Acute Life-threatening Illness Research Articles

Prehospital lactate-glucose interaction in acute life-threatening illnesses: metabolic response and short-term mortality.

Lactate is an already recognized biomarker for short-term mortality. However, how glycemia and diabetes affect the predictive ability of lactate needs to be revealed. To determine how hypoglycemia, normoglycemia, and hyperglycemia modify the predictive ability of lactate for short-term mortality (3 days). The secondary objective was to evaluate the predictive ability of lactate in diabetic patients. Prospective, observational study performed between 26 October 2018 and 31 December 2022. Multicenter, EMS-delivery, ambulance-based study, considering 38 basic life support units and 5 advanced life support units referring to four tertiary care hospitals (Spain). Eligible patients were adults recruited from among all phone requests for emergency assistance who were later evacuated to emergency departments. The primary outcome was in-hospital mortality from any cause within the third day following EMS attendance. The main predictors considered were lactate, blood glucose levels and previous diabetes. A total of 6341 participants fulfilled the inclusion criteria. 68 years (IQR: 51-80); 41.4% were female. The 3-day in-hospital mortality rate was 3.5%. The predictive capacity of lactate for 3-day mortality was only significantly different between normo-glycemia and hyperglycemia. The best predictive result was for normo-glycemia - AUC = 0.897 (95% CI: 0.881-0.913) - then hyperglycemia - AUC = 0.819 (95% CI: 0.770-0.868) and finally, hypoglycemia - AUC = 0.703 (95% CI: 0.422-0.983). The stratification according to diabetes presented no statistically significant difference, and the predictive results were AUC = 0.924 (95% CI: 0.892-0.956), AUC = 0.906 (95% CI: 0.884-0.928), and AUC = 0.872 (95% CI: 0.817-0.927) for nondiabetes, uncomplicated cases, and end-organ damage diabetes, respectively. Our results demonstrated that glycemia, but not diabetes, alters the predictive ability of lactate. Therefore, hyperglycemia should be considered when interpreting lactate, since this could improve screening to detect cryptic shock conditions.

Post-traumatic stress disorder and stroke in the elderly

IntroductionPosttraumatic stress disorder (PTSD) is common in survivors of acute life-threatening illness, but little is known about the burden of PTSD in survivors of stroke attack.ObjectivesThis study estimated the prevalence of PTSD in post-stroke in the elderly and to look for the factors which are correlated with it.MethodsParticipants were outpatients of Psychiatry B department in Hedi chaker University Hospital Center in Tunisia, over the age of 65, hospitalized in psychiatry for a major depressive episode, recruted between 2000 and 2015. The data was collected using a pre-established sheet containing socio-demographic information, the clinical and evolutionary characteristics of the depressive episode and the therapeutic data concerning the depressive episode.Results30 patients were included in this study with an average age (69 Y) and sex ratio (0.66). More than half (53.3%, 16 patients) had a history of chronic somatic disease. The average length of hospitalization was 26 days. The most frequent reason for hospitalization is sadness of mood (43.3%) with cognitive impairment as the predominant clinical symptomatology (40%). 93.3% of the population received as treatment an antidepressant mainly Fluoxetine (50%).Conclusionsclinicians should be mindful that PTSD can be a devastating mental health condition and should consider screening for PTSD in stroke survivors.

Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings.

There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns. To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019. We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response. Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice. We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies. Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

Brain-related outcome measures in trials recruiting critically-ill children.

Randomized controlled trials leading to innovations that improve outcomes in acute life-threatening illnesses in children are scarce. A key issue is how we refocus research on outcomes that matter and are more relevant to those making emergency decisions, and those involved with managing and living with the late-outcome. We have used information from recent trials in critically ill children - in particular those illnesses without any primary neurologic involvement - to develop an approach to brain-related outcomes that will maximize child and family benefit from research. Fifteen recent pediatric critical care trials illustrate four types of brain-related outcomes assessment: death or organ-system-failures - as illustrated by studies in systemic illness; neurological and neuropsychological outcomes - as illustrated by the glycemic control studies; cognitive outcomes - as illustrated by a sedative trial; and composite outcomes - as illustrated by the therapeutic hypothermia studies. The 15 research trials point to five areas that will need to be addressed and incorporated into future trial design, including use of: neurologic monitoring during intensive care unit admission; postdischarge outcomes assessments; strategies to improve retention in long-term follow-up; child and family-centered outcomes; and core outcomes datasets.

Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings

Background There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns. Objectives To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019. Selection criteria We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response. Data collection and analysis Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice. Main results We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies. Authors' conclusions Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

HIV, trauma and the emergency departments: The CDC opt-out approach should be adopted in South Africa

Background. Trauma is the fourth burden of disease in South Africa (SA). The risk group is the same as that for HIV/AIDS. The Centers for Disease Control and the World Health Organization promulgated the opt-out testing system 10 years ago and several high- and lower-middleincome countries have adopted this approach. Objective. To review the feasibility of implementing the opt-out system in SA emergency departments. Methods. We examined the clinical, economic, practical and patient/provider perceptions concerning the scientific and ethical aspects of the opt-out concept. Results. Patients were generally positive about the opt-out system and the overall test rate and disease identification rates were better than with other systems. Although initial costs may increase, the long-term cost benefit and prevention of transmission, due to linking to care, make this option attractive. Conclusion. The opt-out option for patients presenting to emergency departments with an acute life-threatening illness or trauma, and for those in critically ill states in an intensive care unit, is justifiable based on international and regional practices. This also has the potential to advance early highly active antiretroviral therapy and reduce treatment costs and the disease-adjusted life years for HIV management and trauma critical care. SA should adopt an opt-out testing system instead of the current tedious opt-in system.

Identification of novel VP35 inhibitors: Virtual screening driven new scaffolds.

Ebola virus is a single-stranded, negative-sense RNA virus that causes acute and serious life-threatening illness. In recent years the Ebola virus has spread through several countries in Africa, highlighting the need to develop new treatments for this disease and boosting a new research effort on this subject. However, so far there is no valid treatment for disease created by this pathogen. The Ebola virus Viral Protein 35 (VP35) is a multifunctional protein which is critical for virus replication and infection, and it is considered as a future target for drug development. In this study, we collected 144 VP35 inhibitors which shared the same core scaffold, and a common feature pharmacophore model HypoA was built based on inhibitor-receptor complexes. All 141 compounds were aligned based on the common feature pharmacophore model HypoA (three compounds could not map onto HypoA). The pharmacophore model HypoA was further optimized according to the actual interactions between inhibitors and VP35 protein, resulting in a new pharmacophore model HypoB which was applied for virtual screening. A 3D QSAR model was established by applying the 141 aligned compounds. For the training set, the 3D QSAR model gave a correlation coefficient r2 of 0.897, for the test set, the correlation coefficient r2 was 0.757. Then a virtual screening was carried out, which comprehensively employing the common feature pharmacophore model, 3D QSAR model and docking study, their combination in a hybrid protocol could help to mutually compensate for their limitations and capitalized on their mutual strengths. After the above three virtual screening methods orderly filtering, seven potential inhibitors with novel scaffolds were identified as new VP35 inhibitors. The mapping results of hit compounds onto pharmacophore model and 3D QSAR model, and the molecular interactions of the potential inhibitors with the active site residues have been discussed in detail.

Dying within dying: Ethical dilemmas of treating terminally ill patients with acute life-threatening illnesses.

