Acute Health Research Articles

Review of Aluminium Phosphide Poisoning

Agricultural revolution and increasing pesticidal use have brought its share of downsides in the form of pesticidal poisoning. Every year approximately 300,000 deaths happen worldwide due to pesticide poisoning. Organophosphates, chlorates, and aluminum phosphide are the commonly used pesticides. Alkaline phosphatase (ALP) is the most lethal among the available pesticides and no antidote is available and aptly called as suicide poison. The common use and easy availability of ALP is causing acute and chronic health effects which have reached major proportions in Asian and Middle Eastern countries such as India, Bangladesh, Iran, Jordan, and Sri Lanka. Toxicity of ALP is related to prompt release of lethal phosphine gas as ALP tablet absorbs moisture. Phosphine gas mainly affects cardiovascular system gastrointestinal tracts, lungs, and kidneys. The clinical features of poisoning include nausea, vomiting, abdominal pain, pulmonary edema, cyanosis shock arrhythmias, and alter sensorium. Diagnosis of ALP poisoning largely depends on history and clinical setting and treatment is usually initiated without waiting for silver nitrate paper test or gastric aspirate analysis. Treatment includes early gastric lavage symptomatic supportive therapy and palliative care. There has been greater understanding about the mechanism and pathophysiology of ALP toxicity over the years, although that cannot be commented about the treatment modalities. Government efforts to restrict sale have been offset by the lack of strict enforcement by regulatory agencies. Case fatality rates from ALP poisoning have shown some decline over the years due to early supportive management. Different treatment modalities and protocols have been tried at various centers with variable success; however, further research for an antidote is the need of the hour.

The Prognostic Potential of Three Scoring Systems for Mortality Prediction in the Intensive Care Unit: A systematic review and meta-analysis

Background: The predictive potential of scoring systems used in intensive care units (ICUs) to distinguish patients’ mortality is heavily investigated but scarcely pooled. Objectives: To statistically analyze the accuracy of three ICU generic scores, including Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS II), and Sequential Organ Failure Assessment (SOFA), to predict mortality. Methods: A meta-analysis was conducted involving prospective studies published between January 2000 and February 2019 to analyze the performance of APACHE II, SAPS II, and SOFA to predict patients’ mortality through pooling their discriminative indicators, such as sensitivity specificity, and the area under the hierarchical summary receiver operating characteristic curve (HSROC). The inconsistency index (I²) was used to assess heterogeneity in sensitivity and specificity, while meta-regression analysis was performed to detect the potential sources of heterogeneity. Deek’s funnel plots were used to assess the potential publication bias. Results: In a total of 37 studies (7612 patients, 63.58% males, 75.7% assessed in-hospital mortality), 2170 observed deaths were reported. APACHE II, SAPS II, and SOFA scoring systems showed good mortality predictive performances, where the pooled sensitivities were 0.81, 0.76, and 0.80, respectively, specificities were 0.78, 0.89, and 0.79, respectively, and pooled HSROCs were 0.87, 0.85, and 0.88, respectively. For APACHE II, SAPS II, and SOFA, there were significant in-between study heterogeneities in sensitivity (I²=85.21%, 84.31%, and 71.67%, respectively) and specificity (I²=93.74%, 92.65%, and 89.41%, respectively) while no publication bias was detected (P=0.689, 0.465, and 0.181, respectively). There was significant heterogeneity among studies that investigated APACHE II with a cut-off score of > 20 (P = 0.04) and those investigating SAPS II for > 24 months (P < .001). Conclusion: Within the limitations of the study, ICU scores showed good prognostic performance. Future studies should be conducted using fixed-time endpoints of mortality, involving multiple countries and employ a combination of generic ICU scores.

A Feasibility Study to Implement and Evaluate a Third Sector Mental Health Recovery Programme to Support the Transition to Community Living from Acute Mental Health Care

This brief reports outlines a 9-month feasibility study aimed at introducing and evaluating a third-sector mental health recovery programme to support patients on an acute mental health ward transitioning to community discharge. The study outcome data indicates that the recovery programme improved self-reported well-being (p = 0.01) and self-reported recovery progress (p = 0.01). The sample size for this study is small, and the results should be interpreted with caution. Recommendations are made as to ways in which third sector recovery programmes can be further developed in inpatient mental health services. The study was a collaborative endeavour between NHS mental health services and a third sector mental health charity. The provision findings indicates that collaborative working between healthcare and third sector at the time of discharge from acute mental health care can improve service users’ well-being.

