Electronic structure of p-type perylene monoimide-based donor-acceptor dyes on the nickel oxide (100) surface: a DFT approach

A p-type dye-sensitized solar cell, where the dye injects a hole into the semiconductor, could be combined with a typical Grätzel cell to create an efficient tandem device. However, the current p-type devices suffer from low efficiency. Here, geometries and electronic structures of four perylenemonoimide-based dyes () both as free and adsorbed on the NiO(100) semiconductor surface have been investigated to gain a better understanding of the p-type devices. In particular, the electronic transitions relevant to charge transfer between the dye and the surface have been identified. Excitations have been evaluated using the time-dependent DFT calculations, and the roles of frontier orbitals and band edges in transitions have been assessed. The adsorbed dyes can adopt either upright or slightly tilted geometries depending on the structure of the anchoring group and the binding mode of the dye. The adsorption slightly lowers the NiO band gap, from 4.06 eV to 3.90-3.96 eV, depending on the surface-adsorbate system and the band gaps of the dye molecules by 0.1-0.2 eV. Additionally, the adsorption mode of dye moves the LUMO+1 level down by 0.5 eV. The effective mass of charge carrier holes is significantly smaller at the NiO surface than in the bulk indicating the importance of surface conductivity. We also found that the potential drop, i.e. the driving force for charge transfer from NiO to the dye molecule, depends on the adsorption mode of .

Deterministic and statistical characterization of rigid frame porous materials from impedance tube measurements

A method to characterize macroscopically homogeneous rigid frame porous media from impedance tube measurements by deterministic and statistical inversion is presented. Equivalent density and bulk modulus of the samples are reconstructed with the scattering matrix formalism, and are then linked to its physical parameters via the Johnson-Champoux-Allard-Lafarge model. The model includes six parameters, namely the porosity, tortuosity, viscous and characteristic lengths, and static flow and thermal permeabilities. The parameters are estimated from the measurements in two ways. The first one is a deterministic procedure that finds the model parameters by minimizing a cost function in the least squares sense. The second approach is based on statistical inversion. It can be used to assess the validity of the least squares estimate, but also presents several advantages since it provides valuable information on the uncertainty and correlation between the parameters. Five porous samples with a range of pore properties are tested, and the pore parameter estimates given by the proposed inversion processes are compared to those given by other characterization methods. Joint parameter distributions are shown to demonstrate the correlations. Results show that the proposed methods find reliable parameter and uncertainty estimates to the six pore parameters quickly with minimal user input.

On describing the optoelectronic characteristics of poly(benzodithiophene-co-quinoxaline)–fullerene complexes: the influence of optimally tuned density functionals

Tuning the range-separation parameter and including the dispersion corrections are important on describing the local optoelectronic properties of polymer–fullerene interfaces.

Modeling of photoactive conjugated donor–acceptor copolymers: the effect of the exact HF exchange in DFT functionals on geometries and gap energies of oligomer and periodic models

Commonly used density functionals including an optimally tuned OT-ωB97X functional are benchmarked on oligomer and periodic models of donor–acceptor copolymers.

A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery

Deep neuromuscular blockade during certain surgical procedures may improve operating conditions. Sugammadex can be used to reverse deep neuromuscular blockade without waiting for spontaneous recovery. This randomised study compared recovery times from neuromuscular blockade induced by rocuronium 0.6 mg.kg(-1), using sugammadex 4 mg.kg(-1) administered at 1-2 post-tetanic count (deep blockade) or neostigmine 50 μg.kg(-1) (plus atropine 10 μg.kg(-1)) administered at the re-appearance of the second twitch of a train-of-four stimulation (moderate blockade), in patients undergoing laparoscopic surgery. The primary efficacy variable was the time from the start of sugammadex/neostigmine administration to recovery of the train-of-four ratio to 0.9. Patients receiving sugammadex recovered 3.4 times faster than patients receiving neostigmine (geometric mean (95% CI) recovery times of 2.4 (2.1-2.7) and 8.4 (7.2-9.8) min, respectively, p<0.0001). Moreover, 94% (62/66) of sugammadex-treated patients recovered within 5 min, vs 20% (13/65) of neostigmine-treated patients, despite the difference in the depth of neuromuscular blockade at the time of administration of both drugs. The ability to provide deep neuromuscular blockade throughout the procedure but still permit reversal at the end of surgery may enable improved surgical access and an enhanced visual field.

Metabolic syndrome, periodontal infection, and dental caries

Only a few studies have examined the association of metabolic syndrome with periodontal infection and dental caries. The aim in this study was to examine the association of metabolic syndrome with periodontal infection and dental caries using the European Group for the Study of Insulin Resistance (EGIR) definition and its separate components. This study population consisted of dentate, non-diabetic individuals aged 30 to 64 years (N = 2050) who had never smoked. Relative risks (RR) were estimated with Poisson regression models. Metabolic syndrome was associated with teeth with deepened periodontal pockets 4 mm deep or deeper [adjusted RR 1.19 (95% CI 1.01-1.42)], with pockets 6 mm deep or deeper [adjusted RR 1.50 (95% CI 0.96-2.36)], and carious teeth [adjusted RR 1.25 (95% CI 0.93-1.70)]. The results suggest that metabolic syndrome or some of its components are associated weakly with periodontal infection.

Scandinavian clinical practice guidelines for therapeutic hypothermia and post-resuscitation care after cardiac arrest

BACKGROUND AND AIM

Sudden cardiac arrest survivors suffer from ischaemic brain injury that may lead to poor neurological outcome and death. The reperfusion injury that occurs is associated with damaging biochemical reactions, which are suppressed by mild therapeutic hypothermia (MTH). In several studies MTH has been proven to be safe, with few complications and improved survival, and is recommended by the International Liaison of Committee on Resuscitation. The aim of this paper is to recommend clinical practice guidelines for MTH treatment after cardiac arrest from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI).

METHODS

Relevant studies were identified after two consensus meetings of the SSAI Task Force on Therapeutic Hypothermia (SSAITFTH) and via literature search of the Cochrane Central Register of Controlled Trials and Medline. Evidence was assessed and consensus opinion was used when high-grade evidence (Grade of Recommendation, GOR) was unavailable. A management strategy was developed as a consensus from the evidence and the protocols in the participating countries.

RESULTS AND CONCLUSION

Although proven beneficial only for patients with initial ventricular fibrillation (GOR A), the SSAITFTH also recommend MTH after restored spontaneous circulation, if active treatment is chosen, in patients with initial pulseless electrical activity and asystole (GOR D). Normal ethical considerations, premorbid status, total anoxia time and general condition should decide whether active treatment is required or not. MTH should be part of a standardized treatment protocol, and initiated as early as possible after indication and treatment have been decided (GOR E). There is insufficient evidence to make definitive recommendations among techniques to induce MTH, and we do not know the optimal target temperature, duration of cooling and rewarming time. New studies are needed to address the question as to how MTH affects, for example, prognostic factors.