Sir, With the advent of palliative care, severely ill patients with terminal illnesses are often treated in accordance with their autonomy and with dignity, compassion, and comfort.[1] However, this most often happens if the patient is dying from the said terminal illness such as renal or heart failure or cancer.[2] Such patients may choose to die at home or even in palliative care wards. It is a comforting feeling for physicians and families that nonbeneficial life-sustaining and often agonizing care is not being delivered against a patient's wishes. There are pathways, protocols, and advance care plans for identifying and allowing such patients to complete their journey at the end of life.[3] However, an alarming number of patients with terminal illnesses fall through the cracks of this optimal situation.[4] Patients may receive care that is not in keeping with their natural trajectory of illness or wishes if they are admitted with an acute potentially “reversible” pathology while having a background terminal illness such as developing pneumonia, suffering myocardial infarctions, or be involved in trauma.[5] The rising costs of admitting and treating terminally ill patients with acute illness with modern day technology is unsustainable. The aim of this letter is to provide a brief review of the literature on the ethical difficulties that physicians and families face when decision-making in a terminally ill patient (at times with an advance care plan in place) is thrown off balance by a sudden acute illness. The question here is “should physicians feel morally obliged to treat an acute illness when the patient is already far along his or her end of life journey?” The thematic analysis of these papers revealed the following subtopics: Family communication, reiteration of diagnosis, burden of critical treatment, and goal setting. There was general agreement that terminally ill patients should have continuity of care and preferably be referred to the same center familiar with their terminal diagnosis and end of life goals. In an aging world with limited critical care resources, there are many demands on acute care settings such as Intensive Care Units. Patients who may not benefit from aggressive life-sustaining care perhaps should not be offered such treatment options such as life-saving surgery, if in fact it is merely prolonging their ultimate fate, unless it can add to alleviating suffering. Instead, effort and resources should be used in trying to match their goals and values, including palliation and providing mindful dignity and comfort. Often symptom control to provide relief is the driving force behind acute admissions in terminally ill patients; however, it seems that frank and consistent communication with patients and families may allay the ethical conflicts that usually arise when a patient presents in extremis while already dying from a separate illness including old age. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Factors Associated with Non-Reimbursable Activity on an Inpatient Pediatric Consultation–Liaison Service

The aim of this study was to identify factors contributing to clinician time spent in non-reimbursable activity on an inpatient pediatric consultation-liaison (C-L) service. A retrospective study was conducted using inpatient C-L service data on 1,246 consecutive referrals. For this patient population, the strongest predictor of level of non-reimbursable clinical activity was illness chronicity and the number of contacts with C-L service clinicians during their hospital stay. Patients with acute life-threatening illnesses required the highest mean amount of non-reimbursable service activity. On average, 28 % of total clinician time in completing a hospital consultation was spent in non-reimbursable activity. Effective C-L services require a proportion of time spent in non-reimbursable clinical activity, such as liaison and coordinating care with other providers. Identifying referral and systemic factors contributing to non-reimbursable activity can provide insight into budgeting/negotiating for institutional support for essential clinical and non-clinical functions in providing competent quality patient care.

Prevalence of PTSD in Survivors of Stroke and Transient Ischemic Attack: A Meta-Analytic Review

Background and PurposePosttraumatic stress disorder (PTSD) is common in survivors of acute life-threatening illness, but little is known about the burden of PTSD in survivors of stroke and transient ischemic attack (TIA). This study estimated the prevalence of stroke or TIA-induced posttraumatic stress disorder (PTSD) using systematic review and meta-analysis.MethodsPotentially relevant peer-reviewed journal articles were identified by searching the Ovid MEDLINE, PsycINFO, PILOTS Database, The Cochrane Library and Scopus from inception to January 2013; all searches were conducted on January 31, 2013. Observational cohort studies that assessed PTSD with specific reference to a stroke or TIA that occurred at least 1 month prior to the PTSD assessment were included. PTSD rates and characteristics of the study and sample were abstracted from all included studies. The coding of all articles included demographics, sample size, study country, and method and timing of PTSD assessment.ResultsNine studies (N = 1,138) met our inclusion criteria. PTSD rates varied significantly across studies by timing of PTSD assessment (i.e., within 1 year of stroke/TIA versus greater than 1 year post-stroke/TIA; 55% of heterogeneity explained; Q 1 = 10.30; P = .001). Using a random effects model, the estimated rate of PTSD following stroke or TIA was 23% (95% CI, 16%–33%) within 1 year of the stroke or TIA and 11% (95% CI, 8%–14%) after 1 year.ConclusionsAlthough PTSD is commonly thought to be triggered by external events such as combat or sexual assault, these results suggest that 1 in 4 stroke or TIA survivors develop significant PTSD symptoms due to the stroke or TIA. Screening for PTSD in a large population-based prospective cohort study with cardiovascular outcome assessments is needed to yield definitive prevalence, and determine whether stroke or TIA-induced PTSD is a risk factor for subsequent cardiovascular events or mortality.

