 0.892, 95% confidence intervals 0.854 to 0.93, P .001). However, the model was not perfectly calibrated, with the predicted risks tending to overestimate the observed risks of mortality, especially when the predicted risks were %. A high NELA-predicted risk remained significantly associated with mortality after adjusting for other covariates, including sepsis and plasma lactate concentration, suggesting that it is a reliable screening tool for identifying high-risk patients requiring emergency laparotomy.
Publisher: S. Karger AG
Date: 19-02-2010
DOI: 10.1159/000286351
Abstract: i Background: /i Risk, Injury, Failure, Loss, and End-Stage (RIFLE) criteria have been proposed as a standard definition of acute kidney injury (AKI). The most severe form of AKI, class F AKI, can be defined by either severe oliguria or a 3-fold increase in serum creatinine concentrations. We hypothesized that the outcomes of patients with these 2 alternative criteria of severe AKI were different. i Methods: /i A prospective cohort study was conducted of all patients attaining RIFLE class F AKI during a 12-month period in a tertiary critical care facility. i Results: /i Among a total of 2,379 critical care admissions, 129 (5.4%) fulfilled the serum creatinine criteria without oliguria (RIFLE class F) and 99 (4.2%) fulfilled oliguric (RIFLE class F) AKI criteria. Patients with oliguric AKI suffered a more severe disease process than nonoliguric AKI. Oliguric AKI was associated with a significantly higher risk of requiring acute dialysis (70.7 vs. 22.4%, p = 0.001), long-term dialysis days (15 vs. 1.9%, p = 0.006), and hospital mortality (adjusted hazard ratio 3.33, 95% confidence interval, p = 0.001) than nonoliguric AKI. i Conclusions: /i Oliguric RIFLE class F AKI is a more severe form of AKI than nonoliguric class F AKI. These 2 forms of AKI should be considered separately when AKI is evaluated in a clinical trial.
Publisher: Elsevier BV
Date: 09-2014
DOI: 10.1016/J.INJURY.2014.03.007
Abstract: To assess the impact that injury severity has on complications in patients who have had a decompressive craniectomy for severe traumatic brain injury (TBI). This prospective observational cohort study included all patients who underwent a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia from 2004 to 2012. All complications were recorded during this period. The clinical and radiological data of the patients on initial presentation were entered into a web-based model prognostic model, the CRASH (Corticosteroid Randomization After Significant Head injury) collaborators prediction model, to obtain the predicted risk of an unfavourable outcome which was used as a measure of injury severity. Complications after decompressive craniectomy for severe TBI were common. The predicted risk of unfavourable outcome was strongly associated with the development of neurological complications such as herniation of the brain outside the skull bone defects (median predicted risk of unfavourable outcome for herniation 72% vs. 57% without herniation, p=0.001), subdural effusion (median predicted risk of unfavourable outcome 67% with an effusion vs. 57% for those without an effusion, p=0.03), hydrocephalus requiring ventriculo-peritoneal shunt (median predicted risk of unfavourable outcome 86% for those with hydrocephalus vs. 59% for those without hydrocephalus, p=0.001), but not infection (p=0.251) or resorption of bone flap (p=0.697) and seizures (0.987). We did not observe any associations between timing of cranioplasty and risk of infection or resorption of bone flap after cranioplasty. Mechanical complications after decompressive craniectomy including herniation of the brain outside the skull bone defects, subdural effusion, and hydrocephalus requiring ventriculo-peritoneal shunt were more common in patients with a more severe form of TBI when quantified by the CRASH predicted risk of unfavourable outcome. The CRASH predicted risk of unfavourable outcome represents a useful baseline characteristic of patients in observational and interventional trials involving patients with severe TBI requiring decompressive craniectomy.
Publisher: The Korean Society of Critical Care Medicine
Date: 31-05-2021
Publisher: Springer Science and Business Media LLC
Date: 03-05-2016
DOI: 10.1007/S00701-016-2818-0
Abstract: The concept of futility has been debated for many years, and a precise definition remains elusive. This is not entirely unsurprising given the increasingly complex and evolving nature of modern medicine. Progressively more complex decisions are required when considering increasingly sophisticated diagnostic and therapeutic interventions. Allocating resources appropriately amongst a population whose expectations continue to increase raises a number of ethical issues not least of which are the difficulties encountered when consideration is being given to withholding "life-preserving" treatment. In this discussion we have used decompressive craniectomy for severe traumatic brain injury as a clinical ex le with which to frame an approach to the concept. We have defined those issues that initially lead us to consider futility and thereafter actually provoke a significant discussion. We contend that these issues are uncertainty, conflict and consent. We then examine recent scientific advances in outcome prediction that may address some of the uncertainty and perhaps help achieve consensus amongst stakeholders. Whilst we do not anticipate that this re-framing of the idea of futility is applicable to all medical situations, the approach to specify patient-centred benefit may assist those making such decisions when patients are incompetent to participate.
Publisher: SAGE Publications
Date: 07-2021
Publisher: Wiley
Date: 02-2010
DOI: 10.1111/J.1755-5922.2009.00117.X
Abstract: Atrial fibrillation (AF) is very common within the first 5 days of cardiac surgery. It is associated with significant morbidity including stroke, ventricular arrhythmias, myocardial infarction, heart failure, acute kidney injury, prolonged hospital stay, and also short- and long-term mortality. The underlying mechanisms of developing AF after cardiac surgery are multifactorial risk factors may include advanced age, withdrawal of beta-blockers and angiotensin-converting-enzyme inhibitors, valve surgery, obesity, increased left atrial size, and diastolic dysfunction. There are many pharmacological options in preventing AF, but none of them are effective for all patients and they all have significant limitations. Beta-blockers may reduce the incidence of AF by more than a third, but bradycardia, hypotension, or exacerbation of heart failure often limit their utility postoperatively. Recent evidence suggests that class III antiarrhythmic drugs, sotalol and amiodarone, are more effective than beta-blockers, but they both share similar hemodynamic side effects of beta-blockers. Magnesium, antiinflammatory drugs such as statins, omega fatty acids, and low-dose corticosteroids also have some efficacy and they have the advantages of not causing significant hemodynamic side effects. Data on effectiveness of calcium channel blockers, digoxin, alpha-2 agonists, sodium nitroprusside, and N-acetylcysteine are more limited. Because the pathogenesis of AF is multifactorial, a combination of drugs with different pharmacological actions may have additive or synergistic effect in preventing AF after cardiac surgery. Randomized controlled trials evaluating the effectiveness of a multimodality pharmacological approach in patients at high-risk of AF after cardiac surgery are needed.
Publisher: Mary Ann Liebert Inc
Date: 07-2010
Abstract: A number of studies have shown that decompressive craniectomy can reduce intracranial pressure and may improve outcome for patients with severe head injury. This cohort study assessed the long-term outcome of neurotrauma patients who had a decompressive craniectomy for severe head injury in Western Australia between 2004 and 2008. The web-based outcome prediction model developed by the CRASH trial collaborators was applied to the cohort. Predicted outcome and observed outcome were compared. Characteristics of outcome between those who had had a unilateral and those who had had a bilateral decompressive procedure were compared. All complications were recorded. Among a total of 1,786 adult neurotrauma patients admitted during the study period, 147 patients (8.2%) had a decompressive craniectomy. A significant proportion of patients who required unilateral (37.3%) and bilateral (46.5%) craniectomy were able to return to work or study at 18 months after the injury. The patients who required bilateral craniectomy more likely to be associated with an unfavorable outcome (Glasgow Outcome Scale score >or=3) than those who had unilateral craniectomy (odds ratio 4.42 95% confidence interval 1.16,16.81 p = 0.029), after adjusting for the timing of surgery, mechanism of injury, and the predicted risk of unfavorable outcome. The functional outcome after either unilateral or bilateral decompressive craniectomy was significantly better than that predicted by the CRASH head injury prediction model when the predicted risk was less than 80%. This study has demonstrated that in Western Australia decompressive craniectomy is a relatively common surgical procedure for the management of neurotrauma. A significant proportion of patients had a better-than-predicted long-term functional outcome.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-1999
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2015
Publisher: Springer Science and Business Media LLC
Date: 11-03-2011
DOI: 10.1007/S00134-011-2184-6
Abstract: It is uncertain whether smoking has an independent dose-related adverse effect on mortality in critically ill patients. This study assessed whether the intensity of smoking history, measured in pack-years, has a dose-related effect on mortality in critically ill patients. In this multicentre cohort study data were collected from six tertiary intensive care units (ICU) in Australia and New Zealand. Of the 8,962 patients considered in the study, data on patients' smoking status and smoking history were available from 5,063 and 2,865 patients, respectively. Male gender, and chronic respiratory, liver and cardiovascular diseases were over-represented among smokers compared to non-smokers. Smokers had a higher risk of requiring mechanical ventilation and dying in hospital than non-smokers (10.7% vs. 6.7%, p=0.001), particularly after emergency admission. Smokers also had a longer ICU stay than non-smokers (mean 3.2 days, interquartile range 0.8-3.2 vs. 2.8 days, interquartile range 0.8-2.9 p=0.024). After adjusting for age, gender, elective surgical admission, severity of acute illness, and severe chronic illnesses, the intensity of smoking history remained significantly associated with the risk of dying in hospital. This was in a relatively linear fashion (odds ratio 1.08 per 10 pack-years increment, 95% confidence interval 1.02-1.15 p=0.02). Further grouping of smokers into active smokers and ex-smokers, or including patients with unknown smoking status in the sensitivity analyses did not change the association between the intensity of smoking history and mortality. Smoking has a dose-related adverse effect on mortality of critically ill patients after adjusting for other confounders.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 27-10-2015
Abstract: Optimal thromboprophylaxis after cardiac surgery is uncertain. This systematic review aimed to define the incidence and risk factors for deep vein thrombosis ( DVT ), fatal and nonfatal pulmonary embolism ( PE ), and assess whether venous thromboembolism ( VTE ) prophylaxis was effective in reducing VTE without complications after cardiac surgery. Two reviewers independently searched and assessed the quality and outcomes of randomized, controlled trials ( RCT s) and observational studies on VTE after cardiac surgery in the MEDLINE , EMBASE , and Cochrane controlled trial register (1966 to December 2014). Sixty‐eight studies provided data on VTE outcomes or complications related to thromboprophylaxis after cardiac surgery. The majority of the studies were observational studies (n=49), 16 studies were RCT s, and 3 were meta‐analyses. VTE prophylaxis was associated with a reduced risk of PE (relative risk [ RR ], 0.45 95% confidence interval [ CI ], 0.28–0.72 P =0.0008) or symptomatic VTE ( RR , 0.44 95% CI , 0.28–0.71 P =0.0006) compared to the control without significant heterogeneity. Median incidence (interquartile range) of symptomatic DVT , PE , and fatal PE were 3.2% (0.6–8.1), 0.6% (0.3–2.9), and 0.3% (0.08–1.7), respectively. Previous history of VTE , obesity, left or right ventricular failure, and prolonged bed rest, mechanical ventilation, or use of a central venous catheter were common risk factors for VTE . Bleeding or cardiac t onade requiring reoperation owing to pharmacological VTE prophylaxis alone, without systemic anticoagulation, was not observed. Unless proven otherwise by adequately powered RCT s, initiating pharmacological VTE prophylaxis as soon as possible after cardiac surgery for patients who have no active bleeding is highly recommended.
Publisher: Elsevier BV
Date: 04-2010
DOI: 10.1093/BJA/AEQ025
Abstract: Critical illness leading to prolonged length of stay (LOS) in an intensive care unit (ICU) is associated with significant mortality and resource utilization. This study assessed the independent effect of ICU LOS on in-hospital and long-term mortality after hospital discharge. Clinical and mortality data of 22 298 patients, aged 16 yr and older, admitted to ICU between 1987 and 2002 were included in this linked-data cohort study. Cox's regression with restricted cubic spline function was used to model the effect of LOS on in-hospital and long-term mortality after adjusting for age, gender, acute physiology score (APS), maximum number of organ failures, era of admission, elective admission, Charlson's co-morbidity index, and diagnosis. The variability each predictor explained was calculated by the percentage of the chi(2) statistic contribution to the total chi(2) statistic. Most hospital deaths occurred within the first few days of ICU admission. Increasing LOS in ICU was not associated with an increased risk of in-hospital mortality after adjusting for other covariates, but was associated with an increased risk of long-term mortality after hospital discharge. The variability on the long-term mortality effect associated with ICU LOS (2.3%) appeared to reach a plateau after the first 10 days in ICU and was not as important as age (35.8%), co-morbidities (18.6%), diagnosis (10.9%), and APS (3.6%). LOS in ICU was not an independent risk factor for in-hospital mortality, but it had a small effect on long-term mortality after hospital discharge after adjustment for other risk factors.
Publisher: Wiley
Date: 05-01-2018
DOI: 10.1111/EJH.12992
Abstract: We aimed to assess whether whole-blood viscoelastic tests are useful to identify patients who are hypercoagulable and at increased risk of thromboembolism. Two investigators independently analyzed studies in the MEDLINE, EMBASE, and Cochrane controlled trial register databases to determine the ability of viscoelastic tests to identify a hypercoagulable state that is predictive of objectively proven thromboembolic events. Forty-one eligible studies, including 10,818 patients, were identified and subject to meta-analysis. The majority of the studies (n = 36, 88%) used the maximum clot strength to identify a hypercoagulable state which had a moderate ability to differentiate between patients who developed thromboembolic events and those who did not (area under the summary receiver operating characteristic [sROC] curve = 0.70, 95% confidence interval [CI]: 0.65-0.75). The pooled sensitivity, specificity, and diagnostic odds ratio to predict thromboembolism were 56% (95%CI: 44-67), 76% (95%CI: 67-83), and 3.6 (95%CI: 2.6-4.9), respectively. The predictive performance did not vary substantially between patient populations, and publication bias was not observed. Current evidence suggests that whole-blood viscoelastic tests have a moderate ability to identify a variety of patient populations with an increased risk of thromboembolic events and can be considered as a useful adjunct to clinical judgment to stratify a patient's risk of developing thromboembolism.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 14-04-2009
DOI: 10.1161/CIRCULATIONAHA.108.848218
Abstract: Background— Cardiopulmonary bypass and cardiac surgery are associated with a significant systemic inflammatory response that may increase postoperative complications. This meta-analysis assessed whether the benefits and risks of corticosteroid use were dose dependent in adult cardiac surgery. Methods and Results— Randomized controlled trials of the use of corticosteroid prophylaxis in adult cardiac surgery ( years of age) requiring cardiopulmonary bypass were selected from MEDLINE (1966 to August 1, 2008), EMBASE (1988 to August 1, 2008), and the Cochrane controlled trials register without any language restrictions. A total of 3323 patients from 50 randomized controlled trials were identified and subject to meta-analysis. Corticosteroid prophylaxis reduced the risk of atrial fibrillation (25.1% versus 35.1% number needed to treat, 10 relative risk, 0.74 95% confidence interval [CI], 0.63 to 0.86 P .01) and length of stay in the intensive care unit (weighted mean difference, −0.37 days 95% CI, −0.21 to −0.52 P .01) and hospital (weighted mean difference, −0.66 days 95% CI, −0.77 to −1.25 P =0.03) compared with placebo. The use of corticosteroid was not associated with an increased risk of all-cause infection (relative risk, 0.93 95% CI, 0.61 to 1.41 P =0.73), but hyperglycemia requiring insulin infusion after corticosteroid prophylaxis was common (28.2% relative risk, 1.49 95% CI, 1.11 to 2.01 P .01). No additional benefits were found on all outcomes beyond a total dose of 1000 mg hydrocortisone, and very high doses of corticosteroid were associated with prolonged mechanical ventilation. Conclusions— Evidence suggests that low-dose corticosteroid is as effective as high-dose corticosteroid in reducing the risk of atrial fibrillation and duration of mechanical ventilation but with fewer potential side effects in adult cardiac surgery.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2011
Publisher: Public Library of Science (PLoS)
Date: 17-09-2008
Publisher: Springer Science and Business Media LLC
Date: 2009
DOI: 10.1186/CC7988
Publisher: Elsevier BV
Date: 11-2015
DOI: 10.1016/J.SOARD.2015.01.005
Abstract: A multidisciplinary bariatric surgical approach is currently the most effective treatment for obesity. However, little is known about how the physiologic impact of weight reduction surgery superimposed on premorbid obesity-related co-morbidities may adversely influence perioperative renal function. This observational, multicenter study investigated all bariatric surgery patients (n = 590) admitted to any intensive care unit (ICU) in Western Australia between 2007 and 2011. Using Acute Kidney Injury Network (AKIN) criteria, we ascertained the incidence and contributing risk factors for acute kidney injury (AKI). Acute kidney injury (AKI) occurred in 103 patients, accounting for 17.5% of all ICU admissions after bariatric surgery with 76.8% of the AKI episodes limited to AKIN stage 1. In a multivariate analysis, male gender, premorbid hypertension, higher admission APACHE II scores, and blood transfusions were all associated with AKI, while preexisting chronic kidney disease and body mass index (BMI) appeared not to influence renal decline. Both ICU (6.7 versus 2.5 d, P<.001) and hospital (18.6 versus 6.8 d, P<.001) length of stays were significantly increased after AKI. Six patients required hemodialysis while both ICU mortality (2.9 versus 0%, P = .005) and long-term mortality (18.2 versus 4.7 deaths per 1000 bariatric patient-yr, P = .01) were greater in patients experiencing AKI. AKI is common in bariatric patients requiring critical care support leading to increased healthcare utilization, prolonged hospitalization, and is associated with a higher mortality. BMI, a previously described risk factor, was not predictive of AKI in this cohort.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2015
Publisher: Georg Thieme Verlag KG
Date: 2013
DOI: 10.1160/TH12-09-0658
Abstract: It is uncertain whether thrombocytosis without underlying myeloproliferative diseases is associated with an increased risk of acute pulmonary embolism (PE). We investigated the relationship between thrombocytosis and risk of symptomatic acute PE, and whether Pulmonary Embolism Severity Index (PESI) was reliable in predicting mortality of acute PE. This multicentre registry study involved a total of 609,367 critically ill patients admitted to 160 intensive care units (ICUs) in Australia or New Zealand between 2006 and 2011. Forward stepwise logistic regression was used to assess the relationship between risk of acute PE and platelet counts on intensive care unit (ICU) admission. Acute PE (n=3387) accounted for 0.9% of all emergency ICU admissions. Over 20% of all PE required mechanical ventilation, 4.2% had cardiac arrest, and the mortality was high (14.8%). Thrombocytosis, defined by a platelet count ×109 per litre, occurred in 2.1% of the patients and was more common in patients with acute PE than other diagnoses (3.4 vs. 2.0%). The platelet counts explained about 4.5% of the variability and had a linear relationship with the risk of acute PE (odds ratio 1.19 per 100×109 per litre increment in platelet count, 95% confidence interval 1.06–1.34), after adjusting for other covariates. The PESI had a reasonable discriminative ability (area under receiver-operating-characteristic curve = 0.78) and calibration to predict mortality across a wide range of severity of acute PE. In summary, thrombocytosis was associated with an increased risk of symptomatic acute PE. PESI was useful in predicting mortality across a wide range of severity of acute PE.