Clinical value of left ventricular diastolic function in predicting the short-term prognosis of sepsis-associated acute lung injury/acute respiratory distress syndrome in the elderly

Objective To investigate the clinical and prognosis value of left ventricular diastolic function(LVDF)in predicting the short-term prognosis of sepsis-associated acute lung injury/acute respiratory distress syndrome(ALI/ARDS)in the elderly. Methods This was a prospective case-control study.A total of 93 elderly patients with sepsis-associated ALI/ARDS, who admitted to our hospital between February 2015 and February 2018, were selected as the study subjects.And they were divided into ALI group(n=52)and ARDS group(n=41). Meanwhile 50 elderly sepsis patients without ALI/ARDS were selected as the control group.Based on the prognosis at the 28th days of admission, patients with ALI/ARDS were divided into a death group and a survival group.General clinical data and left ventricular diastolic function index at different time points after admission were compared between groups. Results There were statistically significant differences among the ALI group, ARDS group and control group(P<0.05)on admission and at 3 and 7 days after admission in the parameters as the following: heart rate, mean arterial pressure(MAP), acute physiology and chronic health evaluation system Ⅱ(APACHEⅡ)score, acute lung injury score(LIS), oxygenation index(PaO2/FiO2), arterial blood lactic acid, blood glucose, serum creatinine, troponin I, B-type brain natriuretic peptide(BNP), procalcitonin(PCT), C-reactive protein(CRP)and early diastolic transmitral velocity to early mitral anulus diastolic velocity ratio(E/Em). APACHEⅡscore, LIS score, blood glucose, troponin I, BNP, PCT, CRP and E/Em were higher in the death group than in the survival group on admission and at 3 and 7 days after admission(all P<0.05). Multivariate logistic regression analysis showed that E/Em on admission and at 3 and 7 days after admission were the independent predictors for mortality in patients with sepsis-associated ALI/ARDS(OR=1.346, 2.150 and 1.954, respectively, P<0.05). ROC curve analysis showed that the area under curve(AUC)of E/Em for predicting death on admission and at 3 and 7 days after admission were 0.687, 0.840 and 0.771, respectively, with the optimal threshold value of 13.26, 14.90 and 14.62, respectively, and the sensitivity and specificity were 74.2% and 67.1%, 81.5% and 84.2%, 79.1% and 87.8%, respectively, .The mortality rate was higher in patients with E/Em above the optimal threshold value than below the optimal threshold value at each time point(all P<0.05). Conclusions The impairment of LVDF is serious in elderly patients with sepsis-associated ALI/ARDS, may be an independent predictor for recent death in such patients, and has a good predictive value for the prognosis of elderly patients with sepsis-associated ALI/ARDS. Key words: Ventricular function, left; Sepsis; Acute lung injury; Respiratory distress syndrome, adult; Prognosis

Comparing the treatment needs of participants with co-occurring mental health and substance use disorders in drug and veterans treatment courts

ABSTRACTObjective: Despite the growing research on the effectiveness of specialty courts, including drug treatment courts (DTCs) and veterans treatment courts (VTCs), little is known about the unique treatment needs of individuals with co-occurring mental health and substance use disorders (COD) who are commonly served by these courts. This pilot study examines individuals with COD across two DTCs and two VTCs in Massachusetts to understand the characteristics and treatment needs of these unique populations.Methods: Baseline data for 112 individuals enrolled in a community-based COD treatment program within two DTCs (N = 86) and two VTCs (N = 26) with a Monte Carlo simulation of 10,000 samples were analyzed to assess differences in treatment needs.Results: DTC participants experienced more lifetime convictions (p = .000), months incarcerated (p = .000), and had a longer lifetime history of illicit drug use (p = .004). Meanwhile, a higher proportion of VTC participants experienced trauma (p < .002) and chronic medical problems (p < .001), and VTC participants experienced more severe acute behavioral health symptoms as measured by the BASIS-32 (p = .021).Conclusions: Given the unique differences in treatment needs between DTC and VTC participants, these findings have implications for specialty court management such as treatment planning, referrals to meet participants’ service needs, and even docket sizes.