Creating a Climate for Healing: A Visual Model for Goals of Care Discussions

Journal of Palliative MedicineVol. 16, No. 7 Letters to the EditorCreating a Climate for Healing: A Visual Model for Goals of Care DiscussionsTammy Newman Bhang and Juan C. IreguiTammy Newman BhangSearch for more papers by this author and Juan C. IreguiSearch for more papers by this authorPublished Online:21 Jun 2013https://doi.org/10.1089/jpm.2012.0633AboutSectionsView articleView Full TextPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Creating a Climate for Healing: A Visual Model for Goals of Care Discussions." , 16(7), p. 718FiguresReferencesRelatedDetailsCited ByThe In-Between Conversations: What Do We Talk About the Day After a Big Discussion? Maie El-Sourady, Sara Martin, and Thomas Carroll3 February 2022 | Journal of Palliative Medicine, Vol. 25, No. 2Goals-of-Care Discussions in Acute Life-Threatening Illness: A Three-Question Framework to Get Your Learners Started Maie El-Sourady and Sara Martin13 August 2021 | Journal of Palliative Medicine, Vol. 24, No. 9MVP–Medical Situation, Values, and Plan: A Memorable and Useful Model for All Serious Illness ConversationsJournal of Pain and Symptom Management, Vol. 60, No. 5Effects of a Primary Palliative Care Educational System for Teaching Learners at Different Levels of Training7 March 2019 | American Journal of Hospice and Palliative Medicine®, Vol. 36, No. 8The House Model: An Updated Visual Framework for Goals of Care Conversations Tammy Newman Bhang and Juan C. Iregui1 August 2019 | Journal of Palliative Medicine, Vol. 22, No. 8Empathy as Care: the Model of Palliative Medicine22 March 2019 | Society, Vol. 56, No. 2Practical Tips for ICU Bedside TeachingChest, Vol. 154, No. 4How to Teach Communication Skills for Palliative Care Conversations29 September 2016A Wounded Healer’s Reflections on Healing21 May 2015The Bow Tie Model of 21st Century Palliative CareJournal of Pain and Symptom Management, Vol. 47, No. 1A Paradigm Shift: Healing, Quality of Life, and a Professional ChoiceJournal of Pain and Symptom Management, Vol. 47, No. 1 Volume 16Issue 7Jul 2013 InformationCopyright 2013, Mary Ann Liebert, Inc.To cite this article:Tammy Newman Bhang and Juan C. Iregui.Creating a Climate for Healing: A Visual Model for Goals of Care Discussions.Journal of Palliative Medicine.Jul 2013.718-718.http://doi.org/10.1089/jpm.2012.0633Published in Volume: 16 Issue 7: June 21, 2013Online Ahead of Print:May 15, 2013PDF download

Streptococcal toxic shock-like syndrome (TSLS)

Toxic shock syndrome (TSS) is a rare, toxin-mediated acute life-threatening illness, usually precipitated by infection with either Staphylococcus aureus or group A Streptococcus (GAS), also called Streptococcus pyogenes. We present a case of 37-year-old male immunocompetent Caucasian who was hospitalized at the Clinic for Infectious Diseases because of diarrhea and vomiting with no signs of systemic infection. The symptoms disappeared after parenteral rehydration. Two days after the short lived improvement, the patient was highly febrile (40°C) with subicteric and petechial skin changes. Rapidly, respiratory, renal as well as psychical failure was observed with tachypnea, oliguria and finally anuria. Blood studies revealed inflammatory response and the indicators of hepatic and renal failure were high. Blood culture was positive on Streptococcus pyogenes. Although therapy procedures were initiated, acute respiratory distress syndrome had developed and the patient was intubated at Intensive Care Unit. Roentgenogram of the chest showed metastasis of infection, pleural effusion, and heart enlargement. The ECG showed changes characteristic of pericardial effusion as well as septal fibrosis. Splenomegaly was confirmed with computed tomography. After four weeks of treatment and further monitoring the patient was discharged from hospital in good general condition, stable vital functions and normal findings on physical systems. This was the first case of toxic shock-like syndrome described in the Department for Infectious Diseases of Clinical Center in Kragujevac.

Investigation of the child with an acute metabolic disorder

Inherited biochemical defects may present with acute life-threatening illness with a high mortality and morbidity. Some are treatable and have a good outcome with early appropriate intervention. However, because of...