Publisher: SAGE Publications
Date: 06-12-2021
DOI: 10.1177/0310057X211039226
Abstract: Tracheostomy tubes are chosen primarily based on their internal diameter however, the length of the tube may also be important. We performed a prospective clinical audit of 30 critically ill patients following tracheostomy to identify the type of tracheostomy tube inserted, the incidence of malpositioning and the factors associated with the need to change the tracheostomy tube subsequently. Anthropometric neck measurements, distance between the skin and tracheal rings and the position of the tracheostomy cuff relative to the tracheal stoma were recorded and analysed. Malpositioning of the tracheostomy tube was noted in 20%, with a high riding cuff being the most common cause of malpositioning, resulting in an audible leak and a need to change the tracheostomy tube subsequently. A high riding cuff was more common when a small tracheostomy tube (e.g. Portex (Smiths Medical Australasia, Macquarie Park, NSW) ≤8.0 mm internal diameter with length .5 cm) was used, with risk further increased when the patient’s skin to trachea depth was greater than 0.8 cm. Identifying a high riding cuff relative to the tracheal stoma confirmed by a translaryngeal bronchoscopy strongly predicted the risk of air leak and the need to change the tracheostomy tube subsequently. Our study suggests that when a small (and short) tracheostomy tube is planned for use, intraoperative translaryngeal bronchoscopy is warranted to exclude malpositioning of the tracheostomy tube with a high riding cuff.
Publisher: Springer Science and Business Media LLC
Date: 28-08-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-1997
DOI: 10.1097/00000542-199707000-00024
Abstract: Melioidosis is endemic in the remote Katherine region of northern Australia. In a population with high rates of chronic disease, social inequities, and extreme remoteness, the impact of melioidosis is exacerbated by severe weather events and disproportionately affects First Nations Australians. All culture-confirmed melioidosis cases in the Katherine region of the Australian Top End between 1989-2021 were included in the study, and the clinical features and epidemiology were described. The ersity of Burkholderia pseudomallei strains in the region was investigated using genomic sequencing. From 1989-2021 there were 128 patients with melioidosis in the Katherine region. 96/128 (75%) patients were First Nations Australians, 72/128 (56%) were from a very remote region, 68/128 (53%) had diabetes, 57/128 (44%) had a history of hazardous alcohol consumption, and 11/128 (9%) died from melioidosis. There were 9 melioidosis cases attributable to the flooding of the Katherine River in January 1998 7/9 flood-associated cases had cutaneous melioidosis, five of whom recalled an inoculating event injury sustained wading through flood waters or cleaning up after the flood. The 126 first-episode clinical B. pseudomallei isolates that underwent genomic sequencing belonged to 107 different sequence types and were highly erse, reflecting the vast geographic area of the study region. In conclusion, melioidosis in the Katherine region disproportionately affects First Nations Australians with risk factors and is exacerbated by severe weather events. Diabetes management, public health intervention for hazardous alcohol consumption, provision of housing to address homelessness, and patient education on melioidosis prevention in First Nations languages should be prioritised.
Publisher: Elsevier BV
Date: 07-2016
DOI: 10.1016/J.ATHORACSUR.2016.02.002
Abstract: Anomalous aortic origin of the right coronary artery (AAORCA) has been reported to cause myocardial ischemia, leading to angina, dyspnea, and decreased exercise tolerance. Reimplantation is a repair technique devised to exclude the abnormal intramural portion of the anomalous artery and avoid the known late attrition of saphenous vein grafts. Our study aims to evaluate the medium-term clinical outcomes with this technique. A retrospective review was made of patients who underwent repair of AAORCA by reimplantation between 2002 and 2014 in two institutions in Western Australia. Follow-up computed tomography coronary angiography was used to assess the status of the reimplanted right coronary artery (RCA). Data on survival, freedom from symptoms, cardiac events, and cardiac interventions were also analyzed. Of the 16 patients (aged 17 to 70 years old), 14 (88%) were symptomatic before surgery, with angina (50%) and exertional dyspnea (56%) being the most common symptoms. Surgical reimplantation was successful in 15 patients (94%) without operative mortality. One patient required saphenous vein bypass grafting of the RCA intraoperatively after presumed failed repair and difficulty weaning from cardiopulmonary bypass. All patients who had successful reimplantation of AAORCA were symptom-free after surgery, and none had subsequent cardiac events attributable to the RCA or required further interventions. Ten patients (67%) had computed tomography coronary angiography after surgery none had stenosis, kinking, or compression of the RCA by the pulmonary artery. Two further patients (including the patient who underwent saphenous vein grafting for presumed failed reimplantation) underwent conventional angiography, which demonstrated patent reimplantations. To the best of our knowledge, this is the largest reported series of anomalous RCA managed by surgical reimplantation. Our results suggest that this technique is safe and has excellent medium to long-term results regarding symptom-free survival.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2012
Publisher: BMJ
Date: 14-06-2023
Abstract: Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage (aSAH) affects up to 7.2% of patients even with ultra-early treatment within 24 hours. We retrospectively compared the utility of three published re-bleed prediction models and in idual predictors between cases who re-bled matched to controls using size and parent vessel location from a cohort of patients treated in an ultra-early, ‘endovascular first’ manner. On retrospective analysis of our 9-year cohort of 707 patients suffering 710 episodes of aSAH, there were 53 episodes of pre-treatment re-bleeding (7.5%). Forty-seven cases who had a single culprit aneurysm were matched to 141 controls. Demographic, clinical and radiological data were extracted and predictive scores calculated. Univariate, multivariate, area under the receiver operator characteristic curve (AUROCC) and Kaplan–Meier (KM) survival curve analyses were performed. The majority of patients (84%) were treated using endovascular techniques at a median 14.5 hours post-diagnosis. On AUROCC analysis the score of Liu et al. had minimal utility (C-statistic 0.553, 95% confidence interval (CI) 0.463 to 0.643) while the risk score of Oppong et al. (C-statistic 0.645 95% CI 0.558 to 0.732) and the ARISE-extended score of van Lieshout et al. (C-statistic 0.53 95% CI 0.562 to 0.744) had moderate utility. On multivariate modeling, the World Federation of Neurosurgical Societies (WFNS) grade was the most parsimonious predictor of re-bleeding (C-statistic 0.740, 95% CI 0.664 to 0.816). For aSAH patients treated in an ultra-early timeframe matched on size and parent vessel location, WFNS grade was superior to three published models for re-bleed prediction. Future re-bleed prediction models should incorporate the WFNS grade.
Publisher: Elsevier BV
Date: 03-2017
Publisher: MDPI AG
Date: 12-07-2021
Abstract: Resveratrol has been shown to preserve organ function and improve survival in hemorrhagic shock rat models. This study investigated whether seven days of oral resveratrol could improve hemodynamic response to hemorrhage and confer benefits on risk of acute kidney injury (AKI) without inducing coagulopathy in a canine model. Twelve greyhound dogs were randomly allocated to receive oral resveratrol (1000 mg/day) or placebo for seven days prior to inducing hemorrhage until a targeted mean blood pressure of ≤40 mmHg was achieved. AKI biomarkers and coagulation parameters were measured before, immediately following, and two hours after hemorrhage. Dogs were euthanized, and renal tissues were examined at the end of the experiment. All investigators were blinded to the treatment allocation. A linear mixed model was used to assess effect of resveratrol on AKI biomarkers and coagulation parameters while adjusting for volume of blood loss. A significant larger volume of blood loss was required to achieve the hypotension target in the resveratrol group compared to placebo group (median 64 vs. 55 mL/kg respectively, p = 0.041). Although histological evidence of AKI was evident in all dogs, the renal tubular injury scores were not significantly different between the two groups, neither were the AKI biomarkers. Baseline (pre-hemorrhage) maximum clot firmness on the Rotational Thromboelastometry (ROTEM®) was stronger in the resveratrol group than the placebo group (median 54 vs. 43 mm respectively, p = 0.009). In summary, seven days of oral resveratrol did not appear to induce increased bleeding risk and could improve greyhound dogs’ blood pressure tolerance to severe hemorrhage. Renal protective effect of resveratrol was, however, not observed.
Publisher: Elsevier BV
Date: 02-2016
DOI: 10.1016/J.RESUSCITATION.2016.09.019
Abstract: Arterial carbon dioxide tension (PaCO We searched MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL, for studies that evaluated the association between PaCO The systematic review included nine studies eight provided sufficient quantitative data for meta-analysis. Using PaCO From the limited data it appears PaCO
Publisher: Elsevier BV
Date: 04-2016
DOI: 10.1016/J.JCRC.2016.10.005
Abstract: We sought to determine whether quick Sequential Organ Failure Assessment (qSOFA) score can be used to predict mortality of patients without suspected infection. Using prospectively collected data within the first hour of intensive care unit admission, the predictive ability of qSOFA was compared with the Simplified Acute Physiology Score III, Admission Mortality Prediction Model III, Acute Physiology and Chronic Health Evaluation II model, and standard (full-version) SOFA score using area under the receiver operating characteristic (AUROC) curve and Brier score. Of the 2322 patients included, 279 (12.0%) died after intensive care unit admission. The qSOFA score had a modest ability to predict mortality of all critically ill patients (AUROC, 0.672 95% confidence interval [CI], 0.638-0.707 Brier score 0.099) including the noninfected patients (AUROC, 0.685 95% CI, 0.637-0.732 Brier score 0.081). The overall predictive ability and calibration of the qSOFA was comparable to other prognostic scores. Combining qSOFA score with lactate concentrations further enhanced its predictive ability (AUROC, 0.730 95% CI, 0.694-0.765 Brier score 0.097), comparable to the standard SOFA score. The qSOFA score had a modest ability to predict mortality of both septic and nonseptic patients combining qSOFA with plasma lactate had a predictive ability comparable to the standard SOFA score.
Publisher: Elsevier BV
Date: 05-2016
DOI: 10.1016/J.RESUSCITATION.2016.02.011
Abstract: To examine whether early warning scores (EWS) can accurately predict critical illness in the prehospital setting and affect patient outcomes. We searched bibliographic databases for comparative studies that examined prehospital EWS for patients transported by ambulance in the prehospital setting. The ability of the different EWS, including pre-alert protocols and physiological-based EWS, to predict critical illness (sensitivity, odds ratio [OR], area under receiver operating characteristic [AUROC] curves) and hospital mortality was summarised. Study quality was assessed using the Newcastle-Ottawa Scale. Eight studies were identified. Two studies compared the use of EWS to standard practice using clinical judgement alone to identify critical illness: the pooled diagnostic OR and summary AUROC for EWS were 10.9 (95%CI 4.2-27.9) and 0.78 (95%CI 0.74-0.82), respectively. A study of 144,913 patients reported age and physiological variables predictive of critical illness: AUROC in the independent validation s le was 0.77, 95% CI 0.76-0.78. The high-risk patients stratified by the national early warning score (NEWS) were significantly associated with a higher risk of both mortality and intensive care admission. Data on comparing between different EWS were limited the Prehospital Early Sepsis Detection (PRESEP) score predicted occurrence of sepsis better than the Modified EWS (AUROC 0.93 versus 0.77, respectively). EWS in the prehospital setting appeared useful in predicting clinically important outcomes, but the significant heterogeneity between different EWS suggests that these positive promising findings may not be generalisable. Adequately powered prospective studies are needed to identify the EWS best suited to the prehospital setting.
Publisher: Informa UK Limited
Date: 04-2018
DOI: 10.2147/CEOR.S157306
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2013
Publisher: Wiley
Date: 03-11-2022
DOI: 10.1111/IMJ.15936
Abstract: Prothrombinex-VF is being increasingly used as an off-label therapy to correct non-warfarin-related elevations in international normalised ratio (INR) in the critically ill. Currently there are no dosing guidelines for such use. To validate a prediction equation, embedded in a smartphone application (app), to guide dosing of Prothrombinex-VF in critically ill patients. A prospective pilot cohort study of critically ill adult patients with elevated INRs who were treated with Prothrombinex-VF. The main outcome measured was INR following Prothrombinex-VF administration. Of the 31 patients included, five (16%) were taking warfarin prior to admission and 14 (45%) had chronic liver disease. There was a significant decrease in INR after Prothrombinex-VF treatment (P < 0.001) and a significant correlation between the app's predicted INRs and the measured INRs (r = 0.63 and P < 0.001). The app's predicted INRs were less accurate for patients with chronic liver disease than for those without. Overall, the app's recommendations achieved an INR either similar to (29.6%) or better than (55.6%) what would have been achieved had the warfarin reversal guidelines been applied to dose the Prothrombinex-VF. The app appeared to be reasonably accurate at predicting normalisation of elevated INRs after administration of Prothrombinex-VF, especially among patients without liver disease. Its dosing recommendations were similar to or possibly better than preexisting warfarin reversal guidelines in over 85% of the situations analysed, if we assume a higher dose of Prothrombinex-VF would achieve a greater reduction in INR than a lower dose.
Publisher: Wiley
Date: 05-2012
DOI: 10.1111/J.1445-5994.2012.02770.X
Abstract: The incidence and disease severity of Clostridium difficile infection are rising. There is increasing evidence of a potential association between proton-pump inhibitors (PPI) and C. difficile infection. We performed a case-control study to examine the relationship between PPI and polymerase chain reaction (PCR)-proven C. difficile infection in 137 hospitalised patients in a tertiary hospital in Western Australia. Only antibiotic exposure within 3 months prior to onset of diarrhoea was associated with PCR-proven C. difficile infection (odds ratio 5.97, 95% confidence interval 2.40-14.8, P= 0.001). A restricted analysis on those who had exposure to antibiotics within 3 months before the onset of diarrhoea did not change the negative association between PPI exposure and PCR-proven C. difficile infection. Long-term PPI usage and intensity of PPI exposure prior to onset of diarrhoea were not significantly associated with C. difficile infection.
Publisher: BMJ
Date: 24-09-2011
DOI: 10.1136/MEDETHICS-2011-100081
Abstract: The rule of rescue describes the powerful human proclivity to rescue identified endangered lives, regardless of cost or risk. Deciding whether or not to perform a decompressive craniectomy as a life-saving or 'rescue' procedure for a young person with a severe traumatic brain injury provides a good ex le of the ethical tensions that occur in these situations. Unfortunately, there comes a point when the primary brain injury is so severe that if the patient survives they are likely to remain severely disabled and fully dependent. The health resource implications of this outcome are significant. By using a web-based outcome prediction model this study compares the long-term outcome and designation of two groups of patients. One group had a very severe injury as adjudged by the model and the other group a less severe injury. At 18 month follow-up there were significant differences in outcome and healthcare requirements. This raises important ethical issues when considering life-saving but non-restorative surgical intervention. The discussion about realistic outcome cannot be dichotomised into simply life or death so that the outcome for the patient must enter the equation. As in other 'rescue situations', the utility of the procedure cannot be rationalised on a mere cost-benefit analysis. A compromise has to be reached to determine at what point either the likely outcome would be unacceptable to the person on whom the procedure is being performed or the social utility gained from the rule of rescue intervention fails to justify the utilitarian value and justice of equitable resource allocation.
Publisher: Springer Science and Business Media LLC
Date: 06-08-2010
Publisher: Informa UK Limited
Date: 10-05-2013
DOI: 10.3109/02699052.2013.794974
Abstract: Decompressive craniectomy has been used as a lifesaving procedure for many neurological emergencies, including traumatic brain injury, ischaemic stroke, subarachnoid haemorrhage, cerebrovenous thrombosis, severe intracranial infection, inflammatory demyelination and encephalopathy. The evidence to support using decompressive craniectomy in these situations is, however, limited. Decompressive craniectomy has only been evaluated by randomized controlled trials in traumatic brain injury and ischaemic stroke and, even so, its benefits and risks in these situations remain elusive. If one considers a modified Rankin Scale of 4 or 5 or dependency in daily activity as an unfavourable outcome, decompressive craniectomy is associated with an increased risk of survivors with unfavourable outcome (relative risk [RR] = 2.9, 95% confidence interval [CI] = 1.5-5.8, p = 0.002, I(2 )= 0% number needed to operate to increase an unfavourable outcome = 3.5, 95% CI = 2.4-7.4), but not the number of survivors with a favourable outcome (RR = 1.5, 95% CI = 0.9-2.6, p = 0.13, I(2 )= 0%).
Publisher: Mary Ann Liebert Inc
Date: 15-11-2011
Publisher: Elsevier BV
Date: 02-2015
DOI: 10.1016/J.WNEU.2015.09.081
Abstract: To determine whether there is a measureable change in neurologic function after cranioplasty. This is a prospective single-surgeon, single-center study. Fifty patients who required a cranioplasty procedure were assessed neurologically within 72 hours before and 7 days after surgery. The assessment tools were the Functional Independence Measure (FIM) and the Cognitive assessment report (Cognistat). The scores for both assessments were calculated and then compared before and after surgery. FIM assessment was performed on all fifty patients, and a Cognistat assessment was performed on 47 patients. Most improvements were seen in the Cognistat scores however, there appeared to be no specific areas in which there was consistent improvement. There were substantial improvements in the Cognistat assessment in 9 patients. One patient had a much-improved FIM assessment (improved from 18 to 34), but a Cognistat assessment was not possible because of poor neurologic function. These results suggested that improvements after cranioplasty were more likely to occur in the domain of cognitive function than motor function, although overall these results did not reach statistically significance. Bifrontal (vs. unilateral) cranioplasty, timing between decompression and cranioplasty, and age of the patients did not appear to affect the postoperative FIM scores, after we adjusted for preoperative FIM scores and surgical complications. A small but significant number of patients appear to improve clinically after cranioplasty. Neurologic susceptibility to a skull defect may be more common than had been appreciated previously.
Publisher: Portland Press Ltd.
Date: 08-2023
DOI: 10.1042/BSR20231076
Abstract: The study by Kenny et al. is of considerable importance. They concluded that there was a weak association between the ergothioneine levels and maternal age, and if a threshold was set at the 90th percentile of the reference range in the control population (≥462 ng/ml), only one of these 97 women (1%) developed preecl sia, versus 96/397 (24.2%) whose ergothioneine level was below this threshold. These results suggest that there might be a dichotomized association between ergothioneine concentrations and preecl sia and only a high ergothioneine level over 90th percentile of the control population could be protective against preecl sia. With the kind supply of the dataset from the authors, further analysis using univariable as well as multivariable analyses were performed while allowing for non-linearity between ergothioneine concentrations and risk of preecl sia using a 3-knot restricted cubic spline function. The univariable results showed that ergothioneine had a significant non-linear association with preecl sia and it would start to offer protective effect from 300 ng/ml onward. The results were similar to the multivariable analysis. In addition, the analysis also confirmed that body mass index was significantly associated with an increased risk of preecl sia.