Usefulness of different prognostic scores for AECOPD: APACHE II, BAP65, 2008, and CAPS scores

PurposeThe purpose of this study was to compare four different scores [Acute Physiology and Chronic Health Evaluation (APACHE II); elevated blood urea nitrogen, altered mental status, pulse >109/min, age >65 years (BAP65); chronic obstructive pulmonary disease (COPD) and Asthma Physiology Score (CAPS); and 2008 score) to test their predictive properties for the need of mechanical ventilation (MV) and short-term mortality in patients with acute exacerbation COPD (AECOPD).Patients and methodsThis study enrolled 100 consecutive patients with acute exacerbation COPD, over a 6-month duration, admitted to the Emergency Department in Alexandria Main University Hospitals. The four scores were calculated for each patient, and clinical data and outcome (need for MV and mortality during hospitalization or within a week after discharge) were recorded.ResultsTheir mean age was 61.1±10.7 years, and 88% were males. Duration of hospital stay was less than or equal to 20 days in 67%. Mortality rate was 4%. Overall, 40% required MV. Blood urea nitrogen, pulse, CO2, pH, altered consciousness, and white blood cell were significant predictors of mortality in univariate but not multivariate analysis. Previous MV, cyanosis, and paradoxical abdominal movement were significant predictors of need for MV. The highest area under the receiver operating characteristic curve was that of APACHE II score regarding either mortality prediction [area under the curve (AUC), 0.982; P=0.001] or need for MV (AUC, 0.959; P<0.001), followed by BAP65 score for mortality prediction (AUC, 0.967; P=0.002) and 2008 score for predicting the need for MV (AUC, 0.851; P<0.001).ConclusionAll studied scores correlated significantly with mortality, but only APACHE II and 2008 score correlated significantly with the need for MV. The highest area under the receiver operating characteristic curve was that of APACHE II score regarding either mortality or need for MV prediction. Previous need for MV was the most important predictor for the need for MV. The routine use of these practical scores in triage of patients may direct early interventions to reduce mortality rate.

Clinical outcome of weaning in mechanically ventilated patients with chronic obstructive pulmonary disease

BackgroundChronic obstructive pulmonary disease (COPD) represents a significant reason for mortality and morbidity worldwide that induces a high socioeconomic burden, with exacerbations necessitating mechanical ventilation representing a major aspect of illness management. Many patients with COPD frequently presented with troubles in the liberation from mechanical ventilation. The aim of the current study was to verify the validity of the weaning categorization that is classified according to the difficulty and length of the weaning procedure in mechanically ventilated patients with COPD and its effect on the different clinical and mortality outcome variables.Patients and methodsA total of 102 patients with COPD who achieved the weaning criteria were classified according to the length and difficulty of weaning procedure into simple weaning group (n=60, 58.8%) and nonsimple weaning group (which include difficult and prolonged weaning categories) (n=42, 42.2%). The outcome measures are the length of mechanical ventilation, the duration of ICU stay, and lastly the mortality rate.ResultsRegarding baseline data recorded at admission, no significant difference between both weaning groups was found apart from Acute Physiology and Chronic Health Evaluation score II. The nonsimple weaning group had considerably higher duration of invasive mechanical ventilation, length of ICU stays, and lastly the mortality rate, in comparison with the simple weaning group.ConclusionWeaning categorization according to the length and the difficulty of the weaning procedure may be used as a suitable predictor of outcome in severe COPD exacerbation with the requirement for invasive mechanical ventilation.

Key features of an innovative sub-acute residential service for young people experiencing mental ill health

BackgroundNumerous studies across international settings have highlighted a need to improve the appropriateness and continuity of services for young people experiencing mental ill health. This paper examines key features of a sub-acute youth mental health residential service model, Youth Prevention and Recovery Care (Y-PARC) service. Y-PARC provides up to 4 weeks care to 16 to 25 year-olds at risk of hospitalisation and to those transitioning out of hospital inpatient units. The research was conducted at one of three Y-PARCs located in Victoria, Australia.MethodsThis paper presents findings from analysis of two data sources collected during evaluation of a Y-PARC service in 2015–17. Routinely collected administrative data of Y-PARC residents (n = 288) were analysed and semi-structured interviews were conducted with 38 participants: a) former residents (n = 14); b) family members of group a) (n = 5); key stakeholders (n = 9); and, Y-PARC staff (n = 10 respondents in 3 group interviews). Analysis of the qualitative data was thematic and structured by the interview guide, which covered the key service aims.ResultsConsistent with the aims of the service, respondents described practice at Y-PARC that aligns with recovery-oriented care. Key features emphasised were: a safe and welcoming environment for residents and families; provision of person-centred care; promotion of autonomy and self-help; informal interactions with staff allowing for formation of naturalistic relationships; time spent with other young people with similar experiences; and, assurance upon exit that the ‘door is always open.’High levels of satisfaction were reported. Outcomes described included: improved resilience; better understanding of mental health; the importance of seeking help; and, stronger connections to therapeutic services. Longer and multiple stays were associated with progressive and sustained change. Family members and stakeholders widely reported that the service fills a gap between community services and acute inpatient mental health hospital wards.Some challenging areas of practice identified included: integration of evidence-based psychosocial interventions; provision of care within a model that blends clinical and psychosocial support services; and, negotiation of family-inclusive practice.ConclusionsThe Y-PARC service model shows promise with young people experiencing mental ill health, particularly in improving the range and availability of options across a spectrum of need.