On coenrollment in clinical resuscitation studies: Review and experience from randomized trials

Context Patients with acute life-threatening illness are candidates for enrollment in multiple trials. Whether patients are enrolled in multiple trials has implications for patient safety, trial enrollment duration, and study validity. Objective We review issues related to coenrollment and propose guidelines for when it should be allowed. Results There is no regulatory prohibition on coenrollment of patients in more than one study. Randomized trials of interventions for a variety of clinical conditions have allowed coenrollment without any reported deleterious impact on either study. Guidelines for coenrollment are proposed.

Parent/carer views about deferred consent in trials of emergency treatments in children with life-threatening illness

<h3>Introduction</h3> Obtaining informed consent for studies of emergency treatments in children with acute life-threatening illness is difficult and may preclude vital clinical trials. <h3>Aims</h3> To investigate parents9 views regarding consent in a hypothetical emergency resuscitation trial comparing two treatments which are in widespread use, and considered safe in children with sepsis. <h3>Methods</h3> Postal questionnaire survey. Parents were presented with a scenario describing the trial in two parts: (1) Would parents want to be informed about the trial at the time of resuscitation, or would they want to be included and then informed after their child9s condition had stabilised, or not informed at all about the trial? (2) How would parents approach a scenario where a child had been included without prior consent, but the child died before the parents were informed about the trial? Participants were all members of Meningitis Research Foundation with a child affected by bacterial meningitis (BM) or meningococcal septicaemia (MS) within the previous 5 years. The study aimed to include a representative sample from families who had been bereaved due to BM/MS. <h3>Results</h3> 220 families were sent questionnaires (63 bereaved); 68 (31%) responded (equal proportions from bereaved families as from survivors). Three respondents would not want their child included under any circumstances, and 30% would not have wanted inclusion before the trial was explained to them. The principle of deferred consent was acceptable to 66% of respondents; however 33% would not want to be told about the trial at any stage. If the child had died, 51% of respondents did not think it appropriate to inform the parents that their child had been entered into a trial. More bereaved respondents would have wanted to be told about the study at some stage (66% vs 37%, p=0.06). <h3>Conclusion</h3> The majority of parents indicated acceptance of a child9s inclusion into emergency treatment trials without prior informed consent. Efforts to inform families and deferred consent may be acceptable in certain circumstances. Trials of emergency treatments in children are vital, but logistically difficult. The contribution of our findings to the implementation of emergency therapeutic studies will be discussed.

Do Elderly Patients With Non-hematologic Malignancies Have A Worse Outcome in the ICU?

The aim of this study was to evaluate the difference in outcome between older (≥ 65 years) and younger (< 65 years) cancer patients admitted to the intensive care unit (ICU) with acute life-threatening illness. A total of 1,881 patients were admitted to the medical intensive care unit (ICU) of Mackay Memorial Hospital, Taipei, from September 2004 to September 2007. We excluded patients diagnosed with cancer and in remission for > 5 years, ICU stay of < 24 hours, and ICU admission for routine postoperative monitoring. A total of 85 patients were included and divided into younger (< 65 years) and older (≥ 65 years) groups for comparison. The mean ages of the younger and older group were 50.7 ± 3.6 years and 76.1 ± 1.9 years, respectively. There was no significance in ICU length of stay (8.6 ± 2.5 days vs. 11.7 ± 2.6 days; p = 0.09), in the proportion of high Adult Comorbidity Evaluation 27 grade (86.1% vs. 77.6%; p = 0.32). The most frequent reasons for ICU admission in the younger and older groups were acute respiratory failure (50.0% vs. 61.2%) and shock (41.7% vs. 24.5%). The elderly had significantly more sepsis (87.8% vs. 58.3%; p = 0.002) and bloodstream or intraperitoneal infection (34.7% vs. 13.9%; p = 0.03), and received earlier conventional mechanical ventilation (−0.3 ± 0.17 days vs. 0.13 ± 0.36 days; p = 0.045) and shorter vasopressor administration (2.07 ± 0.94 days vs. 5.36 ± 2.63 days; p = 0.03). The hospital survival times in younger and older groups were 36.3 ± 16.3 days and 60.9 ± 33.9 days ( p = 0.20), respectively, and 1-year survival rates were 2.8% and 12.2% ( p = 0.12), respectively. The main cause of death and survival rates, both short-term and long-term, were not worse in elderly patients with non-hematologic malignancies in the ICU, and the main reasons for patient death were sepsis and respiratory failure, rather than the malignancy itself. Therefore, an ICU admission policy should not exclude elderly patients with non-hematologic malignancies merely because of concerns about survival rate or life expectancy.