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 2017
DOI: 10.3171/2015.12.JNS152004
Abstract: Autologous bone is usually used to reconstruct skull defects following decompressive surgery. However, it is associated with a high failure rate due to infection and resorption. The aim of this study was to see whether it would be cost-effective to use titanium as a primary reconstructive material. Sixty-four patients were enrolled and randomized to receive either their own bone or a primary titanium cranioplasty. All surgical procedures were performed by the senior surgeon. Primary and secondary outcome measures were assessed at 1 year after cranioplasty. There were no primary infections in either arm of the trial. There was one secondary infection of a titanium cranioplasty that had replaced a resorbed autologous cranioplasty. In the titanium group, no patient was considered to have partial or complete cranioplasty failure at 12 months of follow-up (p = 0.002) and none needed revision (p = 0.053). There were 2 deaths unrelated to the cranioplasty, one in each arm of the trial. Among the 31 patients who had an autologous cranioplasty, 7 patients (22%) had complete resorption of the autologous bone such that it was deemed a complete failure. Partial or complete autologous bone resorption appeared to be more common among young patients than older patients (32 vs 45 years old, p = 0.013). The total cumulative cost between the 2 groups was not significantly different (mean difference A$3281, 95% CI $−9869 to $3308 p = 0.327). Primary titanium cranioplasty should be seriously considered for young patients who require reconstruction of the skull vault following decompressive craniectomy. Clinical trial registration no.: ACTRN12612000353897 ( anzctr.org.au )
Publisher: SAGE Publications
Date: 27-04-2020
Abstract: Staphylococcal infection is associated with significant morbidity and mortality in critically ill patients. Using data from 16,681 patients who had a nasal Staphylococcus aureus polymerase chain reaction (PCR) assay on admission to the intensive care unit (ICU) of Royal Perth Hospital between March 2006 and September 2016, this retrospective cohort study assessed whether nasal S. aureus colonisation on admission to an ICU was predictive of concurrent or subsequent S. aureus infections. Culture-proven S. aureus infections were identified using the hospital microbiology database. Of the 16,681 patients included, 565 (3.4%) had a positive methicillin-resistant S. aureus (MRSA) assay, 146 (0.9%) had a positive methicillin-sensitive S. aureus (MSSA) assay and eight (0.05%) had both positive MRSA and MSSA assays. Of those 565 patients with a positive MRSA PCR assay, 79 (13.8%) had concurrent or subsequent MRSA infections. Of those 146 patients with a positive MSSA PCR assay, only 5 (3.4%) had MSSA infection. The sensitivity and specificity for the MRSA PCR assay in predicting concurrent or subsequent MRSA infection were 72.7% (95% confidence intervals (CI) 63.4%–80.8%) and 97.0% (95% CI 96.8%–97.3%), respectively. The sensitivity and specificity for the MSSA PCR assay in predicting concurrent or subsequent MSSA infection were 3.3% (95% CI 1.1%–7.6%) and 99.1% (95% CI 98.9%–99.2%), respectively. Both nasal MRSA and MSSA PCR assays had a high specificity and negative predictive value in predicting MRSA and MSSA infections, respectively, suggesting that in centres without endemic S. aureus infections, a negative nasal MRSA or MSSA PCR assay may be useful to reduce unnecessary empirical antibiotic therapy against S. aureus.
Publisher: Elsevier BV
Date: 2009
DOI: 10.1053/J.AJKD.2008.05.019
Abstract: Acute renal failure after major surgery is associated with significant mortality and morbidity that theoretically may be attenuated by N-acetylcysteine. Meta-analysis of relevant studies sourced from the Cochrane Controlled Trial Register (2007 issue 4), EMBASE, and MEDLINE databases (1966 to February 1, 2008) without language restriction. Adult patients undergoing major surgery without the use of radiocontrast. Randomized controlled studies comparing N-acetylcysteine with a placebo perioperatively. Categorical variables are reported as odds ratio (OR) with 95% confidence interval (CI), and continuous variables are reported as weighted-mean-difference (WMD) with 95% CI. Effects of N-acetylcysteine on mortality and acute renal failure requiring dialysis were the main outcomes of interest. Additional outcome measures included an incremental increase in serum creatinine concentration greater than 25% above baseline, surgical reexploration for bleeding, amount of allogeneic blood transfusion, and length of intensive care unit stay. 10 studies involving a total of 1,193 adult patients undergoing major surgery were considered. N-Acetylcysteine use was not associated with a decrease in mortality (OR, 1.05 95% CI, 0.58 to 1.92), acute renal failure requiring dialysis (OR, 1.04 95% CI, 0.45 to 2.37), incremental increase in serum creatinine concentration greater than 25% above baseline (OR, 0.84 95% CI, 0.64 to 1.11), or length of intensive care unit stay (WMD in days, 0.46 95% CI, -0.43 to 1.36). N-acetylcysteine did not appear to increase the risk of surgical reexploration for bleeding (OR, 1.16 95% CI, 0.57 to 2.38) or amount of allogeneic blood transfusion required (WMD in units, 0.31 95% CI, -0.21 to 0.84). Most studied patients had cardiac surgery and normal renal function preoperatively. There is no current evidence that N-acetylcysteine used perioperatively can alter mortality or renal outcomes when radiocontrast is not used.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 27-08-2013
DOI: 10.1161/CIRCULATIONAHA.113.002690
Abstract: Optimal thromboprophylaxis for patients at risk of bleeding remains uncertain. This meta-analysis assessed whether intermittent pneumatic compression (IPC) of the lower limbs was effective in reducing venous thromboembolism and whether combining pharmacological thromboprophylaxis with IPC would enhance its effectiveness. Two reviewers searched MEDLINE, EMBASE, and the Cochrane controlled trial register (1966—February 2013) for randomized, controlled trials and assessed the outcomes and quality of the trials independently. Trials comparing IPC with pharmacological thromboprophylaxis, thromboembolic deterrent stockings, no prophylaxis, and a combination of IPC and pharmacological thromboprophylaxis were considered. Trials that used IPC hours or compared different types of IPC were excluded. A total of 16 164 hospitalized patients from 70 trials met the inclusion criteria and were subjected to meta-analysis. IPC was more effective than no IPC prophylaxis in reducing deep vein thrombosis (7.3% versus 16.7% absolute risk reduction, 9.4% 95% confidence interval [CI], 7.9–10.9 relative risk, 0.43 95% CI, 0.36–0.52 P .01 I 2 =34%) and pulmonary embolism (1.2% versus 2.8% absolute risk reduction, 1.6% 95% CI, 0.9–2.3 relative risk, 0.48 95% CI, 0.33–0.69 P .01 I 2 =0%). IPC was also more effective than thromboembolic deterrent stockings in reducing deep vein thrombosis and appeared to be as effective as pharmacological thromboprophylaxis but with a reduced risk of bleeding (relative risk, 0.41 95% CI, 0.25–0.65 P .01 I 2 =0%). Adding pharmacological thromboprophylaxis to IPC further reduced the risk of deep vein thrombosis (relative risk, 0.54 95% CI, 0.32–0.91 P =0.02 I 2 =0%) compared with IPC alone. IPC was effective in reducing venous thromboembolism, and combining pharmacological thromboprophylaxis with IPC was more effective than using IPC alone.
Publisher: SAGE Publications
Date: 25-06-2021
DOI: 10.1177/1358863X211023559
Abstract: Vena cava filters have been used as a primary means to prevent symptomatic pulmonary embolism (PE) in trauma patients who cannot be anticoagulated after severe injury, but the economic implications for this practice remain unclear. Using a healthcare system perspective to analyze the a priori primary outcome of the da Vinci trial, we report the cost-effectiveness of using vena cava filters as a primary means to prevent PE in patients who have contraindications to prophylactic anticoagulation after major trauma. Of the 240 patients enrolled, complete, prospectively collected, hospital cost data during the entire hospital stay − including costs for the filter, medical/nursing/allied health staff, medical supplies, pathology tests, and radiological imaging − were available in 223 patients (93%). Patients allocated to the filter group ( n = 114) were associated with a reduced risk of PE (0.9%) compared to those in the control group ( n = 109, 5.5% p = 0.048) and the filter’s benefit was more pronounced among those who could not be anticoagulated within 7 days (filter: 0% vs control: 16%, Bonferroni-corrected p = 0.02). Overall, the cost needed to prevent one PE was high (AUD $379,760), but among those who could not be anticoagulated within 7 days, the costs to prevent one PE (AUD $36,156 ~ USD $26,032) and gain one quality-adjusted life-year (AUD $30,903 ~ USD $22,250) were substantially lower. The cost of using a vena cava filter to prevent PE for those who have contraindications to prophylactic anticoagulation within 3 days of injury is prohibitive, unless such contraindications remain for longer than 7 days. (Australian New Zealand Clinical Trials Registry no.: ACTRN12614000963628)
Publisher: BMJ
Date: 18-09-2010
Abstract: Decompressive craniectomy is a technically straightforward procedure whereby a large section of the cranium is temporarily removed in cases where the intracranial pressure is dangerously high. While its use has been described for a number of conditions, it is increasingly used in the context of severe head injury. As the use of the procedure increases, a significant number of patients may survive a severe head injury who otherwise would have died. Unfortunately some of these patients will be left severely disabled a condition likened to the RUB, an acronym for the Risk of Unacceptable Badness. Until recently it has been difficult to predict this outcome, however an accurate prediction model has been developed and this has been applied to a large cohort of patients in Western Australia. It is possible to compare the predicted outcome with the observed outcome at 18&emsp14 months within this cohort. By using predicted and observed outcome data this paper considers the ethical implications in three cases of differing severity of head injury in view of the fact that it is possible to calculate the RUB for each case.
Publisher: Springer Science and Business Media LLC
Date: 09-11-2007
DOI: 10.1007/S00134-007-0928-0
Abstract: The objective was to assess the ability of potential clinical predictors and inflammatory markers within 24 h of intensive care unit (ICU) discharge to predict subsequent in-hospital mortality. A prospective cohort study of 603 consecutive patients who survived their first ICU admission, between 1 June and 31 December 2005, in a 22-bed multidisciplinary ICU of a university hospital. A total of 26 in-hospital deaths after ICU discharge (4.3%) were identified. C-reactive protein (CRP) concentrations at ICU discharge were associated with subsequent in-hospital mortality in the univariate analysis (mean CRP concentrations of non-survivors=174 vs. survivors=85.6 mg/l, p=0.001). CRP concentrations remained significantly associated with post-ICU mortality (a 10-mg/l increment in CRP concentrations increased the odds ratio [OR] of death: 1.09, 95% confidence interval [CI]: 1.03-1.16) after adjusting for age, the Acute Physiology and Chronic Health Evaluation (APACHE) II predicted mortality, and the Delta Sequential Organ Failure Assessment (Delta SOFA) score. The area under the receiver operating characteristic curve of this multivariate model to discriminate between survivors and non-survivors after ICU discharge was 0.85 (95% CI: 0.73-0.96). The destination and timing of ICU discharge, and the Discharge SOFA score, white cell counts and fibrinogen concentrations at ICU discharge were not significantly associated with in-hospital mortality after ICU discharge. A high CRP concentration at ICU discharge was an independent predictor of in-hospital mortality after ICU discharge in our ICU.
Publisher: Oxford University Press (OUP)
Date: 20-10-2012
DOI: 10.1093/EJCTS/EZR007
Abstract: The objective of this systematic review was to assess whether pre-operative brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT pro-BNP) are independent predictors of adverse outcomes after cardiac surgery. MEDLINE, Embase and the Cochrane Controlled Trials Register databases were searched. Eligible studies included observational or randomized control trials measuring natriuretic peptide concentrations before induction of anaesthesia for cardiac surgery. Two investigators independently extracted the data and assessed the validity of the included studies. The predictive ability of pre-operative BNP or NT pro-BNP on mortality, post-operative atrial fibrillation (AF) and intra-aortic balloon pump (IABP) requirement was meta-analysed. The association between BNP or NT pro-BNP and other outcomes was systematically summarized. A total of 4933 patients from 22 studies were considered in the systematic review. Ten studies with one or more outcomes of interest were included in the meta-analyses. The strength of association between pre-operative natriuretic peptide levels and adverse outcomes after surgery was variable, as was the size and quality of the included studies. The summary areas under the receiver operating characteristic curve for mortality, post-operative AF and post-operative IABP requirement were 0.61 (95% confidence interval [CI] 0.51-0.70), 0.61 (95% CI 0.58-0.64) and 0.81 (95% CI 0.73-0.89), respectively. With the limited data available, the associations between pre-operative natriuretic peptide levels and adverse outcomes after cardiac surgery were moderate. Future studies should assess whether pre-operative natriuretic peptides can provide additional independent predictive information to well-validated prognostic scores of cardiac surgery.
Publisher: Elsevier BV
Date: 06-2016
DOI: 10.1016/J.JCRC.2016.02.006
Abstract: Procalcitonin (PCT) has been used to guide treatment in critically ill patients with sepsis, but whether PCT at intensive care unit (ICU) discharge can stratify risks of post-ICU readmission or mortality is unknown. This cohort study compared the ability of PCT with C-reactive protein (CRP) in predicting unexpected adverse post-ICU events. Of the 1877 patients admitted to the multidisciplinary ICU between 1 April 2012 and 31 March 2014, 1653 (88.1%) were discharged without treatment limitations. A total of 71 (4.3%) were readmitted and 18 patients (1%) died unexpectedly after ICU discharge during the same hospitalization. Both PCT (0.6 vs 0.4 μg/L, P = .002) and a high CRP concentration >100 mg/L (58% vs 41%, P = .004) at ICU discharge were associated with an increased risk of adverse post-ICU events in the univariate analyses however, the ability of PCT to discriminate between patients with and without adverse post-ICU outcomes was limited (area under the receiver operating characteristic curve = 0.61 95% confidence interval, 0.55-0.66). In the multivariable analysis, only a high CRP concentration (odds ratio, 1.92 95% confidence interval, 1.12-3.11 P = .008) was associated with an increased adverse post-ICU events. Elevated PCT concentration at ICU discharge was inadequate in its predictive ability to guide ICU discharge.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2017
Publisher: Elsevier BV
Date: 02-2016
Publisher: Springer Science and Business Media LLC
Date: 27-08-2023
DOI: 10.1007/S00068-022-02074-Y
Abstract: To investigate the long-term outcomes of using vena cava filters to prevent symptomatic pulmonary embolism (PE) in major trauma patients who have contraindications to prophylactic anticoagulation. This was an a priori sub-study of a randomized controlled trial (RCT) involving long-term outcome data of 223 patients who were enrolled in Western Australia. State-wide clinical information system, radiology database and death registry were used to assess long-term outcomes, including incidences of venous thromboembolism, venous injury and mortality beyond day-90 follow-up. The median follow-up time of 198 patients (89%) who survived beyond 90 days was 65 months (interquartile range 59–73). Ten patients (5.1%) died after day-90 follow-up and four patients developed venous thromboembolism, including two with symptomatic PE, all allocated to the control group (0 vs 4%, p = 0.043). Inferior vena cava injuries were not recorded in any patients. The mean total hospitalization cost, including the costs of the filter and its insertion and removal, to prevent one short- or long-term symptomatic PE was A$284,820 (€193,678) when all enrolled patients were considered. The number of patients needed to treat (NNT = 5) and total hospitalization cost to prevent one symptomatic PE (A$1,205 or €820) were, however, substantially lower when the filter was used only for patients who could not be anticoagulated within seven days of injury. Long-term complications related to retrievable filters were rare, and the cost of using filters to prevent symptomatic PE was acceptable when restricted to those who could not be anticoagulated within seven days of severe injury.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2013
Publisher: Wiley
Date: 29-11-2015
DOI: 10.1111/ANS.13396
Abstract: The burgeoning problem of obesity is seen most profoundly in older populations. Despite the dramatic increase in bariatric surgery rates over the last 20 years, weight reduction surgery is largely restricted to younger patients. This retrospective, longitudinal, self-matched, population-based cohort study assessed the incidence and outcomes of all patients undergoing bariatric surgery who were ≥55 years old in Western Australia between 2007 and 2011. The mean preoperative and post-operative follow-up periods were 2.5 years and 3.4 years, respectively. Of the 12 062 bariatric surgical operations recorded during the study period, 2179 (18.1%) were performed in patients aged ≥55 years old. Older bariatric patients were statistically more likely to require longer hospital admissions (2.85 versus 2.65 days, P < 0.001), have post-operative complications (12.0 versus 6.3%, P < 0.001) and require intensive care admissions (8.2 versus 4.3%, P = 0.001) compared to patients <55 years old. However, both 30-day (no deaths in the older cohort) and long-term mortality rates (1.07 versus 0.42 deaths per 1000 patient-years, P = 0.10) remained relatively low. All-cause long-term hospitalization rates were also significantly reduced (P < 0.001) after bariatric surgery for patients who were older than 55 years compared to before surgery. Despite older age being associated with a higher risk of complications and longer hospital stays, there was a reduction in subsequent overall hospitalizations for older patients after bariatric surgery, suggesting that bariatric surgery may still confer health benefits to carefully selected obese older patients who cannot achieve weight loss by other means.
Publisher: Springer Science and Business Media LLC
Date: 08-04-2010
DOI: 10.1007/S00134-010-1877-6
Abstract: To assess the effects of using dexmedetomidine as a sedative and analgesic agent on length of intensive care unit (ICU) stay, duration of mechanical ventilation, risk of bradycardia, and hypotension in critically ill adult patients. Two researchers searched MEDLINE, EMBASE, and the Cochrane controlled trial register independently for randomized controlled trials comparing dexmedetomidine with a placebo or an alternative sedative agent, without any language restrictions. A total of 2,419 critically ill patients from 24 trials were subject to meta-analysis. Dexmedetomidine was associated with a significant reduction in length of ICU stay [weighted mean difference -0.48 days, 95% confidence interval (CI) -0.18 to -0.78 days, P = 0.002], but not duration of mechanical ventilation, when compared with an alternative sedative agent. There was, however, significant heterogeneity in these two outcomes between the pooled studies. Dexmedetomidine was associated with increased risk of bradycardia requiring interventions in studies that used both a loading dose and maintenance doses >0.7 microg kg(-1) h(-1) [relative risk (RR) 7.30, 95% CI 1.73-30.81, P = 0.007]. Risks of hypotension requiring interventions (RR 1.43, 95% CI 0.78-2.6, P = 0.25), delirium (RR 0.79, 95% CI 0.56-1.11, P = 0.18), self-extubation, myocardial infarction, hyperglycemia, atrial fibrillation, and mortality were not significantly different between dexmedetomidine and traditional sedative and analgesic agents. Significant heterogeneity existed between the pooled studies. The limited evidence suggested that dexmedetomidine might reduce length of ICU stay in some critically ill patients, but the risk of bradycardia was significantly higher when both a loading dose and high maintenance doses (>0.7 microg kg(-1) h(-1)) were used.