Rescue fecal microbiota transplantation for antibiotic-associated diarrhea in critically ill patients

BackgroundAntibiotic-associated diarrhea (AAD) is a risk factor for exacerbating the outcome of critically ill patients. Dysbiosis induced by the exposure to antibiotics reveals the potential therapeutic role of fecal microbiota transplantation (FMT) in these patients. Herein, we aimed to evaluate the safety and potential benefit of rescue FMT for AAD in critically ill patients.MethodsA series of critically ill patients with AAD received rescue FMT from Chinese fmtBank, from September 2015 to February 2019. Adverse events (AEs) and rescue FMT success which focused on the improvement of abdominal symptoms and post-ICU survival rate during a minimum of 12 weeks follow-up were assessed.ResultsTwenty critically ill patients with AAD underwent rescue FMT, and 18 of them were included for analysis. The mean of Acute Physiology and Chronic Health Evaluation (APACHE) II scores at intensive care unit (ICU) admission was 21.7 ± 8.3 (range 11–37). Thirteen patients received FMT through nasojejunal tube, four through gastroscopy, and one through enema. Patients were treated with four (4.2 ± 2.1, range 2–9) types of antibiotics before and during the onset of AAD. 38.9% (7/18) of patients had FMT-related AEs during follow-up, including increased diarrhea frequency, abdominal pain, increased serum amylase, and fever. Eight deaths unrelated to FMT occurred during follow-up. One hundred percent (2/2) of abdominal pain, 86.7% (13/15) of diarrhea, 69.2% (9/13) of abdominal distention, and 50% (1/2) of hematochezia were improved after FMT. 44.4% (8/18) of patients recovered from abdominal symptoms without recurrence and survived for a minimum of 12 weeks after being discharged from ICU.ConclusionIn this case series studying the use of FMT in critically ill patients with AAD, good clinical outcomes without infectious complications were observed. These findings could potentially encourage researchers to set up new clinical trials that will provide more insight into the potential benefit and safety of the procedure in the ICU.Trial registrationClinicalTrials.gov, Number NCT03895593. Registered 29 March 2019 (retrospectively registered).

Characteristics of obstetric admissions to intensive care unit: APACHE II, SOFA and the Glasgow Coma Scale

Objective To evaluate the characteristics of obstetric admissions to an intensive care unit (ICU) and assess the utility of Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and the Glasgow Coma Scale (GCS). Methods This study is consisted of 160 patients admitted to an ICU during the antenatal period or within 7 days at the postpartum period. Clinical characteristics and ICU scores were evaluated. Results The rate of admission to the ICU was 7.8/1000 deliveries. Four cases ended with maternal mortality (2.5%). The most common hospitalization indications were hypertensive disorders of pregnancy, cardiovascular disorders and obstetric hemorrhage, at 40 (25%), 34 (21.2%), and 31 (19.3%) cases, respectively. The receiver operating characteristics (ROC) curve analysis for prediction of maternal mortality revealed area under curve (AUC) values as 0.971 both for APACHE II and predicted mortality rate (PMR), and 24.5 and 47.1 were determined as the cut-offs with sensitivities of 100%. AUCs were also 0.901 and 0.929 for the initial and worst SOFA score, respectively. The cut-off value for the initial and worst SOFA score was 3.5, with a sensitivity of 100%, and was 10 with a specificity of 98.9%, respectively. Conclusion APACHE II and PMR overpredict maternal mortality, but those higher scores predict maternal mortality. Higher SOFA scores are related with maternal mortalities with high specificity.

