C-reactive protein as a predictor of outcome after discharge from the intensive care: a prospective observational study

BACKGROUND

Recent studies have found plasma C-reactive protein (CRP) to be a predictor of outcome after discharge from the intensive care unit (ICU). To assess the generalizability of this finding, we assessed the value of CRP on the day of ICU discharge as a predictor of unplanned ICU readmission and unexpected death within 2 weeks. Plasma albumin and white cell count at discharge were also considered as markers associated with ongoing inflammation.

METHODS

This was a single-centre observational study involving a medical-surgical ICU in a university teaching hospital. Data were prospectively collected from 1487 admissions involving 1401 patients over a 12 month period. Patients' admission details and APACHE II score were collected in addition to plasma CRP, white cell count, and albumin values from the day of discharge from ICU. We assessed the difference in these variables between patients who were readmitted, who died unexpectedly, and those who did not.

RESULTS

We found that 9.9% of patients discharged were either readmitted (7.0%) or died unexpectedly (2.9%). Patients who were readmitted had a lower plasma albumin concentration [20 (16, 24) vs 22 (19, 27), P<0.001] and a higher admission APACHE II score [median (inter-quartile range, IQR) 16.5 (13, 21) vs 15 (12, 18), P=0.02]. Patients who died unexpectedly on the ward were older [mean (sd): 76 (12) vs 59 (19), P<0.001] and had a higher APACHE II score [21 (17.25, 26) vs 15 (12, 18), P<0.001]. There was not a statistically significant difference in CRP concentration between patients who either required ICU readmissions or died unexpectedly on the ward and those who did not.

CONCLUSIONS

In a mixed medical-surgical intensive care, plasma CRP measured at the day of discharge from intensive care is not a predictor of readmissions or deaths.

Urinary tract pathogens and resistance pattern

BACKGROUND

Epidemiology and resistance patterns of bacterial pathogens in paediatric urinary tract infections (UTIs) show large inter-regional variability, and rates of bacterial resistance are changing due to different antibiotic treatment. Empiric therapy to treat UTI should be tailored to the surveillance data on the epidemiology and resistance patterns of common uropathogens to reduce treatment failures and emergence of bacterial resistance within the community.

OBJECTIVE

A retrospective data review was carried out to evaluate the resistance patterns to commonly used antibiotics in children with culture proven UTIs.

METHODS

All infants and children with culture proven UTI from 2002 to 2008 were included. Urine culture was deemed positive with a pure growth >10(5) (single organism).

RESULTS

A total of 547 UTIs were confirmed on urine cultures in 337 patients. An average of 78 cases were diagnosed each year. E coli was the most commonly grown pathogen (92%). From 2002 to 2008, rising resistance patterns were noted for trimethoprim (p<or=0.05) and Augmentin (p<or=0.001). In contrast, resistance to cefalexin and nitrofurantoin remained relatively low (11% and 7%, respectively, in 2008).

CONCLUSION

Our data suggest that there has been an increasing resistance trend to the first-line antibiotics like trimethoprim and Augmentin against E coli. In accordance with NICE (National Institute for Health and Clinical Excellence) guidance, each region should monitor resistance patterns to urinary pathogens on a regular basis and use antibiotics with a low resistance pattern. Further studies are required from other centres in the UK to look at similar data.

Interobserver reliability and intraobserver reproducibility of the Fernandez classification for distal radius fractures

We have evaluated the clinical application of the Fernandez classification without questioning the scientific validity, by assessing the interobserver reliability and intraobserver reproducibility. A set of 25 radiographs of distal radius fractures were given to six assessors along with details of Fernandez classification. The assessors classified the fractures on two different occasions 3 months apart. The outcome was assessed using kappa statistics and demonstrated poor interobserver reliability and intraobserver reproducibility. Caution should be exercised when using this classification for clinical practice and research.

Medians for second-trimester maternal serum markers: geographical differences and variation caused by median multiples-of-median equations

OBJECTIVES

To establish gestational age-specific mid-trimester normal medians for the prenatal serum markers alpha fetoprotein (AFP), human chorionic gonadotropin (HCG) and unconjugated oestriol (uE3) for a Belgian population by using the Beckman Coulter Access chemiluminiscent immunoassays; to compare these data with data obtained from other geographical regions; to propose regression coefficients for regressed medians and analyse variation induced by different regression equations; to evaluate the effect of formulas used for gestation correction on estimating risk in Down's syndrome.

DESIGN

Data derived from 862 fresh serum samples from women being screened for Down's syndrome pregnancy, composed of selected pregnancies deemed to be normal, were examined in a retrospective study. Regressed medians were calculated by using a first-degree logarithmic-linear fit of the raw data. Multiples-of-median (MoM) values estimated by using a simple logarithmic-linear equation were compared with those calculated with higher-degree polynomials chosen with a goodness-of-fit analysis. Model-specific variation was estimated and the effect on risk for Down's syndrome was evaluated.

RESULTS

Regressed medians (Y) for Access serum markers AFP (IU/ml), HCG (IU/ml) and uE3 (nmol/l) for a Belgian population can be estimated with the equation Y = 10((A+BX)) with X = decimal weeks. The best fit was obtained with a third-degree and a second-degree polynomial for AFP and uE3, respectively. Differences between the medians and among the slopes of the geographical populations were found to be significant (analysis of covariance, p<0.001).