Publisher: Future Medicine Ltd
Date: 06-2022
Abstract: Background: It remains largely unknown whether endothelial biomarkers can be used to predict thromboembolism in critically ill patients with an acquired coagulopathy. Materials & methods: The ability of syndecan-1, P-selectin and microRNA expressions to predict thromboembolism were assessed in 40 critically ill coagulopathic patients. Results: The area under the receiver operating characteristic curves for syndecan-1, P-selectin and the four differentially expressed microRNAs – determined by real-time qPCR analysis – to predict thromboembolism (n = 10, 25%) were 0.71 (95% CI: 0.52–0.89), 0.73 (95% CI: 0.52–0.95) and .80, respectively. Syndecan-1 and P-selectin concentrations were also significantly correlated with one another (R = 0.41, p = 0.008). Conclusion: Endothelial function biomarkers, including endothelial microRNA expressions, were associated with subsequent thromboembolism in critically ill patients who had a deranged coagulation profile.
Publisher: Elsevier BV
Date: 07-2022
Publisher: Mary Ann Liebert Inc
Date: 06-2011
Abstract: There is currently much interest in the use of decompressive craniectomy for intracranial hypertension. Though technically straightforward, the procedure is not without significant complications. A retrospective analysis was undertaken of 164 patients who had had a decompressive craniectomy for severe head injury in the years 2004 to 2009 at the two major hospitals in Western Australia. Eighty-six patients had a bifrontal decompression and seventy-eight had a unilateral decompression. Two patients died due to post-operative care issues. Complications attributable to the decompressive surgery were: herniation of the cortex through the bone defect (42 patients, 25.6%), subdural effusion (81 patients, 49.4%), seizures (36 patients, 22%), hydrocephalus (23 patients, 14%), and syndrome of the trephined (2 patients, 1.2%). Complications attributable to the subsequent cranioplasty included: sudden death due to massive cerebral swelling in 3 patients (2.2%), infection requiring removal of the bone flap in 16 patients (11.6%), and bone flap resorption requiring augmentation in 10 patients (7.2%). After excluding simple complications such as subdural effusion and brain herniation through the skull defect and some patients who died as a direct consequence of traumatic brain or extracranial injury, 81 patients (55.5%) had at least one complication after decompressive craniectomy. The occurrence of at least one complication after decompressive craniectomy was significantly associated with an increased risk of prolonged stay in the hospital or rehabilitation facility (odds ratio 2.54, 95%confidence interval 1.22,5.24, p=0.013), after adjusting for predicted risk of unfavorable outcome.
Publisher: Oxford University Press (OUP)
Date: 15-12-2005
DOI: 10.1093/NDT/GFI339
Publisher: Oxford University Press (OUP)
Date: 30-05-2006
DOI: 10.1093/JAC/DKL234
Abstract: Vascular and epidural catheter-related infections cause significant morbidities and mortality in hospitalized patients. This meta-analysis assessed the effect of chlorhexidine-impregnated dressing on the risk of vascular and epidural catheter bacterial colonization and infection. Literature search was based on MEDLINE (1966 to 1 November 2005), EMBASE and Cochrane Controlled Trials Register (2005 issue 3) databases. Only randomized controlled clinical trials comparing chlorhexidine-impregnated dressing with placebo or povidine-iodine dressing were included in this meta-analysis. Two reviewers reviewed and extracted the data independently. Eight studies assessing a single type of chlorhexidine-impregnated dressing were identified and subjected to meta-analysis. The chlorhexidine-impregnated dressing reduced the risk of epidural [3.6% versus 35%, odds ratio (OR) 0.07, 95% CI: 0.02-0.31, P=0.0005] and intravascular catheter or exit-site bacterial colonization (14.8% versus 26.9%, OR 0.47, 95% CI: 0.34-0.65, P<0.00001) (overall 14.3% versus 27.2%, OR 0.40, 95% CI: 0.26-0.61 P<0.0001). The use of chlorhexidine-impregnated dressing was associated with a trend towards reduction in catheter-related bloodstream or CNS infections (2.2% versus 3.8%, OR 0.58, 95% CI: 0.29-1.14, P=0.11). Local cutaneous reactions to chlorhexidine-impregnated dressing were reported in 5.6% of the patients in three studies (OR 8.17, 95% CI: 1.19-56.14, P=0.04), and 96% of these reactions occurred in neonatal patients. The number needed to prevent one episode of intravascular catheter-related bloodstream infection was 142 for an average period of catheter in situ of 10 days and a change of dressing every 5 days. The cost of preventing one vascular catheter-related bloodstream infection was estimated to be pound298 (US$532.5). Chlorhexidine-impregnated dressing is effective in reducing vascular and epidural catheter bacterial colonization and is also associated with a trend towards reduction in catheter-related bloodstream or CNS infections. A large randomized controlled trial is needed to confirm whether chlorhexidine-impregnated dressing is cost-effective in preventing bacterial infection related to vascular and epidural catheters.
Publisher: Elsevier BV
Date: 10-2021
Publisher: Elsevier BV
Date: 05-2021
Publisher: Public Library of Science (PLoS)
Date: 15-02-2012
Publisher: SAGE Publications
Date: 11-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2006
Publisher: Wiley
Date: 07-1997
DOI: 10.1111/J.1365-2044.1997.146-AZ0150.X
Abstract: Splanchnic ischaemia is thought to be of central importance in the development of multi-organ failure and hence death in critically ill patients. It has been suggested that the arterial to gastric intramucosal pH gradient and the difference in partial pressure of carbon dioxide between gastric mucosa and arterial blood are more sensitive markers of splanchnic ischaemia than gastric intramucosal pH itself and thus should be predictors of mortality in the critically ill. We studied 62 critically ill patients within 6 h of admission to the intensive care unit and found no significant difference at 0, 12 or 24 h after admission to the study in either the arterial to gastric intramucosal pH gradient or the difference in partial pressure of carbon dioxide between gastric mucosa and arterial blood between survivors and nonsurvivors. We conclude that in contrast to gastric intramucosal pH neither the arterial to gastric intramucosal pH gradient nor the difference in partial pressure of carbon dioxide between gastric mucosa and arterial blood distinguish survivors from nonsurvivors.
Publisher: Elsevier BV
Date: 03-2009
DOI: 10.4065/84.3.234
Publisher: S. Karger AG
Date: 2022
DOI: 10.1159/000522341
Abstract: b i Background: /i /b In 2004, the term acute kidney injury (AKI) was introduced with the intention of broadening our understanding of rapid declines in renal function and to replace the historical terms of acute renal failure and acute tubular necrosis (ATN). Despite this evolution in terminology, the mechanisms of AKI have stayed largely elusive with the pathophysiological concepts of ATN remaining the mainstay in our understanding of AKI. b i Summary: /i /b The proximal tubule (PT), having the highest mitochondrial content in the kidney and relying heavily on oxidative phosphorylation to generate ATP, is vulnerable to ischaemic insults and mitochondrial dysfunction. Histologically, pathological changes in the PT are more consistent than changes to the glomeruli or the loop of Henle in AKI. Physiologically, activation of tubuloglomerular feedback due to PT dysfunction leads to an increase in preglomerular afferent arteriole resistance and a reduction in glomerular filtration. Pharmacologically, frusemide – a drug commonly used in the setting of oliguric AKI – is actively secreted by the PT and its diuretic effect is compromised by its failure to be secreted into the urine and thus be delivered to its site of action at the loop of Henle in AKI. Increases in the urinary, but not plasma biomarkers, of PT injury within 1 h of shock suggest that the PT as the initiation pathogenic target of AKI. b i Key Message: /i /b Therapeutic agents targeting specifically the PT epithelial cells, in particular its mitochondria – including amino acid ergothioneine and superoxide scavenger MitoTEMPO – show great promises in ameliorating AKI.
Publisher: Wiley
Date: 12-2009
DOI: 10.1111/J.1365-2044.2009.06078.X
Abstract: Citrate, as an anticoagulant for continuous renal replacement therapy in critically ill patients, has some potential advantages over heparin, including a prolonged dialysis filter life and reduced risk of bleeding. The key parameter involved in monitoring the adequacy and safety of citrate anticoagulation during continuous renal replacement therapy pertains to the ionised and total plasma calcium levels. We report a case of severe systemic hypocalcaemia during continuous renal replacement therapy with citrate anticoagulation resulting from relentless sequestration of calcium due to undiagnosed evolving rhabdomyolysis. Although excessive systemic citrate accumulation can also cause hypocalcaemia, this complication was not observed in our patient. While an acceptable lower limit of ionised calcium remains unknown, severe rhabdomyolysis needs to be considered when a patient's ionised calcium levels are not responsive to standard calcium replacement therapy during continuous renal replacement therapy using citrate anticoagulation in critically ill patients.
Publisher: Wiley
Date: 03-1997
DOI: 10.1111/J.1365-2044.1997.071-AZ0070.X
Abstract: Dettol liquid is a commonly used household disinfectant and although it is labelled nonpoisonous, serious respiratory complications have been reported in up to 8% of cases of Dettol ingestion. We report a case in which the delayed onset of upper airway obstruction was treated with emergency awake, fibreoptic guided nasotracheal intubation. Based on information available in published cases and on our own experience, we suggest that patients who have ingested large volumes of Dettol, have a history of vomiting or unprotected lavage, or have evidence of ongoing oropharyngeal inflammation, are at high risk of this complication. They should be closely observed for at least 48 h after ingestion and the facilities and staff required for emergency airway management should be immediately available.
Publisher: Wiley
Date: 02-2010
DOI: 10.1111/J.1365-2044.2009.06206.X
Abstract: Healthcare utilisation can affect quality of life and is important in assessing the cost-effectiveness of medical interventions. A clinical database was linked to two Australian state administrative databases to assess the difference in incidence of healthcare utilisation of 19,921 patients who survived their first episode of critical illness. The number of hospital admissions and days of hospitalisation per patient-year was respectively 150% and 220% greater after than before an episode of critical illness (assessed over the same time period). This was the case regardless of age or type of surgery (i.e. cardiac vs non-cardiac). After adjusting for the ageing effect of the cohort as a whole, there was still an unexplained two to four-fold increase in hospital admissions per patient-year after an episode of critical illness. We conclude that an episode of critical illness is a robust predictor of subsequent healthcare utilisation.
Publisher: Wiley
Date: 05-01-2016
DOI: 10.1111/TME.12272
Abstract: It is uncertain whether hypocalcaemia is associated with an increased risk of bleeding. This study assessed the dose-related relationship between ionised calcium concentrations and in vitro clot strength measured by maximum litude (MA) on the thromboelastograph (TEG). A total of 610 patients who were at risk of bleeding or had active bleeding between 2010 and 2014 were considered in this retrospective cohort study. A scatter plot with Pearson correlation coefficient (r) and multiple linear regression was used to assess the dose-related relationship between ionised calcium concentrations and MA on the TEG. The mean ionised calcium of the patients was 1·10 mmol L(-1) (interquartile range: 1·04-1·17) and 235 (38·5%) of them had hypocalcaemia ( 1 mmol L(-1) , during critical bleeding is recommended.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2012
Publisher: Mary Ann Liebert Inc
Date: 10-02-2017
Abstract: Furosemide, a loop diuretic, is used to increase urine output in patients with acute kidney injury (AKI). It remains uncertain whether the benefits of furosemide in AKI outweigh its potential harms. We investigated if furosemide influenced oxidative stress in 30 critically ill patients with AKI by measuring changes in F
Publisher: Springer Science and Business Media LLC
Date: 27-10-2012
Publisher: Elsevier BV
Date: 06-2010
DOI: 10.1053/J.JVCA.2007.10.011
Abstract: The purpose of this study was to evaluate whether central venous oxygen saturation can be used as an alternative to mixed venous oxygen saturation in patients with cardiogenic and septic shock. Prospective clinical study. A tertiary intensive care unit in a university hospital. Twenty patients with cardiogenic or septic shock requiring a pulmonary artery catheter and inotropic support. None. The central venous oxygen saturation overestimated the mixed venous oxygen saturation by a mean bias (or an absolute difference) of 6.9%, and the 95% limits of agreement were large (-5.0% to 18.8%). The difference between central and mixed venous oxygen saturation appeared to be more significant when mixed venous oxygen saturation was <70%. The changes in central and mixed venous oxygen saturation did not follow the line of perfect agreement closely in different clinical conditions. The central or mixed venous oxygen saturation had a significant ability to predict the status of cardiac output state, but this ability was reduced when the effect of hyperoxia was not considered. Central and mixed venous oxygen saturation measurements are not interchangeable numerically.
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 09-2016
Publisher: Elsevier BV
Date: 04-2003
Publisher: Springer Science and Business Media LLC
Date: 29-03-2006
DOI: 10.1007/S00134-006-0128-3
Abstract: To investigate the potential beneficial and adverse effects of early post-pyloric feeding compared with gastric feeding in critically ill adult patients with no evidence of impaired gastric emptying. Randomised controlled studies comparing gastric and post-pyloric feeding in critically ill adult patients from Cochrane Controlled Trial Register (2005 issue 3), EMBASE and MEDLINE databases (1966 to 1 October 2005) without any language restriction were included. Two reviewers reviewed the quality of the studies and performed data extraction independently. Eleven randomised controlled studies with a total of 637 critically ill adult patients were considered. The mortality (relative risk [RR] 1.01, 95% CI 0.76-1.36, p=0.93 I2=0%) and risk of aspiration or pneumonia (RR 1.28, 95% CI 0.91-1.80, p=0.15 I2=0%) were not significantly different between patients treated with gastric or post-pyloric feeding. The effect of post-pyloric feeding on the risk of pneumonia or aspiration was similar when studies were stratified into those with and those without the use of concurrent gastric decompression (RR ratio 0.95, 95% CI 0.48-1.91, p=0.89). The risk of diarrhoea and the length of intensive care unit stay (weighted mean difference in days -1.46, 95% CI -3.74 to 0.82, p=0.21 I2=24.6%) were not statistically different. The gastric feeding group had a much lower risk of experiencing feeding tube placement difficulties or blockage (0 vs 9.6%, RR 0.13, 95% CI 0.04-0.44, p=0.001 I2=0%). Early use of post-pyloric feeding instead of gastric feeding in critically ill adult patients with no evidence of impaired gastric emptying was not associated with significant clinical benefits.
Publisher: Wiley
Date: 06-2008
DOI: 10.1111/J.1399-3062.2007.00290.X
Abstract: Pulmonary aspergillosis in immunosuppressed patients is associated with significant mortality and morbidity. We assessed the prophylactic and therapeutic effect of nebulized hotericin B (AmB) on mortality of immunosuppressed animals with pulmonary aspergillosis in this meta-analysis. Literature search was based on MEDLINE (1966 to January 15, 2007), EMBASE, and Cochrane-Controlled Trials Register (2006 issue 4) databases. Only randomized-controlled studies comparing nebulized AmB with placebo on immunosuppressed animals were included. Two reviewers reviewed and extracted the data independently. Eight studies including 839 immunosuppressed animals were considered. The overall mortality of the immunosuppressed animals with pulmonary aspergillosis treated with nebulized AmB was reduced (69.4% versus 87.7%, odds ratio [OR] 0.12, 95% confidence interval [CI]: 0.08-0.19 P < 0.0001). The effect of nebulized AmB on mortality was more significant when the drug was administered as prophylaxis before the inoculation of Aspergillus fumigatus (OR 0.07, 95% CI: 0.03-0.12, P = 0.0001 I(2) = 0) than as a therapeutic agent (OR 0.20, 95% CI: 0.11-0.36, P < 0.0001 I(2) = 0) (ratio of the 2 ORs = 2.86, 95% CI: 1.03-6.11 P = 0.04). The effectiveness of AmB desoxycholate (OR 0.16, 0.06-0.38, P < 0.0001 I(2) = 0) and lipid-associated (liposomal, or lipid complex or colloidal dispersion) hotericin (OR 0.11, 95% CI: 0.06-0.20, P < 0.0001 I(2) = 0) was not significantly different (ratio of the 2 ORs = 1.46, 95% CI: 0.49-4.39 P = 0.50). Three studies evaluated the potential side effects of nebulized hotericin and showed that there was no significant renal toxicity but the hotericin desoxycholate had some detrimental effects on pulmonary surfactant function. The use of nebulized hotericin, either as a prophylactic or therapeutic agent, is effective in reducing mortality of immunosuppressed animals with pulmonary aspergillosis. A large randomized controlled trial is needed to confirm whether combining nebulized hotericin with systemic antifungal agents will reduce mortality in immunosuppressed patients with suspected or proven pulmonary aspergillosis.
Publisher: Mary Ann Liebert Inc
Date: 2011
Abstract: The use of a prognostic model to aid clinician decision-making with regard to decompressive craniectomy for patients with severe neurotrauma has not been examined. Thus in this study we assessed whether an internationally validated prediction model would influence clinician decision-making about craniectomy. A two-part structured interview, given before and after knowing the predicted risks of unfavorable neurological outcomes at 6 months, was used to assess the participants' recommendations about performing decompressive craniectomy in three patients with severe traumatic brain injury. The participants rated their preferences when there was no surrogate decision maker available, when the next of kin requested surgical intervention, when the patient had an advance directive, and when the participant was the injured party. A visual analogue scale (1-10) was used to assess the strength of their opinions. A total of 50 neurosurgeons and intensive care physicians participated in this study. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves, especially when the next of kin of the patient demanded the procedure, and were more similar in their own preferences to patients who had advance directives. Clinicians' preferences to perform the procedure for both themselves and their patients was significantly reduced after knowing the predicted risks of unfavorable outcomes, and these changes in attitude were consistent across those with different specialties, regardless of the amount of experience caring for similar patients, or religious background. In conclusion, the predicted risks of unfavorable outcomes influenced clinician decision-making about recommending decompressive craniectomy for patients with very severe neurotrauma.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2000
DOI: 10.1097/00000539-200011000-00029
Abstract: We investigated the efficacy of IV atropine for preventing spinal anesthesia-induced hypotension in elderly patients. Seventy-five patients undergoing transurethral prostate or bladder surgery were randomized to receive either placebo (n = 25), atropine 5 microg/kg (small-dose atropine, n = 25) or atropine 10 microg/kg (large-dose atropine, n = 25) after the induction of spinal anesthesia. All the patients received an IV infusion of 10 mL/kg 0.9% normal saline over 10 min before the induction of anesthesia. The systolic blood pressure decreased in all three groups after spinal anesthesia. There was a significant increase in the mean heart rate in both atropine groups as compared to the placebo group (placebo group: 78 bpm, 95% confidence interval [CI]: 76.6-78.5 small-dose atropine group: 86 bpm, 95% CI 83.9-88.8 large-dose atropine group: 97 bpm, 95% CI 94.5-100.3 P: = 0.001). There was a significant decrease in the incidence of hypotension in patients who received atropine (placebo group: 76%, small-dose atropine group: 52%, large-dose atropine group: 40%, P: = 0.03). The mean dose of ephedrine required was significantly decreased in the atropine groups (placebo group: 12.2 mg [SD= 10.5], small-dose atropine group: 7.4 mg [SD= 10.0], large-dose atropine group: 5.4 mg [SD= 8.7 mg], P: = 0.048). The total amount of IV fluid and number of patients requiring metaraminol in addition to 30 mg of ephedrine were not significantly different among the three groups. Significant side effects, such as confusion, ST segment changes or angina were not detected in any of the patients. We conclude that IV atropine may be a useful supplement to the existing methods in preventing hypotension induced by spinal anesthesia. IV atropine increases heart rate in a dose-dependent manner in elderly patients undergoing spinal anesthesia. It reduces the incidence of hypotension and the dose of ephedrine required. Small-dose atropine may be a useful supplement in preventing spinal anesthesia-induced hypotension in elderly patients.