Taking a holistic approach to acute mental health crisis

An innovative, collaborative model implemented by a UK ambulance service allows patients presenting with a mental health condition to be promptly assisted by a specialist team comprising a paramedic, mental health nurse and police officer. Initial evidence suggests that greater collaboration between emergency services and mental health trusts benefits patients and services: leading to timely assessments, reductions in patient distress levels, and decreasing emergency department overcrowding while providing substantial savings for the NHS. This article explores existing care pathways for patients experiencing acute mental health crisis. Current research from the UK is discussed, and compared with working practices of paramedics internationally. Through reflection of a case study, common difficulties faced in paramedic practice are identified. A multi-agency response to ensure the right care is provided in the right place at the right time is proposed.

Effect of dexmedetomidine on stress response and immune balance in mechanical ventilation patients with acute respiratory distress syndrome

Objective To investigate the effect of dexmedetomidine on stress response and immune balance in patients with acute respiratory distress syndrome(ARDS) undergoing mechanical ventilation. Methods From March 2016 to September 2018, 90 ARDS patients with mechanical ventilation in Chongqing Three Gorges Center Hospital were randomly divided into dexmedetomidine group(D group, 30 cases), propofol group(P group, 30 cases), midazolam group(M group, 30 cases) by random number table method.Another 30 healthy workers in our hospital were selected as normal control group(C group). In M, P and D groups, the sedative drugs were infused by micro-pump on the basis of analgesic treatment(fentanyl citrate). The heart rate(HR), mean arterial pressure(MAP), Murray score, acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score, plasma norepinephrine(NS), plasma cortisol(Cor), and blood T lymphocyte subsets(CD4+, CD8+, CD4+/CD8+) were observed in all patients at T0(the beginning of sedation), T1 (6h after sedation), T2 (24h after sedation), T3(48h after sedation). The levels of NS and Cor in plasma and blood T lymphocyte subsets(CD4+, CD8+, CD4+/CD8+) in C group were measured at 8∶00 a. m.the next day. Results The plasma NS and Cor at T0 in M, P and D group were higher than those in C group (all P 0.05). The levels of CD8+ at T2 and T3 in P and D groups were higher than that of M group (all P<0.05). The level of CD4+/CD8+ at T3 in D group were higher than that in M and P group[(1.46±0.30) vs.(1.26±0.33), (1.46±0.30) vs.(1.32±0.34)](t=0.21, 0.15, all P<0.05). Conclusion Sedation with dexmedetomidine or propofol can alleviate stress response and improve immune function in ARDS patients undergoing mechanical ventilation, and dexmedetomidine is better than propofol. Key words: Respiratory distress syndrome, Adult; Ventilators, mechanical; T-Lymphocytes; Dexmedetomidine; Propofol; Midazolam

P3401Comparison of APACHE II, SAPS II and GRACE 2.0 risk scores to estimate early and late mortality in patients with ST-segment elevation acute myocardial infarction

Abstract Background Many specific prognostic risk scores have been validated for myocardial infarction (MI), such as the Global Registry of Acute Coronary Events (GRACE) 2.0. Other general risk scores are used in intensive care units (ICUs), such as the Acute Physiologic and Chronic Health Evaluation (APACHE) II and the Simplified Acute Physiology Score (SAPS) II. Purpose Compare the ability of GRACE 2.0, APACHE II and SAPS II risk scores to estimate in-hospital, 3- and 12-month mortality after primary angioplasty (PA) for ST-segment elevation MI (STEMI). Methods Retrospective cohort of 427 consecutive STEMI patients (64 years [55–75]; 78% men) admitted to a general ICU between November-2013 and February-2017. We used Area under the Receiver Operating Characteristic (ROC) curve (AUC) analysis to asses performance of risk scores, and the Hosmer-Lemeshow (HL) goodness of fit test and the Standardized Mortality Ratio (SMR) to assess calibration. Results All risk scores were associated with in-hospital, 3- and 12-month mortality (P&lt;0.001). SAPS II had the highest sensitivity for short-term mortality and the highest AUC for in-hospital, 3- and 12-month mortality (Figure). SAPS II had the highest calibration and the less underestimation of mortality in all follow-up periods analysed (Table). Performance of prognostic risk scores Youden index (J) Sensitivity (%) Specificity (%) AUC (95% CI) H-L (P value) SMR In-Hospital mortality (5.4%) SAPS II 32 87.0 89.4 0.938 (0.887–0.988) 1.826 (0.969) 1.64 GRACE 2.0 150 86.9 83.7 0.922 (0.865–0.979) 8.111 (0.423) 1.77 APACHE II 17 82.6 93.8 0.896 (0.841–0.986) 11.941 (0.154) 1.92 3-month mortality (5.6%) SAPS II 32 79.2 89.1 0.913 (0.854–0.973) 3.635 (0.821) 1.85 GRACE 2.0 150 79.1 85.4 0.902 (0.842–0.962) 5.149 (0.742) 2.0 APACHE II 17 79.1 93.8 0.882 (0.792–0.971) 9.244 (0.322) 2.0 12-month mortality (7.0%) SAPS II 32 73.3 89.7 0.880 (0.809–0.951) 1.994 (0.960) 1.58 GRACE 2.0 150 76.7 84.1 0.878 (0.816–0.941) 4.073 (0.850) 2.31 APACHE II 17 70.0 92.4 0.824 (0.722–0.927) 7.464 (0.487) 2.14 AUC: Area under the curve; H-L: Hosmer-Lemeshow; SMR: Standardized Mortality Ratio. Area under the ROC curves (AUC) Conclusions SAPS II represents the best model to estimate mortality in this cohort of STEMI patients, with an appropriate calibration and less underestimation of mortality. Underestimation of mortality showed by all risk scores suggests the need of creating new risk prediction models that improve identification of high risk STEMI patients.