The Defined Trial Period in Ethical Decision Making

In the face of acute life-threatening illness, especially when superimposed upon chronic illness, patients and their families often face great difficulty in establishing treatment preferences and goals of care. This is especially true early in treatment when prognostication is difficult. The “defined trial period” is discussed and emphasized as a useful strategy in resolving some of these dilemmas. This strategy depends on acceptance of the moral and legal equivalency of withholding and withdrawing treatment. An unusual case is presented in which the use of a defined trial period enabled the entire care team to form a consensus on a treatment plan. Society faces a great challenge in how it balances competing interests in the allocation of scarce resources.

Effect of heat stress and bezafibrate on mitochondrial β-oxidation: Comparison between cultured cells from normal and mitochondrial fatty acid oxidation disorder children using in vitro probe acylcarnitine profiling assay

Hyperpyrexia occasionally triggers acute life-threatening encephalopathy-like illnesses, including influenza-associated encephalopathy (IAE) in childhood, and can be responsible for impaired fatty acid β-oxidation (FAO). In this regard, patients with impaired FAO may be more susceptible to febrile episodes. The effects of heat stress and a hypolipidemic drug, bezafibrate, on mitochondrial FAO were investigated using cultured cells from children with FAO disorders and from normal controls, using an in vitro probe acylcarnitine (AC) profiling assay. Fibroblasts were incubated in medium loaded with unlabelled palmitic acid for 96 h at 37 and 41 °C, with or without bezafibrate. AC profiles in culture medium were analyzed by electrospray ionization tandem mass spectrometry. Heat stress, introduced by 41 °C, significantly increased acetylcarnitine (C2) but slightly decreased the other acylcarnitines (ACs) in controls and medium-chain acyl-CoA dehydrogenase (MCAD)-deficient cells. On the other hand, in very long-chain acyl-CoA dehydrogenase (VLCAD)-deficient cells, accumulation of long-chain ACs were enhanced at 41 °C, compared with that at 37 °C. In contrast, bezafibrate decreased long-chain ACs with significant increase of C2 in both control and VLCAD-deficient cells at 37 °C. These data suggest that heat stress specifically inhibits long-chain FAO, whereas bezafibrate recovers the impaired FAO. Our approach is a simple and promising strategy to evaluate the effects of heat stress or therapeutic drugs on mitochondrial FAO.

Pain Management Principles in the Critically Ill

This article addresses conventional pharmacologic and nonpharmacologic treatment of pain in patients in ICUs. For the critically ill patient, opioids have been the mainstay of pain control. The optimal choice of opioid and dosing regimen for a specific patient varies depending on factors such as the pharmacokinetics and physicochemical characteristics of an opioid and the body's handling of the opioid, concomitant sedative regimen, potential or actual adverse drug events, and development of tolerance. The clinician must appreciate that favorable pharmacokinetic properties such as a short-elimination half-life do not necessarily translate into clinical advantages in the ICU setting. A variety of medications have been proposed as alternatives or adjuncts to the opioids for pain control that have unique considerations when contemplated for use in the critically ill patient. Most have been relatively unstudied in the ICU setting, and many have limitations with respect to availability of the GI route of administration in patients with questionable GI absorptive function. Nonpharmacologic, complementary therapies are low cost, easy to provide, and safe, and many clinicians can implement them with little difficulty or resources. However, the evidence base for their effectiveness is limited. At present, insufficient research evidence is available to support a broad implementation of nonpharmacologic therapies in ICUs.

Telemedicine in critical care.

Critical care medicine is the specialty that cares for patients with acute life-threatening illnesses where intensivists look after all aspects of patient care. Nevertheless, shortage of physicians and nurses, the relationship between high costs and economic restrictions, and the fact that critical care knowledge is only available at big hospitals puts the system on the edge. In this scenario, telemedicine might provide solutions to improve availability of critical care knowledge where the patient is located, improve relationship between attendants in different institutions and education material for future specialist training. Current information technologies and networking capabilities should be exploited to improve intensivist coverage, advanced alarm systems and to have large critical care databases of critical care signals.