Publisher: Tsinghua University Press
Date: 03-08-2011
Publisher: American Association for Cancer Research (AACR)
Date: 15-04-2020
DOI: 10.1158/1078-0432.CCR-19-2641
Abstract: The majority of deaths from breast cancer occur following the development of metastatic disease, a process inhibited by β-blockers in preclinical studies. This phase II randomized controlled trial evaluated the effect of preoperative β-blockade with propranolol on biomarkers of metastatic potential and the immune cell profile within the primary tumor of patients with breast cancer. In this triple-blind placebo-controlled clinical trial, 60 patients were randomly assigned to receive an escalating dose of oral propranolol (n = 30 80–160 mg daily) or placebo (n = 30) for 7 days prior to surgery. The primary endpoint investigated the effect of propranolol on prometastatic and proinflammatory gene expression within the primary tumor. Propranolol downregulated primary tumor expression of mesenchymal genes (P = 0.002) without affecting epithelial gene expression (P = 0.21). Bioinformatic analyses implicated downregulation of Snail/Slug (P = 0.03), NF-κB/Rel (P & 0.01), and AP-1 (P & 0.01) transcription factors in structuring the observed transcriptome alterations, and identified changes in intratumoral neutrophil, natural killer cell, and dendritic cell recruitment (all P & 0.01). Patients with clinical evidence of drug response (lowered heart rate and blood pressure) demonstrated elevated tumor infiltration of CD68+ macrophages and CD8+ T cells. One week of β-blockade with propranolol reduced intratumoral mesenchymal polarization and promoted immune cell infiltration in early-stage surgically-resectable breast cancer. These results show that β-blockade reduces biomarkers associated with metastatic potential, and support the need for larger phase III clinical trials powered to detect the impact of β-blockade on cancer recurrence and survival. See related commentary by Blaes et al., p. 1781
Publisher: Springer Science and Business Media LLC
Date: 13-06-2015
DOI: 10.1007/S11695-015-1763-Y
Abstract: It is uncertain whether bariatric surgery can be safely performed in secondary hospitals without on-site intensive care unit (ICU) support. This study describes the outcomes of elective bariatric surgery patients who required inter-hospital transfers for unplanned ICU management, extrapolating this as a parameter for secondary hospital safety after bariatric surgery. This was a retrospective, statewide, population-based, linked data cohort study capturing all adult bariatric surgery patients for an entire Australian state between 2007 and 2011 (n = 12,062) with minimum 12-month follow-up. In secondary hospitals, 2663 (22.1%) bariatric patients were operated on, with the majority (n = 2553) undergoing sleeve gastrectomies (SG) or adjustable gastric bands (LAGB). Forty-two patients (including 19 LAGB and 20 SG) required inter-hospital transfer to a tertiary hospital for unplanned ICU care (1.6%, 95% confidence interval 1.2-2.1), mainly due to surgical complications. Inter-hospital transfers incurred two deaths, both following sleeve gastrectomies. When compared to patients requiring unplanned ICU admissions after bariatric surgery in tertiary hospitals with an on-site ICU (n = 155), there was no difference in their demographic parameters, comorbid illnesses, or mortality (4.8 vs 3.9%, p = 0.68). The mortality following bariatric procedures both statewide (0.2%) and in secondary hospitals (0.2%) was both uncommon and comparable. Statewide inter-hospital transfers for unplanned ICU care from secondary hospitals were low. Inter-hospital transfer mortality was comparable to a similar bariatric cohort requiring unplanned ICU care after surgery in a tertiary hospital. This suggests that certain bariatric procedures can be safely done in most secondary hospitals where elective ICU admission is deemed unnecessary.
Publisher: Public Library of Science (PLoS)
Date: 23-02-2012
Publisher: Elsevier BV
Date: 09-2012
DOI: 10.1111/J.1538-7836.2012.04846.X
Abstract: It is uncertain whether reactive thrombocytosis is associated with an increased risk of venous thromboembolism. This study assessed the incidence of reactive thrombocytosis, defined as platelet count ≥ 500 × 10(9) L(-1) , at intensive care unit discharge and its association with subsequent venous thromboembolism. This cohort study involved linkage of routinely collected intensive care unit, laboratory, radiology and death registry data of critically ill patients admitted to the intensive care unit between January 2009 and March 2010. The census date for survival and radiologically confirmed venous thromboembolism was 31 October 2011. Of the 1446 patients who survived to intensive care unit discharge, 139 patients had reactive thrombocytosis (9.6%, 95% confidence interval [CI] 8.2-11.2%). Twenty-nine patients developed venous thromboembolism after discharge (2%, 95% CI 1.4-2.9% 67 per 100 person-years, 95% CI 45-97) and the median time to develop venous thromboembolism was 25 days (interquartile range 8-148). Reactive thrombocytosis was associated with an increased risk of subsequent venous thromboembolism (hazard ratio 5.3, 95% CI 1.7-16.4), after adjusting for other covariates. Platelet counts explained about 34% of the variability in the risk of venous thromboembolism and had a relatively linear relationship with the risk of venous thromboembolism when the platelet counts were > 400 × 10(9) L(-1) . Venous thromboembolism after intensive care unit discharge was associated with an increased risk of mortality (hazard ratio 2.0, 95% CI 1.1-3.9), after adjusting for reactive thrombocytosis. Reactive thrombocytosis during the recovery phase of critical illness was associated with an increased risk of subsequent venous thromboembolism.
Publisher: AMPCo
Date: 05-2012
DOI: 10.5694/MJA11.11485
Publisher: Wiley
Date: 08-05-2012
DOI: 10.1111/J.1365-2753.2012.01857.X
Abstract: Given the considerable interest in the use of evidence-based medicine to guide clinical practice, it is surprising that the results of a recent randomized controlled trial have been met with such a limited response. The DECompressive CRAniectomy study investigators have recently published the results of a landmark trial in neurosurgery, comparing early decompressive craniectomy with standard medical therapy in patients who developed intracranial hypertension after diffuse closed traumatic brain injury (TBI). This is the first ever randomized controlled trial investigating the surgical management of adult patients with severe TBI. The trial clearly demonstrated that early decompression did not provide clinical benefit however, rather than having a significant impact on clinical practice, it has been almost uniformly criticized. While there were some problems with randomization and crossover, we feel that the trial has been somewhat misinterpreted and in this article we address some of the key issues.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2008
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2000
Publisher: Elsevier BV
Date: 11-2023
Publisher: Wiley
Date: 07-08-2012
DOI: 10.1111/J.1365-2044.2012.07265.X
Abstract: Standard cardiorespiratory monitoring may fail to detect occult tissue ischaemia. This study assessed whether a near infra-red spectroscopy tissue oxygen saturation monitor (InSpectra™) could detect progressive peripheral tissue ischaemia and whether hyperoxia may confound tissue oxygen saturation measurement. Tissue oxygen and arterial oxygen saturations were measured continuously in 30 healthy volunteers, first during a period of progressive increase in inspired oxygen concentration and subsequently during two periods of low- and high-pressure limb ischaemia. Increasing inspired oxygen concentration was associated with a small increase in mean (SD) tissue oxygen saturation of 5.3 (7.1) %, reaching a plateau between 30% and 40% inspired oxygen. The rate and magnitude of decreases in tissue oxygen saturations were greater during high- than low-pressure ischaemia with a mean (SD) desaturation rate of 3.3 (0.9) vs 1.8 (0.8) %.min(-1) (p<0.01). The dose-related association and lack of confounding by hyperoxia suggest that tissue oxygen saturation monitoring may be a useful adjunct to detect occult ischaemia.
Publisher: SAGE Publications
Date: 20-12-2021
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2011
Publisher: SAGE Publications
Date: 06-01-2023
DOI: 10.1177/00033197221150673
Abstract: It is uncertain whether monitoring or targeting anti-Xa levels is necessary when using low-molecular-weight-heparin (LMWH) to prevent venous thromboembolism (VTE). This stratified meta-analysis assessed whether monitoring trough or peak anti-Xa levels with LMWH dosing would reduce risk of VTE. Twelve non-randomized studies involving 3604 hospitalized patients met the inclusion criteria and were subject to meta-analysis. Eight studies assessed the association between VTE and peak anti-Xa levels (between .2 and .5 IU/ml) and four studies assessed the benefits of targeting the trough anti-Xa levels ( .1 IU/ml). Achieving an adequate peak or trough anti-Xa level was associated with a reduced risk of VTE (random-effects model odds ratio [OR] .52, 95% confidence interval [CI] .34-.77 P = .001, I 2 = 30% and P-value for heterogeneity = .171) compared with using a fixed standard dose of LMWH. Targeting the trough level (OR .40, 95%CI 0.22–.75, P = .004) appeared to be more effective than targeting the peak level (OR .62, 95%CI 0.37–1.03, P = .066), although a formal interaction analysis did not confirm they were statistically different (ratio of ORs = 1.52, 95%CI 0.68–3.40 z score = 1.03, P = .306). Targeting a higher anti-Xa level did not appear to increase the risk of bleeding or transfusion (OR 1.20, 95%CI 0.46–3.17, P = .707).
Publisher: Springer Science and Business Media LLC
Date: 11-03-1999
Publisher: American Medical Association (AMA)
Date: 06-2016
Publisher: Elsevier BV
Date: 09-2006
DOI: 10.1016/J.JCRC.2006.01.005
Abstract: The purpose of this study is to assess the ability of potential clinical predictors and inflammatory markers to predict intensive care unit (ICU) readmission during the same hospitalization. A nested case-control study utilized prospectively collected de-identified data of a 22-bed multidisciplinary ICU in a university hospital. There were 1,405 consecutive ICU admissions in 2004, and of these, 18 were regarded as ICU readmissions (1.3%). The destination and timing of ICU discharge, the Sequential Organ Failure Assessment scores, white cell counts, and fibrinogen concentrations at discharge were not associated with ICU readmission. C-reactive protein (CRP) concentration within 24 hours before ICU discharge was associated with ICU readmission (mean CRP concentrations of cases vs controls, 177.8 vs 56.5 mg/L, respectively P < .0001). The results remained unchanged after adjustment with the propensity scores. The area under the receiver operating characteristic curve for the CRP concentrations to predict ICU readmission was 0.884 (95% confidence interval, 0.765-0.999 P < .0001). Patients readmitted to the ICU had a higher predicted mortality in their second ICU admission (34.9% vs 26.1% P < .01) and a longer total hospital stay (33.3 vs 20.3 days P < .003) than patients without ICU readmission. A high CRP concentration within 24 hours before ICU discharge is associated with a higher risk of readmission to the ICU.
Publisher: Springer Science and Business Media LLC
Date: 06-01-2022
DOI: 10.1007/S11239-021-02618-W
Abstract: Venous thromboembolism (VTE) is common in patients after major trauma. Attributable cost of VTE and whether this is related to the severity of injury have not been thoroughly investigated. We aimed to define the hospitalization costs of VTE and assess whether the costs were related to the severity of injury in this prospective economic study. Cost data of each patient enrolled in the da Vinci trial were drawn from hospital finance departments and standardized to 2020 Australian dollars (A$) and Injury Severity Score and Trauma Embolic Scoring System were used to quantify the severity of injury. Of the 223 patients who had complete financial cost data available until day-90 follow-up, 37 (16.6%) developed VTE, including upper limb (n = 3) and lower limb deep vein thrombosis (n = 25), pulmonary embolism (n = 7) and clots entrapped in a vena cava filter. The median total radiology (A$4307) as well as the hospitalization costs (A$138,526) of those who had VTE were significantly higher than those without VTE (A$1210 p < 0.001 and A$105,842 p = 0.023, respectively). The incremental hospitalization cost attributable to VTE was most apparent among those who had sustained extremely severe injuries, and estimated to be between A$43,292 (95% confidence interval [CI] 12,624-73,961, p = 0.006) and 41,680 (95%CI 7766-75,594, p = 0.016) after adjusted for Trauma Embolic Scoring System and Injury Severity Scores, respectively. VTE was common after major trauma and incurred a substantial incremental financial cost to the healthcare system, especially among those who had extremely severe injuries.
Publisher: Elsevier BV
Date: 12-2018
DOI: 10.1016/J.PLEFA.2018.11.004
Abstract: The synthetic glucocorticoid dexamethasone is a commonly administered antiemetic. It has immunosuppressive effects and may alter postoperative blood glucose concentrations. Dexamethasone can effect key enzymes involved in inflammation resolution that is an active process driven by specialised lipid mediators of inflammation resolution (SPM). The purpose of this study in healthy volunteers was to examine whether dexamethasone effects cell populations and synthesis of SPM that are critical for the resolution of inflammation. Thirty-two healthy volunteers were randomly allocated to receive saline (Control) or dexamethasone 2 mg, 4 mg or 8 mg intravenously. Venous blood s les were collected at baseline before administration of treatment, and at 4 h, 24 h and one-week post-treatment. At each time point, measurements included blood glucose and macrophage migration inhibition factor (MMIF), full blood count including lymphocyte subsets, monocytes, neutrophils, eosinophils and basophils by flow cytometry, and plasma SPM using liquid chromatography tandem mass spectrometry. The effect of dexamethasone dose and time on all measures was analysed using linear mixed models. There was a dose-dependent increase in neutrophil count after dexamethasone that persisted for 24 h. In contrast, there was a dose-dependent reduction in counts of monocytes, lymphocytes, basophils and eosinophils 4 h after dexamethasone, followed by a rebound increase in cell counts at 24 h. Seven days after administration of dexamethasone, all cell counts were similar to baseline levels. MMIF concentration, glucose and natural killer cell counts were not significantly affected by dexamethasone. There was a significant gender effect on plasma SPM such that levels of 17-HDHA, RvD1, 17R-RvD1 and RvE2 in females were on average 14%-50% lower than males. In a linear mixed model that adjusted for neutrophil count, there was a significant interaction between the dose of dexamethasone and time, on plasma 17R-RvD1 such that plasma 17R-RvD1 fell in a dose-dependent manner until 4 h after administration of dexamethasone. There were no significant effects of dexamethasone on the other plasma SPM (18-HEPE, RvE2, 17-HDHA, RvD1, RvD2 and 14-HDHA) measured. This is the first study in healthy volunteers to demonstrate that commonly employed antiemetic doses of dexamethasone affect immune cell populations and plasma levels of 17R-RvD1 an SPM with anti-nociceptive properties. If similar changes occur in surgical patients, then this may have implications for acute infection risk in the post-operative period.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2008
Publisher: Wiley
Date: 03-02-2023
Abstract: The electrochemical reduction of carbon dioxide (CO 2 ) to value‐added chemicals is a promising strategy to mitigate climate change. Metalloporphyrins have been used as a promising class of stable and tunable catalysts for the electrochemical reduction reaction of CO 2 (CO 2 RR) but have been primarily restricted to single‐carbon reduction products. Here, we utilize functionalized earth‐abundant manganese tetraphenylporphyrin‐based (Mn‐TPP) molecular electrocatalysts that have been immobilized via electrografting onto a glassy carbon electrode (GCE) to convert CO 2 with overall 94 % Faradaic efficiencies, with 62 % being converted to acetate. Tuning of Mn‐TPP with electron‐withdrawing sulfonate groups (Mn‐TPPS) introduced mechanistic changes arising from the electrostatic interaction between the sulfonate groups and water molecules, resulting in better surface coverage, which facilitated higher conversion rates than the non‐functionalized Mn‐TPP. For Mn‐TPP only carbon monoxide and formate were detected as CO 2 reduction products. Density‐functional theory (DFT) calculations confirm that the additional sulfonate groups could alter the C−C coupling pathway from *CO→*COH→*COH‐CO to *CO→*CO‐CO→*COH‐CO, reducing the free energy barrier of C−C coupling in the case of Mn‐TPPS. This opens a new approach to designing metalloporphyrin catalysts for two carbon products in CO 2 RR.
Publisher: Informa UK Limited
Date: 25-07-2013
DOI: 10.3109/02688697.2013.817532
Abstract: To assess changes in neurological function after cranioplasty. Functional and neurocognitive assessments including activities of daily living assessment, functional independence measure (FIM) and the Cognitive assessment report (COGNISTAT) were conducted on all patients within 72 h before and 7 days after cranioplasty. A change in the total FIM score of 2 points was taken to be clinically significant. Assessments were performed on 25 patients. The functional status was unchanged in eighteen patients (72%), four patients (16%) demonstrated a significant improvement and three patients (12%) deteriorated significantly. Those with deterioration after cranioplasty had some forms of complications including pneumocephalus or seizure. After excluding the three patients who had immediate medical or surgical complications after surgery, there was a mild overall improvement in the mean FIM score (2.1, 95% confidence interval 0.1-4.3, p = 0.049), mainly due to an improvement in their motor function. A small but significant number of patients appear to improve clinically following cranioplasty. The so-called syndrome of the trephined may be more common than had been previously appreciated.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-1999
Publisher: Elsevier BV
Date: 12-2016
Publisher: Wiley
Date: 03-2010
DOI: 10.1111/J.1365-2044.2009.06228.X
Abstract: Furosemide, a potent loop diuretic, is frequently used in different stages of acute kidney injury, but its clinical roles remain uncertain. This review summarises the pharmacology of furosemide, its potential uses and side effects, and the evidence of its efficacy. Furosemide is actively secreted by the proximal tubules into the urine before reaching its site of action at the ascending limb of loop of Henle. It is the urinary concentrations of furosemide that determine its diuretic effect. The severity of acute kidney injury has a significant effect on the diuretic response to furosemide a good 'urinary response' may be considered as a 'proxy' for having some residual renal function. The current evidence does not suggest that furosemide can reduce mortality in patients with acute kidney injury. In patients with acute lung injury without haemodynamic instability, furosemide may be useful in achieving fluid balance to facilitate mechanical ventilation according to the lung-protective ventilation strategy.