Dysnatremia in hospitalized elderly patients

Dysnatremia is the most common electrolyte disorder in hospitalized patients; it encompasses hyponatremic and hypernatremic conditions. Dysnatremia is also a common finding at Intensive Care Unit admission. Abnormal serum sodium concentrations are known to adversely affect physiologic function and an increasing evidence suggests that dysnatremia may be associated with adverse outcome.Aim: to detect the prevalence of dysnatremia in Geriatric patients, and also to evaluate association between dysnatremia and in-hospital mortality in Intensive Care Unit older patients.Results: the current study found that in hospitalized elderly participants, 23.8% had hyponatremia (6.4%,9.2%, 8.2% had mild, moderate, severe hyponatremia, respectively), 6.8% had hypernatremia (2.6%, 2%, 2.2% had mild, moderate, severe hypernatremia, respectively) (p value= 0.000). while prevalence of dysnatremia was higher in the ICU patients, 28.2% had hyponatremia (7.6%, 9.8%, 10.8% had mild, moderate, severe hyponatremia, respectively), 9.6% had hypernatremia (3.3%, 3.0%, 3.3% had mild, moderate, severe hypernatremia, respectively) (p value= 0.000). Intensive Care Unit hospital mortality rate was 40.7%, the dead subjects were older (p value= 0.012), has higher mean s. Na (p value=0.002), had higher Modified Acute Physiology and Chronic Health Evaluation II score (p value=0.000), higher Multiple Organ Dysfunction score (p value=0.000), higher length of stay (p value= 0.167).Conclusion: Dysnatremia prevalence is high in geriatric elderly patients, hyponatremia is more frequent than hypernatremia, dysnatremia in Intensive Care Unit patients is more than ward patients, in hospital mortality among geriatric patients with dysnatremia is related to severity and nature of underling diseases as well as severity of dysnatremia itself.

Prognostic factors in patients with acute kidney injury requiring continuous renal replacement therapy

Objective To identify prognostic factors for mortality in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). Methods A retrospective study was conducted in 138 patients with initiated CRRT due to AKI who were admitted to the Emergency Intensive Care Unit of Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine from May 2012 to December 2016. According to whether these patients survived after 28 days, they were divided into the death group (58 cases) and survived group (80 cases). Demographic and clinical parameters were retrieved and compared between the two groups. Logistic multivariate regression analysis was performed to determine the risk factors related to mortality. Results Of the 138 patients included, 58 patients (42.0%) died after 28 days. Patients in the death group were older, more likely to be male, had a higher score on the acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), higher serum lactate level and lower serum creatinine level on admission, higher prevalence of coronary artery disease, and were more likely to be mechanically ventilated or treated with vasopressors. Multivariate logistic regression analysis revealed that age (OR=1.064, 95%CI: 1.022-1.108, P=0.002), APACHEⅡ score (OR=1.127, 95%CI: 1.003-1.265, P=0.044), mechanical ventilation (OR=7.432, 95%CI: 2.183-25.308, P=0.001) and use of vasopressors (OR=24.558, 95%CI: 7.651-78.825, P<0.01) were independent risk factors for mortality. Conclusions Older age, higher APACHEⅡ score, mechanical ventilation and use of vasopressors are risk factors for mortality in EICU patients with acute kidney injury requiring CRRT. Key words: Acute kidney injury; Continuous renal replacement therapy; Prognosis; ICU; Risk factors