Intensive care of the elderly in Finland

BACKGROUND

The ageing of the population will increase the demand for health care resources. The aim of this study was to determine how age affects resource consumption and outcome of intensive care in Finland.

METHODS

Data on 79,361 admissions to 26 Finnish intensive care units (ICUs) during the years 1998-2004 were analysed. The severity of illness was measured using Simplified Acute Physiology II scores and the intensity of care using Therapeutic Intervention Scoring System scores.

RESULTS

The median age was 62 years; 8.9% of patients were aged 80 years or over. The hospital mortality rate was 16.2% in the overall patient population, but 28.4% in patients aged 80 years or over. Old age was an independent risk factor for hospital mortality. The mean intensity of care was at its highest in the age groups 60-69, 70-74 and 75-79 years. It was notably lower for patients aged 80 years or over. If the need for intensive care remains unchanged in each age group, the change in the age distribution of the Finnish population will increase the demand for ICU beds by 19% by the year 2020 and by 25% by the year 2030.

CONCLUSION

The hospital mortality rate increases with increasing age. The mean intensity of care is lower for the oldest patients than for patients aged less than 80 years. The ageing of the population will probably cause a remarkable increase in the need for intensive care in the near future.

Auditory-evoked potentials in bispectral index-guided anaesthesia for cardiac surgery

BACKGROUND AND OBJECTIVE

Midlatency auditory-evoked potentials, as measures of the anaesthetic state, were evaluated at similar levels of bispectral index in cardiac surgical patients maintained with either propofol or isoflurane anaesthesia.

METHODS

Twenty-four patients were randomly allocated to anaesthesia with propofol (n = 12) or isoflurane (n = 12). Bispectral index was maintained below 60 during surgery. Auditory-evoked potentials were collected before induction of anaesthesia, 10 min after intubation, 30 min after sternotomy, during cardiopulmonary bypass at the time of cross-clamping of the aorta and during stable mild hypothermia, after de-clamping of the aorta, and after the operation.

RESULTS

At the pre-determined time points, bispectral index values showed comparable depth of hypnosis in both groups. The latency of the Nb component of midlatency auditory-evoked potentials was significantly increased in the isoflurane group after intubation (P < 0.001) and that of both the Nb and the Pa components after sternotomy (P < 0.001) compared with the propofol group. No differences between the groups were detected with respect to haemodynamic variables. No patient reported recall of intraoperative events.

CONCLUSION

After intubation and surgical stimulation, when bispectral index was at a constant level, there was a difference in the Nb and Pa components of the midlatency auditory-evoked potentials between the two anaesthetic regimens, indicating a distinction in the state of anaesthesia. Our results suggest that the parallel use of these two electrophysiological methods can show differences in the components of anaesthesia between various anaesthesia methods in cardiac surgical patients.

Fatal inhalation injury caused by airway fire during tracheostomy

A 45-year-old man needed emergency tracheostomy and cranioplasty. He was intubated with a cuffed oral polyvinylchloride endotracheal tube and ventilated with 100% oxygen before tracheal incision. During opening of the trachea using diathermy, a popping sound was heard and flames originating from the tracheal incision were observed. The endotracheal tube was charred and its lumen had melted. Immediately after the incident, bronchofibroscopic examination revealed inhalation injury. After remaining for 8 weeks in hospital, the patient was transferred to a health care centre, where he was found dead in his bed.

Outcome from intensive care after cardiac arrest: comparison between two patient samples treated in 1986-87 and 1999-2001 in Finnish ICUs

BACKGROUND

The aim of the study was to find out whether the characteristics of patients and the outcome from intensive care after cardiac arrest have changed over time.

METHODS

Two nationwide databases were compared: (i) The Finnish National Intensive Care Study data in 1986-87 and (ii) data on 28,640 admissions to Finnish ICUs in 1999-2001. Patients whose reason for ICU admission was cardiac arrest were included. The former study included 604 patients treated in 18 medical and surgical ICUs in and the latter 1036 patients in 25 medical and surgical ICUs. Data on the components of Acute Physiology and Chronic Health Evaluation (APACHE II) were prospectively collected in both study periods. Logistic regression analysis was used to test the independent contribution of the study period on hospital mortality.

RESULTS

In 1986-87, patients were younger and the proportion of males was lower than in 1999-2001. The hospital mortality in 1986-87 was 61.3% and in 1999-2001 59.1% (P= 0.396). Among patients aged < 57 years, the hospital mortality in 1986-87 was 62.1% and in 1999-2001 48.8% (P < 0.01). In multivariate analysis, controlling for age, gender, Glasgow coma score (GCS), chronic health evaluation points and source of admission, treatment during 1986-87 was an independent predictor for hospital death among all patients (OR 1.273; 95% CI 1.015-1.594), those aged < 57 years (OR 1.959; 95% CI 1.270-3.021) and among males (OR 1.384; 95% CI 1.050-1.825).

CONCLUSION

Since the late 1980s, the outcome from intensive care after cardiac arrest may have improved especially among younger patients and males.

Excess mortality in winter in Finnish intensive care

BACKGROUND

In the general population, mortality from acute myocardial infarctions, strokes and respiratory causes is increased in winter. The winter climate in Finland is harsh. The aim of this study was to find out whether there are seasonal variations in mortality rates in Finnish intensive care units (ICUs).

METHODS

We analysed data on 31,040 patients treated in 18 Finnish ICUs. We measured severity of illness with acute physiology and chronic health evaluation II (APACHE II) scores and intensity of care with therapeutic intervention scoring system (TISS) scores. We assessed mortality rates in different months and seasons and used logistic regression analysis to test the independent effect of various seasons on hospital mortality. We defined 'winter' as the period from December to February, inclusive.

RESULTS

The crude hospital mortality rate was 17.9% in winter and 16.4% in non-winter, P = 0.003. Even after adjustment for case mix, winter season was an independent risk factor for increased hospital mortality (adjusted odds ratio 1.13, 95% confidence interval 1.04-1.22, P = 0.005). In particular, the risk of respiratory failure was increased in winter. Crude hospital mortality was increased during the main holiday season in July. However, the severity of illness-adjusted risk of death was not higher in July than in other months. An increase in the mean daily TISS score was an independent predictor of increased hospital mortality.

CONCLUSION

Severity of illness-adjusted hospital mortality for Finnish ICU patients is higher in winter than in other seasons.

Allocation of tasks between anesthesiologists and anesthesia nurses in Finland

BACKGROUND

The shortage of anesthesiologists in Finland is worsening. A survey was carried out in 2003 among head anesthesiologists and head nurses to clarify current practice and the potentials for reorganizing tasks between anesthesiologists and anesthesia nurses. A national working group analyzed the results.