Publisher: Oxford University Press (OUP)
Date: 08-02-2010
DOI: 10.1093/JAC/DKQ025
Publisher: Elsevier BV
Date: 10-2023
Publisher: Elsevier BV
Date: 08-2012
DOI: 10.1016/J.JCRC.2011.11.013
Abstract: Patients who survive an episode of critical illness continue to experience significant mortality after hospital discharge. This study assessed the accuracy of physician prediction of 2-year mortality and compared it with 2 objective prognostic models. Sensitivity (probability of a prediction of death in patients who died within 2 years) and specificity (probability of a prediction of survival in patients who survived at least 2 years) of physicians' 2-year prediction were compared with those from 2 objective prognostic models, Acute Physiology and Chronic Health Evaluation (APACHE) II and Predicted Risk Existing Disease Intensive Care Therapy (PREDICT). Physician prediction of 2-year mortality was available for 2497 (94.8%) intensive care unit admissions. Specificity was high (85.2% 95% confidence interval [CI], 83.7-86.4), but sensitivity (65.0% 95% CI, 61.1-68.8) and positive predictive value (57.4% 95% CI, 53.6-61.2) were relatively low, suggesting overpessimistic prediction of 2-year mortality. Age, Charlson comorbidity index, and APACHE score were independent risk factors for an inaccurate physician prediction. The diagnostic odds ratio for the physician predictions was at least comparable with the APACHE and PREDICT models, which both had very good discrimination of mortality at 2-year follow-up. Physicians tended to overpredict the risk of 2-year mortality of critically ill patients, but accuracy was comparable with 2 objective prognostic models.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2017
DOI: 10.1097/ALN.0000000000001466
Abstract: Glucocorticoids are increasingly used perioperatively, principally to prevent nausea and vomiting. Safety concerns focus on the potential for hyperglycemia and increased infection. The authors hypothesized that glucocorticoids predispose to such adverse outcomes in a dose-dependent fashion after elective noncardiac surgery. The authors conducted a systematic literature search of the major medical databases from their inception to April 2016. Randomized glucocorticoid trials in adults specifically reporting on a safety outcome were included and meta-analyzed with Peto odds ratio method or the quality effects model. Subanalyses were performed according to a dexamethasone dose equivalent of low (less than 8 mg), medium (8 to 16 mg), and high (more than 16 mg). The primary endpoints of any wound infection and peak perioperative glucose concentrations were subject to meta-regression. Fifty-six trials from 18 countries were identified, predominantly assessing dexamethasone. Glucocorticoids did not impact on any wound infection (odds ratio, 0.8 95% CI, 0.6 to 1.2) but did result in a clinically unimportant increase in peak perioperative glucose concentration (weighted mean difference, 20.0 mg/dl CI, 11.4 to 28.6 P & 0.001 or 1.1 mM CI, 0.6 to 1.6). Glucocorticoids reduced peak postoperative C-reactive protein concentrations (weighted mean difference, −22.1 mg/l CI, −31.7 to −12.5 P & 0.001), but other adverse outcomes and length of stay were unchanged. No dose–effect relationships were apparent. The evidence at present does not highlight any safety concerns with respect to the use of perioperative glucocorticoids and subsequent infection, hyperglycemia, or other adverse outcomes. Nevertheless, collated trials lacked sufficient surveillance and power to detect clinically important differences in complications such as wound infection.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2005
DOI: 10.1097/01.CCM.0000181726.32675.37
Abstract: To investigate the preventive effect of topical nonabsorbable gastrointestinal antifungal prophylaxis on the incidence of fungal infection in critically ill immunocompetent patients. Randomized controlled studies involving critically ill pediatric and adult patients in different languages from the Cochrane Controlled Trial Register (2004, issue 1), EMBASE, and MEDLINE databases (1966 to 30 April 2004) were included. Studies evaluating absorbable antifungal prophylaxis were excluded. Two reviewers assessed the quality of the studies and performed data extraction independently. Amphotericin B and nystatin were used as the nonabsorbable antifungal prophylaxis in the 15 studies included in this meta-analysis. Ten studies used a concomitant systemic antibiotic and four more studies used concomitant topical nonabsorbable antibiotics in the treatment group. Only one study compared topical nonabsorbable antifungal prophylaxis alone with placebo. The total incidence of fungal infections (relative risk [RR], 0.30 95% confidence interval [CI], 0.18-0.48 p < .00001 extent of inconsistency [I(2)] = 0%) and proportion of patients with fungal infection (RR, 0.50 95% CI, 0.28-0.87 p = .02 I(2) = 0%) were significantly reduced with topical nonabsorbable antifungal prophylaxis. The incidence of fungal urinary tract infection was significantly reduced (RR, 0.27 95% CI, 0.10-0.74 p = .01 I(2)= 0%) but not fungal pneumonia (RR, 0.57 95% CI, 0.28-1.16 p = .12 I(2)= 0%). Fungemia and catheter-related fungal sepsis were rare and not significantly reduced with nonabsorbable antifungal prophylaxis. The results remained unchanged in the sensitivity analyses after exclusion of studies with unclear study quality or exclusion of the contribution of fungal urinary tract infections to the total incidence of fungal infections. In critically ill immunocompetent patients who are at high risk of fungal infection, topical nonabsorbable gastrointestinal antifungal prophylaxis was associated with a reduced incidence of urinary fungal infections and a trend toward reduction in respiratory fungal infections and fungemia. Limitations in study data are such that many of these infections may have represented superficial infections of uncertain clinical importance a large, randomized, controlled trial is needed to assess the cost-effectiveness and safety of topical nonabsorbable antifungal prophylaxis in critically ill patients.
Publisher: Elsevier BV
Date: 08-2018
DOI: 10.1016/J.JCRC.2018.04.009
Abstract: Using urinary indices as a quick bedside test to assist management of oliguria and acute kidney injury (AKI) has long been sought. This study assessed whether urinary potassium excretion is related to simultaneously calculated creatinine clearance (CrCl) and can predict AKI in the critically ill. In this prospective cohort study, the correlation between 2-h urinary potassium excretion and simultaneously calculated CrCl of 61 critically ill patients was assessed by Pearson's correlation coefficient, and their ability to predict AKI (≥stage 1 KDIGO) in the subsequent 7 days was assessed by area under the receiver-operating-characteristic (AUROC) curve. Urinary potassium excretion (median 6.2 mmol, range 0.8-24.3) correlated linearly with CrCl (correlation coefficient: 0.58, 95% confidence interval [CI] 0.38-0.72 p = 0.001), and had a moderate ability to predict subsequent AKI (n = 19 [31%] AUROC 0.747, 95%CI 0.620-0.850 p = 0.001), especially in patients without prior exposure to furosemide within 24-h (correlation coefficient 0.61, 95%CI 0.41-0.76 AUROC 0.789, 95%CI 0.654-0.890 p = 0.001, respectively). Urinary potassium excretion correlates with CrCl and predicts AKI in the critically ill without recent furosemide exposure. Given 2-h urinary potassium excretion can be measured easily, its potential as a marker of renal function deserves further study.
Publisher: Springer Science and Business Media LLC
Date: 2005
DOI: 10.1186/CC3913
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2014
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 12-2013
Abstract: The object of this study was to assess the long-term outcome and quality of life of patients who have survived with severe disability following decompressive craniectomy for severe traumatic brain injury (TBI). The authors assessed outcome beyond 3 years among a cohort of 39 patients who had been adjudged either severely disabled or in vegetative state 18 months after decompressive craniectomy for TBI. Assessments performed included the Extended Glasgow Outcome Scale, modified Barthel Index (mBI), Zarit Burden Interview, and 36-Item Short-Form Health Survey (SF-36). The issue of retrospective consent for surgery was also assessed. Of the 39 eligible patients, 7 died, 12 were lost to follow-up, and 20 patients or their next of kin consented to participate in the study. Among those 20 patients, 5 in a vegetative state at 18 months remained so beyond 3 years, and the other 15 patients remained severely disabled after a median follow-up of 5 years. The patients' average daily activity per the mBI (Pearson correlation coefficient [r] = −0.661, p = 0.01) and SF-36 physical score (r = −0.543, p = 0.037) were inversely correlated with the severity of TBI. However, the SF-36 mental scores of the patients were reasonably high (median 46, interquartile range 37–52). The majority of patients and their next of kin believed that they would have provided consent for surgical decompression even if they had known the eventual outcome. Substantial physical recovery beyond 18 months after decompressive craniectomy for severe TBI was not observed however, many patients appeared to have recalibrated their expectations regarding what they believed to be an acceptable quality of life.
Publisher: Wiley
Date: 30-12-2012
DOI: 10.1111/J.1537-2995.2011.03505.X
Abstract: Recombinant activated factor VII (rFVIIa) is widely used as an off-label rescue treatment for patients with nonhemophilic critical bleeding. Using data from the intensive care unit, transfusion service, and death registry, the long-term survival after using rFVIIa and the associated cost per life-year gained in a consecutive cohort of patients with critical bleeding requiring massive transfusion (≥ 10 red blood cell [RBC] units in 24 hr) were assessed. rFVIIa was only used as a lifesaving treatment when conventional measures had failed. Of the 353 patients with critical bleeding requiring massive transfusion, 81 (23%) required rFVIIa as a lifesaving rescue treatment. The patients requiring rFVIIa received a greater number of transfusions (number of units: RBCs, 18 vs. 12 fresh-frozen plasma, 16 vs. 10 platelets, 4 vs. 2 p < 0.001) and had a shorter survival time (24 months vs. 33 months p = 0.002) than those who did not require rFVIIa. The total cost per life-year gained of massive transfusion and incremental cost of rFVIIa as a lifesaving treatment were US$1,148,000 (£711,760 95% confidence interval [CI], US$825,000-US$1,471,000) and US$736,000 (£456,320 95% CI, US$527,000-US$945,000), respectively. The incremental costs of rFVIIa increased with severity of illness and transfusion requirement and were greater than the usual acceptable cost-effective limit (<US$100,000 per life-year) for most patients with critical bleeding. As a lifesaving treatment for critical bleeding, the incremental cost of rFVIIa was high. Careful patient selection is critical to balance the potential benefits of rFVIIa in an in idual patient against the cost to the community.
Publisher: BMJ
Date: 09-2019
DOI: 10.1136/BMJOPEN-2019-030402
Abstract: The intraoperative administration of dexamethasone for prophylaxis against postoperative nausea and vomiting is a common and recommended practice. The safety of the administration of this immunosuppressive agent at a time of significant immunological disruption has not been rigorously evaluated in terms of infective complications. This is a pragmatic, multicentre, randomised, controlled, non-inferiority trial. A total of 8880 patients undergoing elective major surgery will be enrolled. Participants will be randomly allocated to receive either dexamethasone 8 mg or placebo intravenously following the induction of anaesthesia in a 1:1 ratio, stratified by centre and diabetes status. Patient enrolment into the trial is ongoing. The primary outcome is surgical site infection at 30 days following surgery, defined according to the Centre for Disease Control criteria. The PADDI trial has been approved by the ethics committees of over 45 participating sites in Australia, New Zealand, Hong Kong, South Africa and the Netherlands. The trial has been endorsed by the Australia and New Zealand College of Anaesthetists Clinical Trials Network and the Australian Society for Infectious Diseases Clinical Research Network. Participant recruitment began in March 2016 and is expected to be complete in mid-2019. Publication of the results of the PADDI trial is anticipated to occur in early 2020. ACTRN12614001226695.
Publisher: Elsevier BV
Date: 12-2015
DOI: 10.1093/BJA/AEV364
Abstract: With increasing rates of bariatric surgery and the consequential involvement of increasingly complex patients, uncertainty remains regarding the use of intensive care unit (ICU) services after bariatric surgery. Our objective was to define the incidence, indications, and outcomes of patients requiring ICU admission after bariatric surgery and assess whether unplanned ICU admission could be predicted using preoperative factors. All adult bariatric surgery patients between 2007 and 2011 in Western Australia were identified from the Department of Health Data Linkage Unit database and merged with a separate database encompassing all subsequent ICU admissions pertaining to bariatric surgery. The minimal and mean follow-up periods were 12 months and 3.4 yr, respectively. Of the 12 062 patients who underwent bariatric surgery during the study period, 590 patients (4.9% 650 ICU admissions) were admitted to an ICU after their bariatric surgery. Patients admitted to the ICU were older (48 vs 43 yr, P<0.001), more likely to be male (49.7 vs 20.2%, P<0.001), and more likely to require revisional bariatric surgery (14.4 vs 7.1%, P<0.001). One hundred and seventy-six patients required an emergent unplanned ICU admission, with 51 requiring multiple ICU admissions. Revisional or open surgery, diabetes mellitus, chronic respiratory disease, and obstructive apnoea were the strongest preoperative factors associated with unplanned ICU admission. Intensive care unit admission after bariatric surgery was uncommon (4.9% of all patients), with 30.9% of all referrals being unplanned. A nomogram and smartphone application based on five important preoperative factors may assist anaesthetists to conduct preoperative planning for high-risk bariatric surgical patients.
Publisher: Elsevier BV
Date: 05-2013
DOI: 10.1016/J.AUCC.2013.06.001
Abstract: There continues to be considerable amount of interest in decompressive craniectomy however its use is controversial. It is technically straightforward however it is not without significant complications and although there is currently unequivocal evidence available that it can be a life saving intervention, evidence that outcome is improved over and above standard medical therapy is less forthcoming. This narrative review considers the current role of decompressive craniectomy in the management of neurological emergencies and focuses on four specific questions, namely (i) Is the decompressive craniectomy a life saving procedure? (ii) Does decompressive craniectomy improve outcome? (iii) Are there any risks associated with decompressive craniectomy? (iv) How do patients feel about their eventual outcome? Finally the future directions for the use of decompressive craniectomy are explored.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2016
DOI: 10.1097/CCM.0000000000001823
Abstract: This study assessed the determinants of urinary output response to furosemide in acute kidney injury specifically, whether the response is related to altered pharmacokinetics or pharmacodynamics. Prospective cohort. Tertiary ICU. Thirty critically ill patients with acute kidney injury without preexisting renal impairment or recent diuretic exposure. A single dose of IV furosemide. Baseline markers of intravascular volume status were obtained prior to administering furosemide. Six-hour creatinine clearance, hourly plasma/urinary furosemide concentrations, and hourly urinary output were used to assess furosemide pharmacokinetics harmacodynamics parameters. Of 30 patients enrolled, 11 had stage-1 (37%), nine had stage-2 (30%), and 10 had stage-3 (33%) Acute Kidney Injury Network acute kidney injury. Seventy-three percent were septic, 47% required norepinephrine, and 53% were mechanically ventilated. Urinary output doubled in 20 patients (67%) following IV furosemide. Measured creatinine clearance was strongly associated with the amount of urinary furosemide excreted and was the only reliable predictor of the urinary output after furosemide (area under the receiver-operating-characteristic curve, 0.75 95% CI, 0.57–0.93). In addition to an altered pharmacokinetics ( p 0.01), a reduced pharmacodynamics response to furosemide also became important when creatinine clearance was reduced to less than 40 mL/min/1.73 m 2 ( p = 0.01). Acute kidney injury staging and markers of intravascular volume, including central venous pressure, brain-natriuretic-peptide concentration, and fractional urinary sodium excretion were not predictive of urinary output response to furosemide. The severity of acute kidney injury, as reflected by the measured creatinine clearance, alters both pharmacokinetics and pharmacodynamics of furosemide in acute kidney injury, and was the only reliable predictor of the urinary output response to furosemide in acute kidney injury.
Publisher: American Association for Cancer Research (AACR)
Date: 31-03-2023
DOI: 10.1158/1078-0432.C.6529944.V1
Abstract: AbstractPurpose: The majority of deaths from breast cancer occur following the development of metastatic disease, a process inhibited by β-blockers in preclinical studies. This phase II randomized controlled trial evaluated the effect of preoperative β-blockade with propranolol on biomarkers of metastatic potential and the immune cell profile within the primary tumor of patients with breast cancer. Patients and Methods: In this triple-blind placebo-controlled clinical trial, 60 patients were randomly assigned to receive an escalating dose of oral propranolol ( i n /i = 30 80–160 mg daily) or placebo ( i n /i = 30) for 7 days prior to surgery. The primary endpoint investigated the effect of propranolol on prometastatic and proinflammatory gene expression within the primary tumor. Results: Propranolol downregulated primary tumor expression of mesenchymal genes ( i P /i = 0.002) without affecting epithelial gene expression ( i P /i = 0.21). Bioinformatic analyses implicated downregulation of Snail/Slug ( i P /i = 0.03), NF-κB/Rel ( i P /i 0.01), and AP-1 ( i P /i 0.01) transcription factors in structuring the observed transcriptome alterations, and identified changes in intratumoral neutrophil, natural killer cell, and dendritic cell recruitment (all i P /i 0.01). Patients with clinical evidence of drug response (lowered heart rate and blood pressure) demonstrated elevated tumor infiltration of CD68 sup + /sup macrophages and CD8 sup + /sup T cells. Conclusions: One week of β-blockade with propranolol reduced intratumoral mesenchymal polarization and promoted immune cell infiltration in early-stage surgically-resectable breast cancer. These results show that β-blockade reduces biomarkers associated with metastatic potential, and support the need for larger phase III clinical trials powered to detect the impact of β-blockade on cancer recurrence and survival. i See related commentary by Blaes et al., p. 1781 /i /
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2014
Publisher: Public Library of Science (PLoS)
Date: 04-06-2020
Publisher: Springer Science and Business Media LLC
Date: 1999
Abstract: The Internet is increasingly being recognised as a source of information in different fields, and medicine is no exception. We investigated the use of the Internet as an aid in preparing for the professional medical examinations. The Internet was compared to a standard textbook in answering a randomly selected past examination paper. Thirty-eight web-sites on the Internet were involved, giving information to all the examination questions. In contrast, the textbook provided adequate information in only 73.3% of the questions. The time required to search for information on the Internet was more than that required for a single textbook. (approximately 2 hours per question compared to 30 minutes per question respectively). However, with the rapid development of computer technology and the cyberspace, the Internet may prove to be a viable alternative or a good supplement to the standard textbook when trainee anaesthetists are preparing for their professional medical examinations.
Publisher: Elsevier BV
Date: 09-2016
DOI: 10.1016/J.INJURY.2016.04.017
Abstract: Predicting long-term neurological outcomes after severe traumatic brain (TBI) is important, but which prognostic model in the context of decompressive craniectomy has the best performance remains uncertain. This prospective observational cohort study included all patients who had severe TBI requiring decompressive craniectomy between 2004 and 2014, in the two neurosurgical centres in Perth, Western Australia. Severe disability, vegetative state, or death were defined as unfavourable neurological outcomes. Area under the receiver-operating-characteristic curve (AUROC) and slope and intercept of the calibration curve were used to assess discrimination and calibration of the CRASH (Corticosteroid-Randomisation-After-Significant-Head injury) and IMPACT (International-Mission-For-Prognosis-And-Clinical-Trial) models, respectively. Of the 319 patients included in the study, 119 (37%) had unfavourable neurological outcomes at 18-month after decompressive craniectomy for severe TBI. Both CRASH (AUROC 0.86, 95% confidence interval 0.81-0.90) and IMPACT full-model (AUROC 0.85, 95% CI 0.80-0.89) were similar in discriminating between favourable and unfavourable neurological outcome at 18-month after surgery (p=0.690 for the difference in AUROC derived from the two models). Although both models tended to over-predict the risks of long-term unfavourable outcome, the IMPACT model had a slightly better calibration than the CRASH model (intercept of the calibration curve=-4.1 vs. -5.7, and log likelihoods -159 vs. -360, respectively), especially when the predicted risks of unfavourable outcome were <80%. Both CRASH and IMPACT prognostic models were good in discriminating between favourable and unfavourable long-term neurological outcome for patients with severe TBI requiring decompressive craniectomy, but the calibration of the IMPACT full-model was better than the CRASH model.