Present practices of rape care management in Thuthuzela Care Centres of the North West Province

We aimed to characterise practices of rape care management centres in a South African setting. Participants were rape survivors consulted in Thuthuzela care centres of the North West Province. They indicated which acute medical management they received when reporting rape, and which mental health care management they received during follow-up care visits. We analysed the descriptive data to characterise practices around acute medical management provided immediately after reporting rape, and to characterise mental health care management that was provided during follow-up care visits. Findings suggest that most of the rape survivors received acute mental care management to manage injuries, Sexually Transmitted Infections (STIs), pregnancy, and Human Immune deficiency Virus (HIV). However, few rape survivors received acute mental health care management during follow-up care visits.

Clinical and cost-effectiveness of contingency management for cannabis use in early psychosis: the CIRCLE randomised clinical trial

BackgroundCannabis is the most commonly used illicit substance amongst people with psychosis. Continued cannabis use following the onset of psychosis is associated with poorer functional and clinical outcomes. However, finding effective ways of intervening has been very challenging. We examined the clinical and cost-effectiveness of adjunctive contingency management (CM), which involves incentives for abstinence from cannabis use, in people with a recent diagnosis of psychosis.MethodsCIRCLE was a pragmatic multi-centre randomised controlled trial. Participants were recruited via Early Intervention in Psychosis (EIP) services across the Midlands and South East of England. They had had at least one episode of clinically diagnosed psychosis (affective or non-affective); were aged 18 to 36; reported cannabis use in at least 12 out of the previous 24 weeks; and were not currently receiving treatment for cannabis misuse, or subject to a legal requirement for cannabis testing. Participants were randomised via a secure web-based service 1:1 to either an experimental arm, involving 12 weeks of CM plus a six-session psychoeducation package, or a control arm receiving the psychoeducation package only. The total potential voucher reward in the CM intervention was £240. The primary outcome was time to acute psychiatric care, operationalised as admission to an acute mental health service (including community alternatives to admission). Primary outcome data were collected from patient records at 18 months post-consent by assessors masked to allocation. The trial was registered with the ISRCTN registry, number ISRCTN33576045.ResultsFive hundred fifty-one participants were recruited between June 2012 and April 2016. Primary outcome data were obtained for 272 (98%) in the CM (experimental) group and 259 (95%) in the control group. There was no statistically significant difference in time to acute psychiatric care (the primary outcome) (HR 1.03, 95% CI 0.76, 1.40) between groups. By 18 months, 90 (33%) of participants in the CM group, and 85 (30%) of the control groups had been admitted at least once to an acute psychiatric service. Amongst those who had experienced an acute psychiatric admission, the median time to admission was 196 days (IQR 82, 364) in the CM group and 245 days (IQR 99, 382) in the control group. Cost-effectiveness analyses suggest that there is an 81% likelihood that the intervention was cost-effective, mainly resulting from higher mean inpatient costs for the control group compared with the CM group; however, the cost difference between groups was not statistically significant. There were 58 adverse events, 27 in the CM group and 31 in the control group.ConclusionsOverall, these results suggest that CM is not an effective intervention for improving the time to acute psychiatric admission or reducing cannabis use in psychosis, at least at the level of voucher reward offered.

Persistent inflammation, immune-suppression and catabolism syndrome secondary to sepsis in elderly patients in medical intensive care unit: a retrospective study

Objective To investigate the clinical characteristics, risk factors and prognosis of patients with persistent inflammation, immune-suppression and catabolism syndrome(PICS)secondary to sepsis in medical intensive care unit(MICU)in initial stage, in order to increase the understanding of PICS and provide the reference experience for the early screening of high-risk patients. Methods A total of 298 elderly patients diagnosed as sepsis admitted into MICU from Aug.2013 to Dec.2016 were retrospectively studied.Of them, 97 patients meeting inclusion criteria were ultimately enrolled and separated into the PICS group and the non-PICS group.General and clinical data and laboratory indexes at first day admitted into MICU were compared between the two groups.The indexes between the two groups were analyzed statistically by multivariate logistic regression analysis.The survival-time distributions were estimated by Kaplan-Meier model, and the difference in prognosis was compared between the two groups. Results Of 97 patients, 36 patients(37.1%)met the diagnosis of PICS.The acute physiological function and chronic health evaluation Ⅱ(APACHEⅡ)score had a significant difference between the two groups(27.7±5.8 vs.22.9±6.0, P 0.05). Conclusions The elderly patients with persistent inflammation, immune-suppression, and catabolism syndrome(PICS)secondary to sepsis in medical intensive care unit(MICU)show the higher levels of APACHEⅡ score and AGI grade, and lower values of platelet counts, CD4+ T cell counts and CD4+ /CD8+ ratio in initial stage.And APACHEⅡ score is an independent risk factor for PICS in elderly sepsis patients, and the optimal cut-off value of APACHEⅡ score for predicting PICS is 26.5.The prognosis for advanced stage and long term prognosis are poor.It is essential to use APACHEⅡ and so on, to timely identify and intervene PICS. Key words: Persistent inflammation, immune-suppression, and catabolism syndrome; Sepsis; Risk factor; Prognosis