CONCLUSIONS

Belgian marker medians versus gestational time are found to show a pattern that is similar to that in the literature. The log-linear equation is observed to give a good fit and can be suggested as a tool for calculating median MoM values for Belgian laboratories that use Access biochemical prenatal markers.

Sclerochoroidal calcification associated with Gitelman syndrome and calcium pyrophosphate dihydrate deposition

Sclerochoroidal calcification is an uncommon condition. Metabolic evaluation and clinical examination are important to exclude associated systemic conditions such as the Bartter and Gitelman syndromes. It has been suggested that the lesions seen in sclerochoroidal calcification are calcium pyrophosphate dihydrate crystals. This report describes the first documented case in the UK of sclerochoroidal calcification associated with Gitelman syndrome and calcium pyrophosphate dihydrate deposition.

A randomised controlled trial comparing Drawtex with standard dressings for exuding wounds

OBJECTIVE

This randomised controlled clinical trial compared a capillary dressing (Drawtex, now rebranded as Vibriant RCD [Vibriant Technology Services]) with routine practice for exuding wounds greater than 2.5 x 2.5 cm.

METHOD

The target population was 300 control and 300 test subjects across three sites in the UK, but recruitment difficulties resulted in only 125 patients being evaluable. Wound progress was recorded by nurses' perception of the progress of wound healing and by objective digital imaging. In the final analysis digital images were randomised (in time order) and a panel of nurses who were not otherwise involved in the research project graded the wound's progress.

RESULTS

After deconvolution of the data, the subjective (nurse perception) method of evaluation determined that the new dressing resulted in wound improvement in 12.7% more patients than did routine practice, but the blinded assessment method (based on the digital images) showed that routine practice was better by 6.6%.

CONCLUSION

Evaluation of wound progress is clearly difficult. Human nature makes us favour novelty if we believe it is going to be better. Making interpretation more objective removed that bias and did not demonstrate a significant advantage for the test dressing. The findings suggest that unblinded assessment by trial nurses is unacceptable on its own. Blinded assessments may miss finer nuances of wound progression, but are likely to be more accurate. The authors suggest that the true result lies somewhere in the middle, with the trial dressing likely to be as effective as, but not more effective than, a standard dressing.

Scale-down of continuous filtration for rapid bioprocess design: Recovery and dewatering of protein precipitate suspensions

The early specification of bioprocesses often has to be achieved with small (tens of millilitres) quantities of process material. If extensive process discovery is to be avoided at pilot or industrial scale, it is necessary that scale-down methods be created that not only examine the conditions of process stages but also allows production of realistic output streams (i.e., streams truly representative of the large scale). These output streams can then be used in the development of subsequent purification operations. The traditional approach to predicting filtration operations is via a bench-scale pressure filter using constant pressure tests to examine the effect of pressure on the filtrate flux rate and filter cake dewatering. Interpretation of the results into cake resistance at unit applied pressure (alpha) and compressibility (n) is used to predict the pressure profile required to maintain the filtrate flux rate at a constant predetermined value. This article reports on the operation of a continuous mode laboratory filter in such a way as to prepare filter cakes and filtrate similar to what may be achieved at the industrial scale. Analysis of the filtration rate profile indicated the filter cake to have changing properties (compressibility) with time. Using the insight gained from the new scale-down methodology gave predictions of the flux profile in a pilot-scale candle filter superior to those obtained from the traditional batch filter used for laboratory development.

A comparison of healing rates on two pressure-relieving systems

The authors have previously reported the preliminary results of a randomized-controlled trial comparing the relative efficacy of two pressure-relieving systems: Huntleigh Nimbus 3 and Aura Cushion, and Pegasus Cairwave Therapy System and ProActive Seating Cushion (Russell et al, 2000). Although both the mattresses and cushions were effective treatments for pressure ulcers, the Huntleigh equipment was demonstrated to be statistically more effective for heel ulcers, but no differences were demonstrated for sacral ulcers. This article gives a more detailed analysis of the 141 patients assessed using computerized-image analysis of the digital images of sacral ulcers captured during the trial and specifically discusses the healing rates and other patient characteristics. Ninety-eight per cent of ulcers examined were deemed superficial (Torrance grade 2a, 2b, 3). Precision of image analysis assessed by within- and between-batch coefficients of variation was excellent: calibration CV 0.93-1.84%; area CV 4.61-5.72%. The healing rates on the two mattresses were not shown to be statistically different from each other.

MRI in a case of muslin-induced granuloma

When intracranial aneurysms are deemed nonclippable, an accepted alternative neurosurgical treatment is to reinforce the aneurysm wall by wrapping or coating it with various materials, including muslin (cotton gauze). Granulomatous or "foreign-body" reactions, sometimes referred to as "muslinomas" or "gauzomas," and adhesive arachnoiditis are known but rare complications. Experience with MRI in these cases is limited. We describe the clinical and MRI features of a muslinoma developing after treatment of an anterior communicating artery aneurysm.

Unusual duplication anomaly of the inferior vena cava with normal drainage of the right IVC and hemiazygous continuation of the left IVC

Duplication of the inferior vena cava (IVC) and other IVC anomalies have been well described in the literature. Although they are often discovered incidentally in patients without symptoms, these anomalies can have significant clinical implications and must be recognized when they occur. In most cases of a duplicated IVC, the right and left iliac veins drain into the right and left IVC, respectively, and the left IVC ends at the level of the left renal vein, subsequently draining into the right IVC. The authors describe a unique case of duplicated IVC with hemiazygous continuation of the left-sided IVC and normal drainage of the right-sided IVC into the right atrium.