METHODS

A questionnaire concerning doctor and nurse resources in anesthesiology, current allocation of tasks, and opinions on how these tasks could be reallocated was sent to 87 head anesthesiologists and 32 head nurses in 45 different hospitals. The answers from the doctors and nurses were compared.

RESULTS

The response rate of doctors and nurses was 87% and 100%, respectively. In the enrolled hospitals there were 64 unoccupied positions for specialists in anesthesiology. The ratio of anesthesiologists to operation rooms (OR) they attended varied between 0.3 and 1.5. Doctors and nurses reported the allocation of tasks quite similarly. The great majority of respondents considered spinal, epidural, and interscalene brachial plexus blocks, and the induction of general anesthesia to be tasks that should be performed by an anesthesiologist. Very few respondents of either profession were willing to reallocate tasks so that nurses could deliver general anesthesia, including endotracheal intubation, even in low-risk patients.

CONCLUSION

Nurses could be trained nationwide to perform procedures already performed by locally trained nurses in some hospitals. To cope with the shortage of anesthesiologists, other strategies must be adopted in addition to transferring part of their work load to nurses.

Supplemental 80% oxygen does not attenuate post-operative nausea and vomiting after breast surgery

BACKGROUND

Although supplemental oxygen has been shown to be as effective as ondansetron in the prevention of post-operative nausea and vomiting (PONV) in one study in abdominal surgery patients, the antiemetic efficacy of supplemental oxygen is controversial on the basis of studies with other patients. We compared the efficacy of 80% and 30% oxygen in decreasing PONV in breast surgery. Ondansetron was used as an active control.

METHODS

Ninety patients were given a standardized sevoflurane anesthetic. They were randomly assigned to three groups: 30% oxygen in nitrogen and saline 2 ml intravenously (i.v.) at the end of surgery (group 30); 80% oxygen in nitrogen and saline 2 ml (group 80); and 30% oxygen in nitrogen and ondansetron 4 mg (group O). Oxygen was administered during surgery and up to 2 h after surgery.

RESULTS

The incidence of total response (no retching or vomiting, no nausea) during the first 24 post-operative hours was not different between group 80 (17%) and group 30 (11%) but was higher in group O (43%) than in group 30 (P<0.05). Compared with group O, patients in group 80 experienced more vomiting during the study period 0-24 h (66% vs. 32%; P<0.05) and more nausea during the period 6-24 h (72% vs. 39%; P<0.05). There was no difference between the groups in their risk for PONV, pain scores, opioid consumption, or patient satisfaction.

CONCLUSIONS

In this study, supplemental 80% oxygen administration failed to decrease PONV in breast surgery.

Impact of gender on treatment and outcome of ICU patients

BACKGROUND

Gender modifies immunologic responses caused by severe trauma or critical illness. The aim of this study was to investigate the impact of gender on hospital mortality, length of intensive care unit (ICU) stay, and intensity of care of patients treated in ICUs.

METHODS

Data on 24,341 ICU patients were collected from a national database. We measured severity of illness with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and intensity of care with Therapeutic Intervention Scoring System (TISS) scores. We used logistic regression analysis to test the independent effect of gender on hospital mortality. We compared the lengths of ICU stay and the intensity of care of men and women.

RESULTS

Male gender was associated with increased hospital mortality among postoperative ICU patients [adjusted odds ratio 1.33 (95% confidence interval 1.12-1.58, P = 0.001)] but not among medical patients [adjusted odds ratio 1.02 (95% confidence interval 0.92-1.13, P = 0.74)]. Male gender was associated with an increased risk of death particularly in the oldest age group (75 years or older) and among the patients with relatively low APACHE II scores (<16). Mean length of ICU stay was 3.2 days for men and 2.6 days for women (P < 0.001). Male patients comprised 61.7% of the study population but consumed 66.0% of days in intensive care.

CONCLUSION

Male gender contributes to poor outcome in postoperative ICU patients. Approximately two-thirds of ICU resources are consumed by male patients.

Supplemental oxygen for prevention of nausea and vomiting after breast surgery

BACKGROUND

Administration of supplemental oxygen 80% has been shown to halve the incidence of postoperative nausea and vomiting (PONV). We tested the efficacy of supplemental oxygen 50% in decreasing the incidence of PONV after breast surgery.

METHODS

One hundred patients receiving standardized sevoflurane anaesthesia were randomly assigned to two groups: oxygen 30% administration (Group 30); and oxygen 50% administration (Group 50). Oxygen was administered during surgery and for 2 h from the end of surgery.

RESULTS

The incidence of PONV over 24 h after surgery showed no difference between the groups: 82% in Group 30 and 89% in Group 50. However, during the postoperative oxygen administration, eight patients vomited in Group 30, compared with none in Group 50 (P<0.05). After oxygen therapy ceased, there was no difference in the incidence of vomiting between the groups. Nausea and need for rescue antiemetics did not differ between the groups.

CONCLUSION

The incidence of vomiting decreased during the short postoperative administration of supplemental oxygen 50%. However, perioperative oxygen 50% administration did not prevent PONV over the 24-h follow-up period in patients undergoing breast surgery performed under general anaesthesia.

Quality assurance in anaesthetic practice: comparison between two methods in detecting complications

BACKGROUND

Reliable identification and documentation of complications is an essential part of a well-functioning quality system (QS) in anaesthetic practice. The criteria for the complications have to be appropriate. The QS of Kuopio University Hospital fulfils the ISO 9002 standard. The validity of the recordings in the QS was ascertained by comparing the routine recordings with external assessment.

METHODS

Three types of complications were predefined: minor, severe and those specific for regional anaesthesia. A total of 1006 anaesthetic charts, including general, regional and intravenous anaesthesia, were randomly selected and retrospectively screened by an external assessor. The retrospective assessment of complications was compared to the recordings in the data management system for operative procedures (DMS) as a part of routine quality assurance. Cohen's kappa statistics was used to indicate agreement between two raters.

RESULTS

Both methods identified complications in 115 procedures (11.4%). The methods, however, did not identify complications in same procedures. There was a fairly close agreement (P < 0.001) between the methods in detecting all (Cohen's kappa 0.72), minor (0.67) and severe (0.66) complications and those specific for regional anaesthesia (0.78). Fifty-eight complications were detected either by retrospective assessment or routine reporting, i.e. the two raters disagreed in 58 complications. Thirteen severe complications recorded in the DMS could not be retrospectively identified. The agreement did not depend on ASA class, the urgency or the length of procedures or on the type of anaesthesia.

CONCLUSIONS

The agreement between external assessment and routine reporting was fairly good, however, there were still some relatively large differences. The selection and definitions of complications need to be reassessed.