Publisher: SAGE Publications
Date: 13-07-2023
DOI: 10.1177/02676591231187958
Abstract: Low cardiac power (product of flow and pressure) has been shown to be associated with mortality in patients with cardiogenic shock after acute myocardial infarction, but has not been studied in cardiac surgical patients. This study’s hypothesis was that cardiac power during cardiopulmonary bypass for cardiac surgery would have a greater association with adverse events than either flow or MAP (mean arterial pressure) alone. We undertook a retrospective observational study using patient data from February 2015 to March 2022 undergoing cardiac surgery at Fiona Stanley Hospital in Perth Australia. Excluded were patient age less than 18 years old, patients undergoing thoracic transplantation, ventricular assist devices, off pump cardiac surgery and aortic surgery. The primary outcome was a composite outcome of 30-days mortality, stroke or new-onset renal insufficiency. Overall, 1984 cardiac surgeries were included in the analysis. Neither duration nor area below thresholds tested for power, MAP or flow was associated with the primary composite outcome. However, we found that an area below MAP thresholds 35–50 mmHg was associated with new renal insufficiency (adjusted odds ratio 1.17 [95% CI 1.02 to 1.35] for patients spending 10 min at 10 mmHg below 50 mmHg MAP compared to those who did not). This study suggests that MAP during cardiopulmonary bypass, but not power or flow, was an independent risk factor for adverse renal outcomes for cardiac surgical patients.
Publisher: Elsevier BV
Date: 11-2010
DOI: 10.1093/BJA/AEQ254
Publisher: Springer Science and Business Media LLC
Date: 29-03-2010
DOI: 10.1007/S00701-010-0626-5
Abstract: There is currently much interest in the use of decompressive craniectomy for patients with severe head injury. A number of studies have demonstrated that not only can the technique lower intracranial pressure but can also improve outcome. Whilst many patients who would otherwise have died or had a poor outcome now go on to make a good recovery, there is little doubt that complications can have a very significant impact on long term outcome. By using the corticosteroid randomisation after significant head injury (CRASH) collaborators outcome prediction model, three patients were selected who had a similar outcome prediction. All three patients developed intracranial hypertension following trauma and had a decompressive craniectomy. Despite having a similar outcome prediction only one patient made an uneventful recovery. The remaining two patients suffered significant complications. This report illustrates the potential clinical applications and limitations of an outcome prediction model and demonstrates the impact that complications can have on eventual outcome.
Publisher: BMJ
Date: 17-07-2012
DOI: 10.1136/MEDETHICS-2012-100672
Abstract: In all fields of clinical medicine, there is an increasing awareness that outcome must be assessed in terms of quality of life and cost effectiveness, rather than merely length of survival. This is especially the case when considering decompressive craniectomy for severe traumatic brain injury. The procedure itself is technically straightforward and involves temporarily removing a large section of the skull vault in order to provide extra space into which the injured brain can expand. A number of studies have demonstrated many patients going on to make a good long-term functional recovery, however, this is not always the case and a significant number survive but are left with severe neurocognitive impairment. Unfortunately, many of these patients are young adults who were previously fit and well and are, therefore, likely to spend many years in a condition that they may feel to be unacceptable, and this raises a number of ethical issues regarding consent and resource allocation. In an attempt to address these issues, we have used the analytical framework proposed by Jonsen, that requires systematic consideration of medical indications, patient preferences, quality of life and contextual features.
Publisher: Elsevier BV
Date: 12-2016
DOI: 10.1016/J.JCRC.2016.08.022
Abstract: This study assessed the determinants of 6-month survival of critically ill patients with an active hematologic malignancy (HM). All patients with an active HM defined by either receiving ongoing or due to receive antineoplastic therapy, admitted to 2 tertiary intensive care units between 2010 and 2015, were included in this retrospective cohort study. Of the 273 patients included in the study (median age, 63[interquartile range, 54-71] years 40.7% female), 116 (42.5% 95% confidence interval, 36.8-48.4) died in hospital. The 6-month mortality was 56.4% (95% confidence interval, 50.5-62.2). Mechanical ventilation, intensive care unit admission source, and the type of active HM were significantly associated with hospital mortality and 6-month survival, after adjusting for severity of acute illness. The type of active HM was the most important prognostic factor, with over a 10-fold difference in 6-month survival between HM with the best and worst prognosis. In addition, recent hematopoietic stem cell transplant (<30 days) was associated with a better 6-month survival. Differences in 6-month survival between critically ill patients with different types of active HM were substantial. Recent hematopoietic stem cell transplant, severity of illness, and use of mechanical ventilation were additional important determinants of 6-month survival in patients with an active HM.
Publisher: Elsevier BV
Date: 04-2011
DOI: 10.1093/BJA/AEQ417
Abstract: The role of corticosteroids in severe sepsis and pneumonia remains controversial. This study described the use of L'Abbé and pooled calibration plots to assess the relationship between severity of illness and effectiveness of corticosteroids for severe sepsis. Randomized controlled trials (RCTs) comparing corticosteroids and placebo from Cochrane Controlled Trial Register, MEDLINE, and EMBASE databases were retrieved. The observed and predicted mortality rates of the placebo groups were used as a measure of the severity of illness of the patients in L'Abbé and calibration plots. A total of 1089 patients from 10 RCTs fulfilled the inclusion criteria and were subject to further analysis. L'Abbé and calibration plots did not suggest significant interactions between the effectiveness of corticosteroids and severity of illness. The pooled calibration plot suggested that the mortality rates of the placebo groups from three studies were higher than predicted. After excluding these studies in the meta-analysis, there was a reduction in the point estimate of benefit of corticosteroids on mortality [odds ratio (OR) 0.97, 95% confidence interval (CI): 0.71-1.33, P=0.87 by a fixed-effect model, P=0.59 by a random-effects model vs OR 0.85, 95% CI: 0.66-1.10%]. The pooled calibration plot suggested that there were excessive deaths in the placebo groups of some RCTs that could explain the apparent benefit of corticosteroids on mortality of patients with severe sepsis. L'Abbé and pooled calibration plots might be useful as adjuncts to assess interactions between severity of illness and effectiveness of an intervention.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2016
Publisher: Elsevier BV
Date: 07-2023
Publisher: Oxford University Press (OUP)
Date: 23-02-2016
DOI: 10.1093/ICVTS/IVW017
Publisher: Springer Science and Business Media LLC
Date: 28-08-2023
DOI: 10.1007/S11739-023-03397-3
Abstract: Biological age is increasingly recognized as being more accurate than chronological age in determining chronic health outcomes. This study assessed whether biological age, assessed on intensive care unit (ICU) admission, can predict hospital mortality. This retrospective cohort study, conducted in a tertiary multidisciplinary ICU in Western Australia, used the Levine PhenoAge model to estimate each patient’s biological age (also called PhenoAge). Each patient’s PhenoAge was calibrated to generate a regression residual which was equivalent to biological age unexplained by chronological age in the local context. PhenoAgeAccel was a dichotomized measure of the residuals, and its presence suggested that one was biologically older than the corresponding chronological age. Of the 2950 critically ill adult patients analyzed, 291 died (9.9%) before hospital discharge. Both PhenoAge and its residuals (after regressing on chronological age) had a significantly better ability to differentiate between hospital survivors and non-survivors than chronological age (area under the receiver-operating-characteristic curve 0.648 and 0.654 vs. 0.547 respectively). Being phenotypically older than one’s chronological age was associated with an increased risk of mortality (PhenoAgeAccel hazard ratio [HR] 1.997, 95% confidence interval [CI] 1.568–2.542 p = 0.001) in a dose-related fashion and did not reach a plateau until at least a 20-year gap. This adverse association remained significant (adjusted HR 1.386, 95% CI 1.077–1.784 p = 0.011) after adjusted for severity of acute illness and comorbidities. PhenoAgeAccel was more prevalent among those with pre-existing chronic cardiovascular disease, end-stage renal failure, cirrhosis, immune disease, diabetes mellitus, or those treated with immunosuppressive therapy. Being phenotypically older than one’s chronological age was more common among those with comorbidities, and this was associated with an increased risk of mortality in a dose-related fashion in the critically ill that was not fully explained by comorbidities and severity of acute illness.
Publisher: American Association for Cancer Research (AACR)
Date: 31-03-2023
DOI: 10.1158/1078-0432.22478397.V1
Abstract: Supplementary Material
Publisher: SAGE Publications
Date: 04-03-2020
Abstract: Microbiota—defined as a collection of microbial organisms colonising different parts of the human body—is now recognised as a pivotal element of human health, and explains a large part of the variance in the phenotypic expression of many diseases. A reduction in microbiota ersity, and replacement of normal microbes with non-commensal, pathogenic or more virulent microbes in the gastrointestinal tract—also known as gut dysbiosis—is now considered to play a causal role in the pathogenesis of many acute and chronic diseases. Results from animal and human studies suggest that dysbiosis is linked to cardiovascular and metabolic disease through changes to microbiota-derived metabolites, including trimethylamine-N-oxide and short-chain fatty acids. Dysbiosis can occur within hours of surgery or the onset of critical illness, even without the administration of antibiotics. These pathological changes in microbiota may contribute to important clinical outcomes, including surgical infection, bowel anastomotic leaks, acute kidney injury, respiratory failure and brain injury. As a strategy to reduce dysbiosis, the use of probiotics (live bacterial cultures that confer health benefits) or synbiotics (probiotic in combination with food that encourages the growth of gut commensal bacteria) in surgical and critically ill patients has been increasingly reported to confer important clinical benefits, including a reduction in ventilator-associated pneumonia, bacteraemia and length of hospital stay, in small randomised controlled trials. However, the best strategy to modulate dysbiosis or counteract its potential harms remains uncertain and requires investigation by a well-designed, adequately powered, randomised controlled trial.
Publisher: American Association for Cancer Research (AACR)
Date: 31-03-2023
DOI: 10.1158/1078-0432.22478397
Abstract: Supplementary Material
Publisher: Elsevier BV
Date: 04-2015
DOI: 10.1016/J.JCRC.2014.11.005
Abstract: The purpose of this study is to determine whether varying the format used to present prognostic data alters the perception of risk among surrogate decision makers in the intensive care unit (ICU). This was a prospective randomized comparative trial conducted in a 23-bed adult tertiary ICU. Enrolled surrogate decision makers were randomized to 1 of 2 questionnaires, which presented hypothetical ICU scenarios, identical other than the format in which prognostic data were presented (eg, frequencies vs percentages). Participants were asked to rate the risk associated with each prognostic statement. We enrolled 141 surrogate decision makers. The perception of risk varied significantly dependent on the presentation format. For "quantitative data," risks were consistently perceived as higher, when presented as frequencies (eg, 1 in 50) compared with equivalent percentages (eg, 2%). Framing "qualitative data" in terms of chance of "death" rather than "survival" led to a statistically significant increase in perceived risks. Framing "quantitative" data in this way did not significantly affect risk perception. Data format had a significant effect on how surrogate decision makers interpreted risk. Qualitative statements are interpreted widely and affected by framing. Where possible, multiple quantitative formats should be used for presenting prognostic information.
Publisher: Springer Science and Business Media LLC
Date: 29-06-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2003
Publisher: Wiley
Date: 05-03-2007
DOI: 10.1111/J.1365-2044.2007.04999.X
Abstract: This study compared the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II score with two organ failure scores in predicting hospital mortality of critically ill patients. A total of 1311 consecutive adult patients in a tertiary 22-bed multidisciplinary intensive care unit (ICU) in Western Australia were considered. The APACHE II score had a better calibration and discrimination than the Max Sequential Organ Failure Score (Max SOFA) (area under receiver operating characteristic (ROC) curve 0.858 vs 0.829), Admission SOFA (area under ROC 0.858 vs 0.791), and the first day or cumulative 5-day Royal Perth Hospital Intensive Care Unit (RPHICU) organ failure score (area under ROC 0.858 vs 0.822 and 0.819, respectively) in predicting hospital mortality. The APACHE II score predicted hospital mortality of critically ill patients better than the SOFA and RPHICU organ failure scores in our ICU.
Publisher: Elsevier BV
Date: 07-2007
DOI: 10.1016/J.JCLINEPI.2006.10.017
Abstract: To describe the use of forest and funnel plots to assess the uniformity of fit in the calibration of a prognostic model for critically ill patients. This study used the administrative database of the Intensive Care Unit (ICU) at Royal Perth Hospital. This database contained 11,107 consecutive ICU admissions between 1 January 1993 and 31 December 2003. We used forest and funnel plots to assess the calibration of the Acute Physiology and Chronic Health Evaluation (APACHE) II prognostic model. The Mantel-Haenszel weighted standardized mortality ratio (SMR) by pooling different risk or age strata and diagnostic subgroups together was 0.84 (95% Confidence Interval [CI]: 0.80-0.88), 0.85 (95%CI: 0.80-0.90), and 0.88 (95%CI: 0.82-0.93), respectively. The chi-square for heterogeneity across different risk or age strata and diagnostic subgroups was 10.94 (P=0.28), 8.92 (P=0.06), and 24.60 (P<0.0001), respectively. Funnel plot suggested that the APACHE II model had poor calibration for patients with multiple trauma. The estimates of the slope and intercept of the calibration curve confirmed that the model was poorly calibrated for this subgroup of patients. Forest and funnel plots could facilitate visual interpretation of the calibration of a prognostic model across different subgroups of critically ill patients.
Publisher: Mary Ann Liebert Inc
Date: 10-2011
Publisher: BMJ
Date: 26-08-2006
Publisher: Wiley
Date: 08-10-2007
DOI: 10.1111/J.1365-2044.2007.05231.X
Abstract: We investigated whether replacing the Acute Physiology and Chronic Health Evaluation (APACHE) II weighted comorbidity score with other measures of prior comorbidity would improve the prediction of hospital mortality in critically ill patients. Clinical data of 24 303 critically ill patients were linked to the Western Australian hospital morbidity database to identify prior comorbidities. Minor comorbidities as described in the Charlson comorbidity index and Elixhauser comorbidities were prevalent in critically ill patients. Among 24 303 admissions, 3615 (14.9%), 10 223 (42.1%), and 11 597 (47.7%) patients had at least one comorbidity as defined in the APACHE II score, Charlson comorbidity index, and Elixhauser comorbidities, respectively. The ability of comorbidity alone to discriminate between hospital survivors and non-survivors was poor. Replacing the APACHE II weighted comorbidity score with other more comprehensive measures of comorbidity did not significantly improve the discrimination of the APACHE II score.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-1998
DOI: 10.1097/00003246-199803000-00015
Abstract: To investigate the possibility of using common iliac venous pressure (CIVP) as an alternative to superior vena cava pressure (SVCP) in mechanically ventilated, critically ill, adult patients. A randomized, blinded comparison. Multidisciplinary intensive care unit at a university teaching hospital. Twenty mechanically ventilated, critically ill, adult patients. None. All patients had a catheter in situ for measuring the SVCP. A new triple-lumen catheter, with a length ranging from 15 to 20 cm, was placed into the common iliac vein via the femoral route. The SVCP and CIVP were simultaneously measured at hourly intervals for 6 hrs. Positive end-expiratory pressure, mean airway pressure, and intra-abdominal pressure were measured at the same time intervals. For 140 paired measurements of CIVP and SVCP in 20 patients, the mean difference was 0.1 +/- 1.06 (SD) mm Hg (95% confidence interval -0.10 to 0.25) the limits of agreement were -2.04 to 2.20 mm Hg (95% confidence interval -2.34 to 2.50). Mean airway pressure, intra-abdominal pressure, and positive end-expiratory pressure had no measurable effect on the difference between SVCP and CIVP. Serious complications arising from insertion of the catheter through the femoral route were not observed. For clinical purposes, CIVP measured by a catheter of 15 to 20 cm placed through the femoral route is interchangeable with SVCP in mechanically ventilated adult patients. This finding provides an alternative route for assessment of central venous pressure when other routes are not appropriate.
Publisher: Wiley
Date: 08-10-2007
DOI: 10.1111/J.1365-2044.2007.05190.X
Abstract: Noninvasive ventilation by facemask is commonly used for patients with respiratory failure. We evaluated the pressure exerted by two types of facemask on the faces of 12 healthy volunteers while they were being given different levels of continuous or bi-level positive airway pressure ventilation. The mean (SD) pressure recorded on the bridge of the nose was much higher than that on the cheek (nose: 65.8 (21.2) vs cheek 15.4 (7.2) mmHg, p < 0.0001). Progressive tightening of the harness and increasing of the volume of air in the facemask cushions increased the pressure on the bridge of the nose, and the effect of these two factors was additive. Some commercially available facemasks can produce substantial pressure on the bridge of the nose and this explains why pressure complications on the bridge of the nose are common during noninvasive ventilation.
Publisher: Springer Science and Business Media LLC
Date: 18-06-2021
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2011
Publisher: Wiley
Date: 23-12-2011
DOI: 10.1111/J.1755-5922.2009.00114.X
Abstract: Cardiopulmonary bypass is associated with significant morbidities, and the ideal temperature management during cardiopulmonary bypass remains uncertain. This review assessed the benefits and risks of maintaining normothermia during cardiopulmonary bypass in adult cardiac surgery. A total of 6,731 patients from 44 randomized controlled trials in 14 countries, comparing normothermic (> 34°C) and hypothermic (≤34°C) cardiopulmonary bypass in cardiac surgery (>18 years of age), were identified from MEDLINE (1966 to August 10, 2009), EMBASE (1988 to August 10, 2009), and Cochrane controlled trials register and subject to meta-analysis. Two investigators examined all studies and extracted the data independently. Mortality after normothermic and hypothermic bypass was not significantly different (1.4% vs. 1.9% respectively, relative risk [RR] 1.38, 95% confidence interval [CI] 0.94-2.04, I(2) = 0%, P = 0.10). Hypothermic bypass was, however, associated with an increased risk of allogeneic red blood cells (RR 1.19, 95% CI 1.07-1.34, I(2) = 0%, P = 0.002), fresh frozen plasma (RR 1.54, 95% CI 1.06-2.24, I(2) = 7.7%, P = 0.02), and platelet transfusion (RR 2.53, 95% CI 1.26-5.06, I(2) = 44%, P = 0.009). The risk of stroke, cognitive decline, atrial fibrillation, use of inotropic support or intra-aortic balloon pump, myocardial infarction, all-cause infections, and acute kidney injury after cardiac surgery was not significantly different between the two groups. The differences in the bypass time and targeted perfusion temperature were not significantly related to the risk of mortality and stroke. The current evidence suggests that maintaining normothermia during cardiopulmonary bypass in adult cardiac surgery is as safe as that of hypothermic surgery, and associated with a reduced risk of allogeneic blood transfusion.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2010
Publisher: Elsevier BV
Date: 12-2011
Abstract: VTE is a preventable cause of death within hospitals. This study aimed to assess the association between omission of early thromboprophylaxis for > 24 h after ICU admission and mortality in critically ill patients. This study involved 175,665 critically ill adult patients admitted to 134 ICUs in Australia and New Zealand between 2006 and 2010. The crude ICU and hospital mortality in patients who did not receive thromboprophylaxis within 24 h of ICU admission was higher than those who were treated with early thromboprophylaxis (7.6% vs 6.3%, P = .001 11.2% vs 10.6%, P = .003, respectively), despite the former patients being associated with a slightly lower acuity of illness (mean APACHE [Acute Physiology and Chronic Health Evaluation] III model predicted mortality, 13% vs 14% P = .001). The association between omission of early thromboprophylaxis and hospital mortality remained significant after adjusting for other covariates (OR, 1.22 95% CI, 1.15-1.30 P = .001), particularly for patients with multiple trauma, sepsis, cardiac arrest, and preexisting metastatic cancer. The estimated attributable mortality effect of omitting early thromboprophylaxis for patients with multiple trauma, sepsis, cardiac arrest, and preexisting metastatic cancer was 3.9% (95% CI, 2.2-5.6), 8.0% (95% CI, 5.6-10.4), 15.4% (95% CI, 11.1-19.8), and 9.4% (95% CI, 6.4-12.4), respectively. Omission of thromboprophylaxis within the first 24 h of ICU admission without obvious reasons was associated with an increased risk of mortality in critically ill adult patients.