Adequacy of Daily Fluid Intake Volume Can Be Identified From Urinary Frequency and Perceived Thirst in Healthy Adults

Objective: Achieving and maintaining an optimal level of hydration has significant implications for both acute and chronic health, yet many hydration assessments are not feasible for the general public. Urinary frequency (UF) is a reliable method to self-assess hydration status in healthy individuals, and thirst can provide additional sensory information on adequacy of daily fluid intake volume (DFI). However, threshold values for these indices to detect optimal hydration have not been determined. In this study, we sought to determine threshold values for 24-hour UF and perceived thirst that could accurately distinguish between optimal and suboptimal hydration states.Methods: Thirty-two healthy adults (age 22 ± 3 years, body mass index 24.9 ± 4.1 kg/m2) collected urine over 24 hours on four separate occasions, where UF was recorded as well as thirst at each void using a numbered perceptual scale. Using urine osmolality as the criterion standard, all samples were either classified as representing an optimal (≤500 mOsm·kg−1) or suboptimal hydration status (>500 mOsm·kg−1).Results: A 24-hour UF ≤6 was able to detect suboptimal hydration with good accuracy (area under the curve [AUC] 0.815) and a 24-hour average perceived thirst rating > 3 (“a little thirsty”) could detect it with reasonable accuracy (AUC 0.725). In addition, a UF ≤4 had a considerably higher positive likelihood ratio to detect suboptimal hydration versus a UF ≤6 (9.03 versus 2.18, respectively).Conclusions: These analyses suggest that individuals with a 24-hour UF ≤6 or perceiving themselves to be, on average, “a little thirsty” throughout the day are likely to be suboptimally hydrated and thus underconsuming an adequate DFI.

Establishment and development of national community-based collaborative innovation demonstration areas to achieve the control target of hepatitis B in China

BackgroundThe major infectious diseases of hepatitis B has constituted an acute public health challenge in China. An effective and affordable HBV control model is urgently needed. A national project of Community-based Collaborative Innovation HBV (CCI-HBV) demonstration areas has optimized the existing community healthcare resources and obtained initial results in HBV control.MethodsBased on the existing community healthcare network, CCI-HBV project combined the community health management and health contract signing service for long-staying residents in hepatitis B screening. Moreover, HBV field research strategy was popularized in CCI-HBV areas. After screening, patients with seropositive results were enrolled in corresponding cohorts and received treatment at an early stage. And the uninfected people received medical supports including health education through new media, behavior intervention and HBV vaccinations. In this process, a cloud-based National Information Platform (NIP) was established to collect and store residents’ epidemiological data. In addition, a special quality control team was set up for CCI project.ResultsAfter two rounds of screening, HBsAg positive rate dropped from 5.05% (with 5,173,003 people screened) to 4.57% (with 3,819,675 people screened), while the rate of new HBV infections was 0.28 per 100 person-years in the fixed cohorts of 2,584,322 people. The quality control team completed PPS sampling simultaneously and established the serum sample database with 2,800,000 serum samples for unified testing.ConclusionsCCI-HBV project has established a large-scale field research to conduct whole-population screening and intervention. We analyzed the HBsAg prevalence and new infection rate of HBV in the fixed population for the epidemic trend and intervention effect. The purpose of CCI-HBV project is to establish and evaluate a practical model of grid management and field strategy, to realize the new goal to control hepatitis B in China. To provide policymakers with a feasible model, our results are directly applicable.Trial registrationThe project was funded by the Major Projects of Science Research for the 11th and 12th five-year plans of China, entitled “The prevention and control of AIDS, viral hepatitis and other major infectious diseases”, Grant Nos. 2009ZX10004901, 2011ZX10004901, 2013ZX10004904, 2014ZX10004007 and 2014ZX10004008.