Procalcitonin and neopterin as indicators of infection in critically ill patients

BACKGROUND

: In critically ill patients, severe infection and systemic inflammation due to non-infectious causes produce very similar clinical presentations, and traditional infection markers do not always differentiate these two conditions. Both procalcitonin and neopterin have been suggested to aid in the early diagnosis of bacterial infections and in differentiating bacterial infections from systemic inflammatory, non-infectious diseases or from viral infections.

METHODS

: Procalcitonin (PCT) and neopterin were analyzed in 208 ICU patients who developed acute fever or septic shock. Blood samples were taken every 8th h within 48 h of the onset of fever or septic shock.

RESULTS

: A total 162/208 of patients had infection, the most common location being the respiratory tract. Mortality was higher in infected patients (31.4% vs. 10.9%; P < 0.01). The optimum cut-off levels in identifying patients with infection of daily peak PCT were 0.8 microg/L on day 1 and 0.9 microg/L on day 2, and both sensitivity (67.7% and 60.9%, respectively) and specificity (47.8% and 63%) were poor. Accordingly, the optimum cut-off values of peak neopterin were 18 and 16 pg/L. The sensitivity was 62.7% on day 1 and 69.3% on day 2, while specificity was correspondingly 78.3% and 67.9%. There were no significant differences between the markers in discriminating between patients with infection or inflammation. Both PCT and neopterin increased with the severity of infection. They were higher in non-survivors.

CONCLUSION

: PCT and neopterin were equally effective, although not very accurate in differentiating between infection and inflammation in critically ill patients. Neopterin was more specific than PCT, suggesting that neopterin is related to the activity of inflammatory response.

Customized prediction models based on APACHE II and SAPS II scores in patients with prolonged length of stay in the ICU

OBJECTIVE

To study customized APACHE II and SAPS II models in predicting hospital death in patients with a prolonged length of stay in the ICU.

DESIGN

Prospectively collected database.

SETTING

Thirteen ICUs with 5-10 beds in Finnish secondary referral hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The database was collected between 1994 and 1999 and included 23,953 ICU admissions. In order to customize the original APACHE II and SAPS II models and to validate the models, the database was randomly divided into customization data ( n=12,064) and into validation data ( n=11,889). Logistic regression analysis was used for customization. As the length of the ICU stay was prolonged, the calibration and discrimination of both customized models worsened gradually in the validation data. Patients whose ICU stay lasted 7 days or longer (1,312 patients) consumed more than one half of all ICU days and TISS-points. Among these patients, goodness-of-fit statistics was 221.5 and 306.3 ( P<0.0001 for both) and the areas under ROC curve 0.65 and 0.62 for the customized APACHE and SAPS models, respectively. The models underestimated the risk of death in the low range and overestimated it in the high range of predicted mortality. On the other hand, both models discriminated well between survivors and non-survivors if the ICU stay was 2 days or less.

CONCLUSIONS

Despite customization, the predictive models may not support clinical decision-making in those patients who require a high share of resources. More relevant instruments are needed for the prediction of outcome of patient groups who consume the major part of ICU resources.

Evidence for excess long-term mortality after treated subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The purpose of this study was to examine the long-term mortality rate of patients with aneurysmal subarachnoid hemorrhage (SAH) compared with that of the general population.

METHODS

Aneurysmal SAH patients who were treated for ruptured aneurysm from 1977 through 1998 in a tertiary referral center (n=1537) were followed up for a median of 7.5 years. Dates and causes of death were determined. Standardized mortality ratios (observed/expected deaths) according to age, sex, and Glasgow Outcome Scale at 12 months after surgery were calculated.

RESULTS

The mortality rate among patients with good recovery at 12 months was twice that of the general population. The excess mortality appeared to be most evident in younger age groups. Cerebrovascular and cardiovascular diseases were the principal causes of premature death. The result was similar among patients without preexisting cardiovascular diseases at the time of SAH.

CONCLUSIONS

Aneurysmal SAH patients have an excess mortality rate even after successful treatment of ruptured aneurysms. Therefore, aneurysmal SAH should be viewed more as one aspect of a chronic general vascular disease, and more attention should be given to treatment of risk factors and long-term follow-up of these patients.

Efficient transfection of novel bovine papillomavirus 1 expression plasmids

A series of novel bovine papillomavirus type 1 (BPV-1)-based expression plasmids was constructed and characterized in vitro as a starting point for the development of an in vivo gene therapeutic method. The order of transfection efficiency for different pBPVlacZ plasmids was pCGalBPV > pTKBPV > pSRalphaBPV in CV1-P cells. In the absence of selection pressure, the expression of pCGalBPVlacZ and pTKBPVlacZ was associated with long-term maintenance. In a comparison of pBPVlacZ with pSVlacZ, expression was maintained up to 12-17 and 8-12 days, respectively. The transfection of pBPVlacZ plasmids was efficient in secondary and primary, dividing and nondividing, neural and nonneural, and human cells and, furthermore, independent of the cell cycle as seen in growing as well as resting cells. All these characteristics are likely to be relevant for in vivo conditions, under which the percentage of proliferating cells could be quite low. In conclusion, the pBPV plasmids were efficiently delivered and expressed in different host cells, and therefore their performance in gene therapy is worth testing.

Outcome and resource utilization in gastroenterological surgery

BACKGROUND

A small minority of patients undergoing gastroenterological surgery are at high risk for postoperative complications, which may lead to prolonged hospital stay, disproportionate use of resources and increased mortality. The nature and frequency of, and predictive factors for, postoperative complications were studied and the impact of complications on resource utilization was assessed.

METHODS

A prospective observational study was undertaken of 503 patients undergoing gastroenterological surgery in a tertiary care centre. The incidence of cardiorespiratory, infective and surgical complications was assessed. The need for reoperation, intensive care and length of hospital stay, readmission, death at 6 months and costs were evaluated.

RESULTS

Some 235 patients (47 per cent) had at least one complication, most commonly delayed oral intake (n = 70). Complications were associated with cardiovascular disease, prolonged operation, high Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, and increased number of Shoemaker's criteria. The length of hospital stay of patients with complications was longer than that of those without complications (11 versus 6 days). Morbidity resulted in a twofold increase in median costs.

CONCLUSION

High-risk patients could be identified by simple clinical criteria, although the commonly used risk criteria were not very sensitive. A reduction in postoperative complication rates would result in marked cost savings.

Intra-institutional prediction of outcome after cardiac surgery: comparison between a locally derived model and the EuroSCORE

OBJECTIVE

To construct models for predicting mortality, morbidity and length of intensive care unit (ICU) stay after cardiac surgery and to compare the performance of these models with that of the EuroSCORE in two independent validation databases.