Publisher: Springer Science and Business Media LLC
Date: 20-09-2019
DOI: 10.1038/S41598-019-50178-0
Abstract: Cardiac arrest (CA) may occur due to a variety of causes with heterogeneity in their clinical presentation and outcomes. This study aimed to identify clinical patterns or subphenotypes of CA patients admitted to the intensive care unit (ICU). The clinical and laboratory data of CA patients in a large electronic healthcare database were analyzed by latent profile analysis (LPA) to identify whether subphenotypes existed. Multivariable Logistic regression was used to assess whether mortality outcome was different between subphenotypes. A total of 1,352 CA patients fulfilled the eligibility criteria were included. The LPA identified three distinct subphenotypes: Profile 1 (13%) was characterized by evidence of significant neurological injury (low GCS). Profile 2 (15%) was characterized by multiple organ dysfunction with evidence of coagulopathy (prolonged aPTT and INR, decreased platelet count), hepatic injury (high bilirubin), circulatory shock (low mean blood pressure and elevated serum lactate) Profile 3 was the largest proportion (72%) of all CA patients without substantial derangement in major organ function. Profile 2 was associated with a significantly higher risk of death (OR: 2.09 95% CI: 1.30 to 3.38) whilst the mortality rates of Profiles 3 was not significantly different from Profile 1 in multivariable model. LPA using routinely collected clinical data could identify three distinct subphenotypes of CA those with multiple organ failure were associated with a significantly higher risk of mortality than other subphenotypes. LPA profiling may help researchers to identify the most appropriate subphenotypes of CA patients for testing effectiveness of a new intervention in a clinical trial.
Publisher: Elsevier BV
Date: 03-2009
DOI: 10.1016/J.JCRC.2007.11.015
Abstract: The aim of this study is to assess the effect of comorbidities on risk of readmission to an intensive care unit (ICU) and the excess hospital mortality associated with ICU readmissions. A cohort study used clinical data from a 22-bed multidisciplinary ICU in a university hospital and comorbidity data from the Western Australian hospital morbidity database. From 16,926 consecutive ICU admissions between 1987 and 2002, and 654 (3.9%) of these patients were readmitted to ICU readmissions within the same hospitalization. Patients with readmission were older, more likely to be originally admitted from the operating theatre or hospital ward, had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-predicted mortality, and had more comorbidities when compared with patients without readmission. The number of Charlson comorbidities was significantly associated with late readmission (>72 hours) but not early readmission (<or=72 hours) in the multivariate analysis. Both early and late ICU readmissions were associated with an increased risk of hospital mortality (odds ratio, 1.68 95% confidence interval, 1.18-2.39 P = .004 odds ratio, 1.45 95% confidence interval, 1.05-1.99 P = .022, respectively) after adjusting for age, admission source, type of admission, the APACHE-predicted mortality, and the number of Charlson comorbidities and APACHE chronic health conditions. Comorbidity was a risk factor for late ICU readmission. Comorbidities could not account for the excess mortality associated with ICU readmissions.
Publisher: Mary Ann Liebert Inc
Date: 04-2016
Abstract: There are a number of commercially available heart rate (HR) monitors on the market. The reliability of these monitors has had varying results. To the best of our knowledge, there are no telemonitoring services utilizing these devices for perioperative prehabilitation services for patients undergoing major surgery. The goal of this study is to pilot the MYZONE Paired HR data from each participant were captured and analyzed using a Bland-Altman plot. Seven healthy participants were included in the study with a total number of paired HR data points of 1,928. The bias (mean difference) between electrocardiogram and the MYZONE MZ-3 was 0.4 beats per minute (bpm) with an adjusted 95% limits of agreement of -4.5 to 5.3 bpm. The commercially available MYZONE MZ-3 HR monitor is a reliable tool for delivering telephysiotherapy to patients undergoing major cancer surgery. Further studies are needed to validate its use in this setting.
Publisher: Wiley
Date: 27-03-2012
DOI: 10.1111/J.1365-2044.2012.07117.X
Abstract: This systematic review and meta-analysis assessed the accuracy of plethysmographic variability index derived from the Massimo(®) pulse oximeter to predict preload responsiveness in peri-operative and critically ill patients. A total of 10 studies were retrieved from the literature, involving 328 patients who met the selection criteria. Overall, the diagnostic odds ratio (16.0 95% CI 5-48) and area under the summary receiver operating characteristic curve (0.87 95% CI 0.78-0.95) for plethysmographic variability index to predict fluid or preload responsiveness was very good, but significant heterogeneity existed. This could be explained by a lower accuracy of plethysmographic variability index in spontaneously breathing or paediatric patients and those studies that used pre-load challenges other than colloid fluid. The results indicate specific directions for future studies.
Publisher: The Korean Society of Critical Care Medicine
Date: 31-05-2021
Publisher: Mary Ann Liebert Inc
Date: 12-2009
Abstract: There is currently a resurgence of interest in the use of decompressive craniectomy. As the procedure is used more frequently, there may be an increasing number of patients surviving a severe traumatic brain injury with severe neurological impairment. The aim of this study was to determine if we could predict those cases that fall into this category. We used the web-based prediction model prepared by the CRASH collaborators and applied it to a cohort of patients who had a decompressive craniectomy in 2006 and 2007 at the two major trauma hospitals in Western Australia. All clinical and radiological data were reviewed and entered into the model, and predicted outcome and actual outcome were compared. Our analysis indicated that a significant cut-off point appeared at which the model predicted a 75% risk of an unfavorable outcome at 6 months 19 of 27 patients with CRASH scores <75% returned to work, whereas none of the 14 patients with higher scores achieved this degree of rehabilitation at 18 months. Statistical analysis of the outcomes in our cohort confirmed that the CRASH model reliably predicted unfavorable outcome. This study demonstrated that our ability to predict poor outcome has improved.
Publisher: Elsevier BV
Date: 08-2012
Publisher: Springer Science and Business Media LLC
Date: 25-06-2008
DOI: 10.1007/S00134-008-1186-5
Abstract: To investigate the effects of using propofol for medium and long-term sedation on mortality and length of intensive care unit (ICU) stay of critically ill adult patients. Randomised controlled studies comparing propofol with an alternative sedative agent in critically ill adult patients were included without language restriction from the Cochrane Controlled Trial Register (2007 issue 3), EMBASE, and MEDLINE databases (1966 to 1 December 2007). Two reviewers reviewed the quality of the studies and performed data extraction independently. Sixteen randomised controlled studies with a total of 1,386 critically ill adult patients were considered. Nine of the pooled studies (56%) limited the doses of propofol infusion to <6 mg/kg h(-1). Mortality was not significantly different between patients sedated with propofol, or an alternative sedative agent (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.80-1.38, P = 0.74 I(2) = 0%). Using propofol for medium and long-term sedation was associated with a significant reduction in length of ICU stay (overall weighted-mean-difference [WMD] in days -0.99, 95%CI -1.51 to -0.47, P = 0.0002 I(2) = 82.26%) when compared to an alternative sedative agent however, this benefit became insignificant (overall WMD in days -0.98, 95%CI -2.86 to 0.89, P = 0.30 I(2) = 78.8%) when the comparison was limited to between propofol and midazolam. Using propofol for prolonged sedation in critically ill patients appears to be safe and may reduce duration of mechanical ventilation. It reduces the length of ICU stay when compared to long acting benzodiazepines, but not when compared to midazolam.
Publisher: American Association for Cancer Research (AACR)
Date: 31-03-2023
DOI: 10.1158/1078-0432.C.6529944
Abstract: AbstractPurpose: The majority of deaths from breast cancer occur following the development of metastatic disease, a process inhibited by β-blockers in preclinical studies. This phase II randomized controlled trial evaluated the effect of preoperative β-blockade with propranolol on biomarkers of metastatic potential and the immune cell profile within the primary tumor of patients with breast cancer. Patients and Methods: In this triple-blind placebo-controlled clinical trial, 60 patients were randomly assigned to receive an escalating dose of oral propranolol ( i n /i = 30 80–160 mg daily) or placebo ( i n /i = 30) for 7 days prior to surgery. The primary endpoint investigated the effect of propranolol on prometastatic and proinflammatory gene expression within the primary tumor. Results: Propranolol downregulated primary tumor expression of mesenchymal genes ( i P /i = 0.002) without affecting epithelial gene expression ( i P /i = 0.21). Bioinformatic analyses implicated downregulation of Snail/Slug ( i P /i = 0.03), NF-κB/Rel ( i P /i 0.01), and AP-1 ( i P /i 0.01) transcription factors in structuring the observed transcriptome alterations, and identified changes in intratumoral neutrophil, natural killer cell, and dendritic cell recruitment (all i P /i 0.01). Patients with clinical evidence of drug response (lowered heart rate and blood pressure) demonstrated elevated tumor infiltration of CD68 sup + /sup macrophages and CD8 sup + /sup T cells. Conclusions: One week of β-blockade with propranolol reduced intratumoral mesenchymal polarization and promoted immune cell infiltration in early-stage surgically-resectable breast cancer. These results show that β-blockade reduces biomarkers associated with metastatic potential, and support the need for larger phase III clinical trials powered to detect the impact of β-blockade on cancer recurrence and survival. i See related commentary by Blaes et al., p. 1781 /i /
Publisher: Springer Science and Business Media LLC
Date: 04-2005
DOI: 10.1007/S00134-005-2613-5
Abstract: To investigate the prevalence and predictors of intensive care nurses' active involvement in end-of-life (EOL) decisions. A survey of intensive care nurses from 36 intensive care units (ICUs) in New Zealand. A total of 611 ICU nurses from 35 ICUs responded to this survey. The response rate was estimated to be between 43% and 81%. Seventy-eight percent of respondents reported active involvement in EOL decisions, especially the senior nurses (level IV vs. I nurses, OR 7.9 nurse educators vs. level I nurses, OR 4.3). Asian (OR 0.2) and Pacific Islander nurses (OR 0.2) were less often involved than European nurses. Sixty-eight percent of respondents preferred more involvement in EOL decisions, and this preference was associated with the perception that EOL decisions are often made too late (OR 2.2). Sixty-five percent believed their active involvement in EOL decisions would improve nursing job satisfaction. Most ICU nurses in New Zealand reported that they are often involved in EOL decisions, especially senior and European nurses.
Publisher: Wiley
Date: 22-12-2010
DOI: 10.1111/J.1537-2995.2010.02975.X
Abstract: Warm fresh whole blood has been advocated for critical bleeding in the military setting. This study assessed whether unrefrigerated young whole blood transfusion, from donation to transfusion less than 24 hours, could reduce mortality of patients with critical bleeding in a civilian setting. A linked data cohort study was conducted on a total of 353 consecutive patients requiring massive transfusion, defined as 10 units or more of red blood cells or whole blood transfusion within 24 hours, in a quaternary health care center in Australia. Of the 353 patients with massive blood transfusion in the study, 77 received unrefrigerated young whole blood transfusion (mean, 4.0 units interquartile range, 2-6). The diagnosis, severity of acute illness, age, sex, and ABO blood group were not significantly different between the patients who received unrefrigerated young whole blood and those who did not. Unrefrigerated young whole blood transfusions were associated with a slightly improved coagulation profile (lowest fibrinogen concentrations 1.7g/L vs. 1.4g/L, p=0.006 worst international normalization ratio, 2.4 vs. 2.8, p=0.05) but did not reduce the total utilization of allogeneic blood products and subsequent use of recombinant Factor VIIa (27% vs. 22%, p=0.358). Thirty-day mortality and 8-year survival after hospital discharge (hazard ratio, 1.05 95% confidence interval, 0.41-2.65 p=0.93) were also not different after the use of unrefrigerated young whole blood transfusion. Unrefrigerated young whole blood transfusion was not associated with a reduced mortality of patients requiring massive transfusion in a civilian setting when other blood products were readily available.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2009
Publisher: Wiley
Date: 12-2009
DOI: 10.1111/J.1365-2044.2009.06129.X
Abstract: This meta-analysis examined the benefits of using remifentanil as a sedative agent in critically ill patients. A total of 11 randomised controlled trials, comparing remifentanil with another opioid or hypnotic agent in 1067 critically ill adult patients, were identified from the Cochrane controlled trials register and EMBASE and MEDLINE databases, and subjected to meta-analysis. Remifentanil was associated with a reduction in the time to tracheal extubation after cessation of sedation (weighted-mean-difference -2.04 h (95% CI -0.39 to -3.69 h) p = 0.02). Remifentanil was, however, not associated with a significant reduction in mortality (relative risk 1.01 (95% CI 0.67-1.52) p = 0.96), duration of mechanical ventilation, length of intensive care unit stay, and risk of agitation (relative risk 1.08 (95% CI 0.64-1.82) p = 0.77) when compared to an alternative sedative or analgesic agent. The current evidence does not support the routine use of remifentanil as a sedative agent in critically ill adult patients.
Publisher: Informa UK Limited
Date: 24-05-2016
DOI: 10.1080/02688697.2016.1187259
Abstract: Cranioplasty is a technically straightforward procedure however, it is becoming increasingly apparent that it is associated with relatively high morbidity and a significant failure rate due to either infection or autologous bone flap resorption. The aim of this study was to determine which factors influenced the incidence of cranioplasty complications and failure. A retrospective analysis was undertaken of all patients who had a cranioplasty at the two major trauma hospitals in Western Australia between the start of 2004 and the middle of 2015. Five hundred and twelve had a cranioplasty after craniectomy for a variety of different indications. Sixty-three patients developed a postoperative intracranial collection following cranioplasty (12.3%, 95% confidence interval [CI] 9.7-15.4), however only 19 required surgical evacuation. One hundred and twenty-one patients had seizures following cranioplasty (23.6%, 95% CI 20.2-27.5) Nine patients died within six months following cranioplasty. Forty-two patients (8.2%, 95% CI 6.1-10.9) developed cranioplasty infection that necessitated removal of the implant. However a change in clinical management of these patients had led to no infections for the past three years. Amongst 330 patients who had autologous cranioplasty, clinically significant bone resorption occurred in 69 patients (20.9%, 95% CI 16.9-25.6). One key finding in this study is the reduction in infection rate that can occur when a single senior clinician performs the procedure and there is strict adherence to aseptic technique. This may result in a significant reduction in morbidity.
Publisher: Springer Science and Business Media LLC
Date: 24-02-2011
DOI: 10.1007/S00701-011-0974-9
Abstract: The aim of this study was to compare the predicted outcome with observed outcome in those patients who have had a unilateral decompressive craniectomy following evacuation of an intracranial mass lesion and to consider some of the ethical issues that need to be addressed when performing life-saving but non-restorative surgery. By using the web-based outcome prediction model developed by the CRASH trial collaborators predicted and observed outcomes were compared for those patients who had had a unilateral decompression after evacuation of a mass lesion in the two major neurotrauma hospitals in Western Australia between 2004 and 2008. Three cases were selected with differing outcome predictions. For the three selected cases the predicted risk of an unfavourable outcome at 6 months was 65.8%, 78.9% and 91.3%, respectively. For the 11 patients in this cohort with an outcome prediction between 61% and 70%, the observed outcome at 18 months (GOS) was: 5 had a good outcome, 4 were moderately disabled, and 3 were severely disabled. For the ten patients with an outcome prediction between 90-100%, observed outcome confirmed: one patient was moderately disabled, four patients were severely disabled, one patient was in a permanent vegetative state, and four patients had died. As the index of injury severity (as adjudged by the CRASH outcome prediction model) increases, clinical decision making and discussion with surrogates must reflect the evidence provided by observed outcome, prior to life-saving but potentially non-restorative decompressive surgery.
Publisher: Springer Science and Business Media LLC
Date: 31-08-2017
DOI: 10.1038/S41598-017-10408-9
Abstract: Area under a receiver-operating-characteristic (AUROC) curve is widely used in medicine to summarize the ability of a continuous predictive marker to predict a binary outcome. This study illustrated how a U-shaped or inverted U-shaped continuous predictor would affect the shape and magnitude of its AUROC curve in predicting a binary outcome by comparing the ROC curves of the worst first 24-hour arterial pH values of 9549 consecutive critically ill patients in predicting hospital mortality before and after centering the predictor by its mean or median. A simulation dataset with an inverted U-shaped predictor was used to assess how this would affect the shape and magnitude of the AUROC curve. An asymmetrical U-shaped relationship between pH and hospital mortality, resulting in an inverse-sigmoidal ROC curve, was observed. The AUROC substantially increased after centering the predictor by its mean (0.611 vs 0.722, difference = 0.111, 95% confidence interval [CI] 0.087–0.135), and was further improved after centering by its median (0.611 vs 0.745, difference = 0.133, 95%CI 0.110–0.157). A sigmoidal-shaped ROC curve was observed for an inverted U-shaped predictor. In summary, a non-linear predictor can result in a biphasic-shaped ROC curve and centering the predictor can reduce its bias towards null predictive ability.
Publisher: BMJ
Date: 30-11-2015
Publisher: Research Square Platform LLC
Date: 25-01-2022
DOI: 10.21203/RS.3.RS-1274022/V1
Abstract: The electrochemical reduction of carbon dioxide (CO2) to value-added materials has received considerable attention. Both bulk transition metal catalysts, and molecular catalysts affixed to conductive non-catalytic solid supports, represents a promising approach towards electroreduction of CO2. Here, we report a combined silver (Ag) and pyridine catalyst through a green and irreversible electrografting process, which demonstrates enhanced CO2 conversion versus the in idual counterparts. We find by tailoring the pyridine carbon chain length, a 200 mV shift in the onset potential is obtainable compared to the bare silver electrode. A 10-fold activity enhancement at -0.7 V vs RHE is then observed with demonstratable higher partial current densities for CO indicating a co-catalytic effect is attainable through the integration of the two different catalytic structures. We extended performance to a flow cell operating at 150 mA/cm2, demonstrating the approach’s potential for substantial adaption with various transition metals as supports, and electrografted molecular co-catalysts.
Publisher: Springer Science and Business Media LLC
Date: 2006
DOI: 10.1186/CC4861
Location: Australia
No related grants have been discovered for Kwok Ho.