METHODS

Clinical data on 4592 cardiac surgery patients operated between 1992 and 1996 were retrospectively collected. In order to derive predictive models and to validate them, the patient population was randomly divided into a derivation database (n=3061) and a validation database (n=1531). Variables that were significant in univariate analyses were entered into a backward stepwise logistic regression model. The outcome was defined as mortality within 30 days after surgery, predefined morbidity, and the length of ICU stay lasting >2 days. In addition to the retrospective database, the models were validated also in a prospectively collected database of cardiac surgical patients operated in 1998-1999 (n=821). The EuroSCORE was tested in two validation databases, i.e. the retrospective and prospective one. Hosmer-Lemeshow goodness-of-fit was used to study the calibration of the predictive models. Area under the receiver operating characteristic (ROC) curve was used to study the discrimination ability of the models.

RESULTS

The overall mortality in the retrospective and the prospective data was 2 and 1%, and morbidity 22 and 18%, respectively. The created predictive models fitted well in the validation databases. Our models and the EuroSCORE were equally good in discriminating patients. Thus, in the prospective validation database, the mean areas under the ROC curve for our models and for the EuroSCORE were similar, i.e. 0.84 and 0.77 for mortality, 0.74 and 0.74 for morbidity, and 0.81 and 0.79 for the length of intensive care unit stay lasting for 2 days or more, respectively.

CONCLUSIONS

Our models and the EuroSCORE were equally good in discriminating the patients in respect to outcome. However, our model provided also well calibrated estimation of the probability of prolonged ICU stay for each patient. As was originally suggested, the EuroSCORE may be an appropriate tool in categorizing cardiac surgical patients into various subgroups in interinstitutional comparisons. Our models may have additive value especially in resource allocation and quality assurance purposes for local use.

Non-suppressed thyrotropin and elevated thyroglobulin are independent predictors of recurrence in differentiated thyroid carcinoma

OBJECTIVE

Although in most cases differentiated thyroid carcinoma (DTC) responds to surgery and radioiodine (RaI) therapy, some patients will have recurrence and eventually cancer-related death. However, although various prognostic factors of DTC have been identified (e.g. staging, suppressed thyrotropin), none of the previous studies have assessed simultaneously their role in multivariate analysis.

DESIGN AND METHODS

In this retrospective population-based study, we reviewed the clinicopathological data of 254 DTC patients treated in eastern Finland during the years 1976-1995, for clinical characteristics, primary treatment, follow-up and cancer recurrence. Tumor stage was based on pathological tumor-node-metastasis (pTNM) classification, and histopathological specimens were re-evaluated.

RESULTS

DTC recurrence occurred in 33 patients (13%). In univariate analyses, the predictors of recurrence were older age (>60 years, P<0.05), follicular tumor type (P<0.01), pTNM classification system (P<0.05) and post-ablative radioiodine uptake outside the neck (P<0.05). Non-suppressed serum thyrotropin (TSH) and elevated serum thyroglobulin (>3 microg/l) measured one year after operation were both related to tumor recurrence (P<0.05 and P<0.001 respectively). In multivariate analysis the independent predictors for recurrence were both elevated thyroglobulin (P<0.001) and non-suppressed TSH (P<0.05) independent of histology, pTNM stage and RaI uptake. Adjusted risk ratio for recurrence of DTC for unsuppressed thyrotropin was 2.3, for elevated thyroglobulin 14.0 and, if both conditions were present, the risk ratio increased to 45.1.

CONCLUSION

Our results suggest that both non-suppressed serum TSH and elevated serum thyroglobulin are related to an increased risk of DTC recurrence independent of tumor type and pTNM stage.

Quality of life after prolonged intensive care

OBJECTIVE

To assess the subjective health status, quality of life, and functional ability of patients whose intensive care stay was prolonged and to compare their quality of life with that of the general population.

DESIGN

Inception cohort study.

SETTING

Twenty-three-bed multidisciplinary intensive care unit (ICU) in a tertiary care center.

PATIENTS

A consecutive sample of 718 patients aged > or = 18 yrs who required intensive care > or = 4 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The Nottingham Health Profile was used to compare the ICU patients with a random sample (n = 2,595) of the general population. The quality of life and functional ability of 368 respondents (78.3% of 470 survivors) were assessed at 6 months after ICU admission. The length of the ICU stay was 13.6+/-11.8 (median, 9; maximum, 81) days. The quality of life and its various dimensions were influenced by the diagnosis for ICU admission and age. Although problems in physical mobility and energy were prevalent among all patient groups, only a small proportion was dependent on others for the management of daily activities. Patients with trauma or respiratory failure experienced the most limitations. The quality of life of elderly patients and patients who had undergone cardiac surgery was comparable with the general population regarding emotional reactions, social isolation, and pain.

CONCLUSIONS

The quality of life of survivors after a prolonged intensive care stay is fairly good, although not comparable with that of the general population. The psychosocial aspects of the quality of life are restored more rapidly than physical performance.

Familial subarachnoid hemorrhage. Outcome study

BACKGROUND AND PURPOSE

The aim of our study was to compare outcome and its determinants in familial subarachnoid hemorrhage and in sporadic subarachnoid hemorrhage in a large and well-documented patient population.

METHODS

Patients with aneurysmal subarachnoid hemorrhage (SAH) treated at the Department of Neurosurgery, Kuopio University Hospital, from 1977 to 1995 were included. Patients with polycystic kidney disease were excluded. The Glasgow Outcome Scale (GOS) score at 12 months was studied.

RESULTS

There were 120 patients (97 first-, 15 second-, and 8 third-degree family connections) in 96 different families with familial SAH and 1237 patients with sporadic SAH. Age, gender, and admission grade on the Hunt and Hess scale did not differ between these 2 groups. In both groups >80% of patients were in relatively good condition at admission. The outcome was good (GOS score of 1 to 2) in 87 patients (73%) with familial SAH and in 874 patients (71%) with sporadic SAH. Analysis of 20 variables, including presence of coexisting diseases, aneurysm site and size, amount of blood shown on CT scan, intraventricular bleeding, preoperative intracerebral hematoma and hydrocephalus, as well as postoperative bleeding and vasospasm, revealed no significant differences between study groups. The degree of family connection (first-, second-, and third-degree) did not have any statistically important effect on outcome in the familial group in the Finnish study population. In multivariate analysis the knowledge of familial SAH was not an independent prognostic factor.

CONCLUSIONS

Admission status, postoperative course, and outcome were similar in the familial and sporadic SAH groups in this Finnish population, in contrast to previous results. Familial SAH may not be a significant risk factor for poor outcome.

Associations between age, parity, hormonal therapy and breed, and pyometra in Finnish dogs

A case-control study of 953 dogs with pyometra and 10,660 unmatched control dogs was used to investigate the relationships between age, parity, hormonal therapy and breed, and pyometra in Finnish dogs. Cases were reported in animals between nine months and 18 years of age, with a median age at diagnosis of nine years. Nulliparous bitches had a moderately higher risk of developing pyometra than primiparous and multiparous animals (adjusted odds ratio point estimate, 6.63). The administration of oestrogen increased the risk of pyometra in bitches up to four years of age (odds ratio point estimate > 6). No significant risk-enhancing effect of progestin treatment was detected and it is unlikely that such a risk, if present, is high (likelihood of the odds ratio exceeding 2 < 0.18). Seventeen breeds had an increased risk, and the wire-haired dachshund and mongrels had a decreased risk of developing the condition.

Quality of life after intensive care

The outcome of intensive care is related to patient selection and case-mix. Especially when assessing QOL, the results should be interpreted in the context of age and the cause of intensive care admission. Only a few QOL studies so far have databases which are large enough to characterize the outcome in specific patient groups. The influence of preexisting chronic diseases should be taken into account as well. A far more difficult issue is how to screen for differences in socioeconomic background. Problems in physical functioning seem to be common among ICU patients in general, but among younger patients the psychosocial problems are also dominant. While the QOL after intensive care as compared with reference values may be better perceived among older patients, the previously healthy and younger ones tend to experience more limitations. The reason for intensive care presumably has impact on the pattern of convalescence. A better understanding of the natural history of recovery from critical illness may help to identify those patients who need more intensive rehabilitation.

Bovine mastitis in Finland in 1988 and 1995--changes in prevalence and antimicrobial resistance

Two surveys were carried out (during 1988 and 1995) to estimate the prevalence of bovine mastitis in Finland. In 1988, 17,111 quarter milk samples were obtained from 4495 cows, and in 1995 the corresponding figures were 10,410 and 2648. Antimicrobial susceptibility of mastitis pathogens was studied. Prevalence of mastitis on cow basis decreased from 47.8% in 1988 to 37.8% in 1995. Staphylococci was the largest group of pathogens isolated. The proportion of Staphylococcus aureus decreased and that of coagulase-negative staphylococci (CNS) increased. The proportion of strains resistant to at least one antibacterial drug increased with regard to S. aureus from 36.9% in 1988, to 63.6% in 1995 and with CNS from 26.6% to 49.7%. Most of the increase in antibacterial resistance was due to a higher number of beta-lactamase producing strains. Multiresistance also increased, but it was proportional to the overall increase in resistance. All the predominant mastitis streptococci were susceptible to beta-lactams tested.

Water as a reservoir for Campylobacter jejuni infection in cows studied by serotyping and pulsed-field gel electrophoresis (PFGE)

The occurrence of campylobacters was studied in the faecal samples of a dairy herd with about 20 animals and in the lake which was their source of drinking water during the grazing period from June to September. Of the total of 141 faecal samples studied, 0-21% were found to be positive for C. jejuni at various sampling times throughout the year. More cows were found to be campylobacter-positive in summer or in autumn after the grazing period than after the winter, when the animals were inside and their drinking water source was municipal chlorinated tap water. C. jejuni was isolated from most of the lake water samples. Serotyping with heat stable antigens and molecular typing with PFGE using SacII- and SmaI-digested DNA revealed that an animal that was permanently infected with C. jejuni sero-/PFGE-type PEN 0:6, 25/I/ND most probably contaminated the lake water in summer 1987. This was the only sero/PFGE-type isolated from the lake water in summer and autumn 1987 and in spring 1988. This sero/PFGE-type was also isolated from four other cows in autumn 1987, suggesting that lake water was the source of the infection. This study is first to employ molecular methods to assess the possible role of contaminated drinking water in the transmission of campylobacter infection within a dairy herd.

Bovine mastitis in Finland in 1988 and 1995--changes in prevalence and antimicrobial resistance

Two surveys were carried out (during 1988 and 1995) to estimate the prevalence of bovine mastitis in Finland. In 1988, 17,111 quarter milk samples were obtained from 4495 cows, and in 1995 the corresponding figures were 10,410 and 2648. Antimicrobial susceptibility of mastitis pathogens was studied. Prevalence of mastitis on cow basis decreased from 47.8% in 1988 to 37.8% in 1995. Staphylococci was the largest group of pathogens isolated. The proportion of Staphylococcus aureus decreased and that of coagulase-negative staphylococci (CNS) increased. The proportion of strains resistant to at least one antibacterial drug increased with regard to S. aureus from 36.9% in 1988, to 63.6% in 1995 and with CNS from 26.6% to 49.7%. Most of the increase in antibacterial resistance was due to a higher number of beta-lactamase producing strains. Multiresistance also increased, but it was proportional to the overall increase in resistance. All the predominant mastitis streptococci were susceptible to beta-lactams tested.

Factors predictive of referral to psychiatric hospital among general hospital psychiatric consultations

The aim of this paper was to explore the factors necessitating psychiatric hospital care in a Finnish multi-centre study of general hospital in-patients referred for psychiatric consultation. The study group consisted of 1251 patients referred to psychiatric hospital (n = 181) and a comparison group (n = 1070) consisting of subjects who were not referred. Differences between groups were studied by univariate analysis. Logistic regression analysis was used both to assess the factors contributing to referral to psychiatric hospital and to create predictive models. The validity of the models was analysed by means of receiver operating characteristic (ROC) curves in an independent sample. Psychiatric hospital care during the previous 5 years was associated with a 3.7-fold (odds ratio) increased risk of hospitalization. A diagnosis of psychosis was associated with a 2.9-fold increased risk, and attempted suicide as a reason for consultation was associated with a 2.1-fold increased risk. Not being married doubled the risk, and the odds ratio was also high in cases of poor psychosocial functioning (as assessed by Global Assessment of Functioning (GAF) score). The predictive model differentiated reasonably well between those patients who were hospitalized and the other patients. In conclusion, this multi-centre study of factors predictive of referral to psychiatric hospital among general hospital patients revealed that the most important determinants were previous psychiatric care, diagnosis of psychosis or severe depression, attempted suicide, being unmarried, and poor psychosocial functioning as assessed by GAF score.

Five-year survival after intensive care--comparison of 12,180 patients with the general population. Finnish ICU Study Group

OBJECTIVES

A) To examine the long-term survival of critically ill patients compared with the general population in a nationwide sample of patients requiring intensive care; and b) to analyze long-term survival stratified by specific diagnostic subgroups.

DESIGN

Prospective, inception cohort study.

SETTING

Twenty-five Finnish Intensive care units (ICUs) at 17 hospitals, including 13 ICUs in five tertiary care centers.

PATIENTS

A consecutive sample of 12,180 adult patients who were admitted to ICUs in 1987. The sample was further divided into seven diagnostic subgroups.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Vital status at 5 yrs after admission to an ICU was examined and compared to the age- and gender-adjusted survival of Finland's general population. Among ICU patients, the 5-yr mortality rate was 3.3 times that of Finland's general population (95% confidence interval 3.0 to 3.4). At 2 yrs, the survival rate paralleled that of the general population. At 5 yrs, the relative survival rate of the ICU patients was 66.7%. Cancer was a strong determinant of a poor outcome in multivariate analysis (relative risk 3.17; 95% confidence interval 2.86 to 3.51). The 5-yr mortality rate of the ICU patients compared with the general population was highest among patients admitted to the ICU after intoxication. Trauma victims and patients admitted to the ICU with a cardiovascular diagnosis reached the risk of death of the general population in the shortest time.

CONCLUSIONS

ICU patients reached a life expectancy similar to the general population, on average, 2 yrs after admission. The time after which the survival parallels that of the general population depends, however, on the diagnostic category.

Analysis of 561 patients with 690 middle cerebral artery aneurysms: anatomic and clinical features as correlated to management outcome

In a series of 1314 consecutive patients with cerebral aneurysms from a defined catchment area in eastern Finland (870,000 inhabitants), 561 patients (43%) had middle cerebral artery aneurysms (MCAAs). One or more associated aneurysms were common; 221 patients with MCAAs (39%) had multiple intracranial aneurysms (MIA). In other words, three-fourths (73%) of all patients with MIA had at least one MCAA. Multiple MCAAs, found in 111 patients (20%), were common in this Finnish population. One hundred of these patients had bilateral MCAAs, of whom 63 had mirror aneurysms, that is, aneurysms at the same site but on different sides. Thirty-five patients had "pure" mirror aneurysms, that is, they did not have any other aneurysms. Most MCAAs (81%) were located at the bifurcation. Three-fourths (72%) of the proximal MCAAs were associated with MIA. Giant aneurysms were significantly more common as single MCAAs than as any other single aneurysm. The frequency of intracerebral hematomas (42%) was by far higher in patients with MCAAs than in patients with ruptured aneurysms at other sites. Most of the intracerebral hematomas occurred in patients with bifurcation MCAAs that pointed laterally. Patients with MCAAs had surprisingly bad management outcomes despite good surgical results in patients with good Hunt and Hess grades. There were significantly more poor outcomes (Glasgow Outcome Scale score, 3-5) among patients with ruptured MCAAs than among those with any other anterior circulation aneurysms (32 and 25%, respectively). Also, the multiplicity of aneurysms increased the risk for poor outcome, which occurred in 39% of the patients who had MIA with one MCAA and 37% of those who had multiple MCAAs. Epilepsy, severe hemiparesis, and visual field deficits were the most common disabilities in long-term survivors, associated far more frequently with MCAAs than with aneurysm at other sites.

Management outcome for multiple intracranial aneurysms

The management outcome of 302 patients with multiple intracranial aneurysms (MIA) from a series of 1314 patients with cerebral aneurysms was assessed using the Glasgow Outcome Scale 1 year after diagnosis and/or treatment. The outcome was significantly poorer for patients with MIA than for those with single intracranial aneurysms (SIA). The difference in the frequencies of poor outcome (Glasgow Outcome Scale Grades 3-5) was most evident in patients with Hunt and Hess Grades 2 or 3 (MIA, 29%; SIA, 19%). The management mortality in all grades attributable to all causes was 24% in patients with MIA and 20% in those with SIA and 16 and 11%, respectively, after surgery. At the 1-year follow-up point, 66% of the patients with MIA were independent (SIA, 72%); after surgery, 74% (SIA, 81%); after subarachnoid hemorrhage, 65% (SIA, 71%); and after subarachnoid hemorrhage and surgery, 73% (SIA, 80%). Patients with aneurysms at the vertebrobasilar arteries fared badly; otherwise, the sites of the aneurysms and their different combinations had no effect on outcome, nor did the timing of surgery. In this study, again, only two-thirds of the detected aneurysms could be secured. The aneurysms left without treatment were mostly in patients with very poor grade (n, 55) and/or old (n, 23) patients or were intracavernous (n, 26). The results seemed to be more unsatisfactory as the number of aneurysms increased. In multivariate analysis, delayed neurological deficit had the most significant independent contribution to outcome in patients with MIA, far more than in patients with SIA. This can be explained by the increased manipulation of cerebral arteries during multiple aneurysm surgery.

Prediction of outcome from intensive care after gastroenterologic emergency

Prognostic factors determining the outcome from intensive care were studied in 952 patients admitted to 25 Finnish ICUs after gastroenterologic emergency. Logistic regression analysis was used to create predictive models based on the APACHE II-system. The models were constructed by using data from a random two-thirds of the study population and validated in the remaining independent one-third together with the original APACHE II-index. The Acute Physiology Score, age, and a pre-existing liver disease were the three most important determinants of outcome. The inclusion of the TISS score describing the intensity of treatment into a model did not enhance the accuracy of the prediction. Our models were better calibrated than the original APACHE II-equation when tested by the goodness-of-fit -statistics. These statistical models may help the clinicians to predict the outcome for an individual patient by providing them information about the relative impacts of predictive factors or about the probability of death. These probabilities should be interpreted cautiously, taking into account the limitations of statistical methods. This is especially important when assessing the highrisk patients. Their number in our study was too low for accurate outcome prediction.

Shunt-dependent hydrocephalus after subarachnoid haemorrhage and aneurysm surgery: timing of surgery is not a risk factor

Early hydrocephalus is a risk factor of shunt-dependent late hydrocephalus (SDHC). In the CT era 1980-1990 we had 835 consecutive patients operated on because of aneurysm and subarachnoid haemorrhage (SAH); 294 had an early hydrocephalus and 67 finally required a shunt. There were 14 patients with normal early CT and SDHC, in all 81 patients needed a shunt (10%). Patients with shunt did worse, they were older (53 vs 49) than the non-shunted group and there was a female preponderance. Pre-operative Grade correlated significantly with the need for a shunt operation; no one in Grade I developed SDHC, incidence in Grades III and IV was high (18% and 10%, respectively). Location was important; in vertebrobasilar area 28% and in anterior communicating area 14% but in middle cerebral area only 4% of the patients had SDHC. The amount of cisternal bleeding correlated significantly with SDHC; in 155 patients with non detectable or minimal cisternal blood only one developed SDHC, with severe cisternal bleeding the incidence was 16%. Ventricular bleeding increased the risk of SDHC, but intracerebral haematoma did not. Timing of surgery had no correlation with the risk of SDHC. Postoperative complications, haematomas and infections increased the risk of late SDHC. Delayed ischaemia correlated with the risk, but so did the treatment with nimodipine. Severe bleeding was the common predictor for the risk of SDHC. Location of the bleeding and postoperative problems are the other major causes. Outcome is, however, not so gloomy; 54% of patients with SDHC are independent one year later.

One-year outcome in early aneurysm surgery: a 14 years experience

In a consecutive series of 1150 patients with cerebral aneurysms diagnosed in our department by angiography or autopsy between the years 1977-1990, 1007 patients underwent definitive operative treatment of their aneurysms mainly by early surgery. More than half (55%) were operated on during the first three days after subarachnoid haemorrhage (SAH), and more than three quarters (77%) during the first week. The surgical mortality at 30 days was 9%; at one-year follow-up 13% had died. The total management mortality was 22%. The 618 patients presenting in Hunt and Hess Grades I-II had a 4% mortality, and 90% had an independent life at follow-up; 270 Grade III patients had a 19% mortality and 68% were independent. There were 99 patients operated on in Grades IV-V with a 46% mortality and 30% were independent. Age of the patient and size of the aneurysm were strongly related to outcome; however, many of the giant aneurysms were operated on as an emergency because of large intracerebral haematomas. Best results were obtained in the anterior communicating artery (ACA) area; the lowest rate of useful recoveries was in the vertebro-basilar artery (VBA) area (71%). Early surgery did not prevent delayed ischaemic deficits. During the first 72 hours patients in Grades I-III can be operated on safely with good results. The results in Grades IV-V are poor, and we suggest that only cases with large haematomas or considerable hydrocephalus or those improving should be operated on in the first days after SAH, with limited hopes of functional recovery.

Saccular aneurysms of the distal anterior cerebral artery and its branches

We report a series of 84 consecutive patients (41 women) with 92 distal anterior cerebral artery aneurysms (DACAA). All aneurysms were saccular. Four different locations of DACAAs were found: proximal, 5 aneurysms; frontobasal, 8; genu corporis callosi, 72; and distal, 7. Sixty-five patients presented with subarachnoid hemorrhage (SAH), the rest were incidental findings in patients with multiple aneurysms. Forty-five patients had single DACAAs. Multiple aneurysms (a total of 117) were found in 39 patients (46.4%), and DACAAs were responsible for SAH in 20 patients. Of the 65 patients with SAH, 54 underwent mainly early direct surgery, and 46 (85%) of these had good outcomes 1 year after surgery. Three patients remained severely disabled, and five patients (9%) died. All of the poor surgical results were obtained in patients with severe preoperative deficits. Exact measurements of DACAA sizes and necks were smaller than those of cerebral aneurysms in other locations. Aside from localization, microsurgery of these aneurysms presented no special difficulties, as compared with surgery of aneurysms in other locations.

Management outcome for vertebrobasilar artery aneurysms by early surgery

Treatment of vertebrobasilar artery aneurysms remains fraught with complications, even in the present era of microneurosurgery. In a series of 1150 consecutive patients with cerebral aneurysms from a defined catchment area with 870,000 inhabitants, 93 with vertebrobasilar artery aneurysms were treated by two surgeons during a 14-year period. Sixty-three patients had surgery, 36 during the first week after bleeding. There was no surgical mortality among 33 good grade patients. Nine (14%) of the 63 surgical cases had died at 1 year. Forty-nine (53%) of the total group of 93 patients were functioning independently at 1 year. Overall management mortality was 37%. All 11 patients admitted in Grade V died. In spite of improvements in surgical techniques, we are far from achieving ideal results. Early diagnosis and surgery before rupture are urgently needed. Arteriosclerotic giant aneurysms remain untreatable.

Acute physiology and chronic health evaluation (APACHE II) and Glasgow coma scores as predictors of outcome from intensive care after cardiac arrest

OBJECTIVES

a) To examine the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Glasgow Coma Scores as predictors of the outcome of patients following resuscitation from cardiac arrest; b) to study the impact of the components of APACHE II on the prediction.

DESIGN

A nationwide study in Finland with prospectively collected data on all patients admitted to intensive care after cardiac arrest during a 14-month period. Two thirds of the cardiac arrest patients included in the study were randomly selected to derive predictive models, and the remaining one third constituted the validation sample.

SETTING

A total of 25 medical and surgical ICUs in Finland (13 in tertiary referral centers).

PATIENTS

Six-hundred nineteen consecutive cardiac arrest patients. Fifteen patients less than 16 yrs were excluded.

MAIN OUTCOME MEASURES

Variables included in the APACHE II or Glasgow Coma Scores were collected at the time of ICU admission and then three times after admission, at 24-hr intervals. ICU- and hospital-mortality rates and a 6-month mortality rate after ICU admission were studied.

RESULTS

Of 604 study patients, 370 (61.3%) patients died in the hospital. The most accurate prediction of hospital outcome was based on data collected after the first day of ICU care, not on the admission values. Twenty-one (21.9%) of 96 patients with a low APACHE II score (less than or equal to 9) died compared with 66 (84.6%) of 78 patients with a high APACHE II score (greater than or equal to 25) (p less than .001). Of 160 patients with a normal Glasgow Coma Score (14 to 15), 45 (28.1%) died, whereas there were 114 (81.4%) nonsurvivors among 140 patients with a low Glasgow Coma Score of 3 (p less than .001). The performance of predictive models, including age, the Chronic Health Evaluation, and either the Acute Physiology Score (Acute Physiology Score model) or the Glasgow Coma Score (Glasgow Coma Score model) were compared with the prediction according to the APACHE II in the validation sample. When using 80% probability of death as a decision rule, the Acute Physiology Score model determined 35 of 153 patients to have high risk of death, 29 of whom died (the positive predictive value being 82.9%). The Glasgow Coma Score model predicted 34 patients to die, 26 of whom died (positive predictive value 76.5%), and the APACHE II score predicted seven deaths, five of whom actually died (positive predictive value 71.4%).

CONCLUSIONS

The APACHE II scoring system cannot be recommended as a prognostic tool to support clinical judgement in cardiac arrest patients, but by modifying it, a more accurate prediction of poor outcome could be achieved. The Glasgow Coma Score explained to a great extent the predictive power of the APACHE II.

Polysorbate 20 as a drug release regulator in ethyl cellulose film coatings

Tablet coatings of hydrophobic ethyl cellulose have been made more hydrophilic by the addition of a non-ionic surfactant, polysorbate (Tween) 20, to the film. As its content increased, so did the release of sodium salicylate from the coated tablets. With a certain content of surfactant and specific thickness of the tablet coat, zero order release kinetics were observed. Leaching of the polysorbate 20 occurred from all formulations. Scanning and transmission electron micrographs showed that the structure of the coats consisted of several layers parallel to the tablet surface. Polysorbate 20 was seen as small drops in some coats.