Bedside Information Research Articles

EFFICACY OF ULTRASOUND MONITORING OF RECRUITMENT MANEUVER IN NEWBORNS WITH PULMONARY ATELECTASIS: A CLINICAL CASE STUDY

Real-time, routine bedside diagnosis of treatment effi cacy without radiation exposure is the greatest challenge facing intensive care medicine in respiratory disease, including neonates. Ultrasound for lung monitoring is a major step forward in the timely diagnosis of respiratory disease. The use of a recruitment maneuver has been shown to be eff ective in the treatment of atelectasis and safe while monitoring lung status. This article presents the experience of using an ultrasound- guided lung recruitment maneuver and a clinical case to demonstrate it.A child with respiratory distress syndrome was diagnosed with pulmonary atelectasis on day 3. A lung ultrasound- guided recruitment maneuver was performed using the method of controlled gradual increase of PEEP from 5 cm to 8 cm H2O for 2 minutes and then to 10-11 cm H2O for the next 2 minutes in PCV mode (pressure- controlled ventilation). PEEP was then titrated (decreased) to the minimum inspiratory pressure (5 cm H2O). SpO2 and capnography were closely monitored, and lung ultrasound was performed every 2 minutes during pressure increase to monitor status. Ultrasound imaging showed improvement of lung ventilation in the aff ected area during the recruitment maneuver (fi rst reduction of B-lines, then normal pattern with A-lines on the background of B-lines, normalization of respiratory movement of the pleura). Chest x-ray confi rmed resolution of atelectasis.The Bioethics Committee of ME «Regional Medical Center of Family Health» DRC» has approved the publication of materials.All anamnestic data, examination results and photographic materials were published with the written informed consent of the parents of the newborn.Conclusions. Ultrasound examination is a valid and appropriate diagnostic method that allows clinicians to obtain non-invasive, rapid, bedside information about the lung status of newborns with pulmonary atelectasis during the recruitment maneuver, avoiding the risks associated with radiography.

Recent advancements in critical care: Part I.

Medical colleges are now developing or refurbishing their anaesthesia intensive care units. In most teaching colleges, the residency post includes working in the critical care unit (CCU). Critical care is a rapidly evolving and popular super-speciality for postgraduate students. In some hospitals, anaesthesiologists play a key role in the management of the CCU. As perioperative physicians, all anaesthesiologists should be aware of the recent advancements in diagnostic and monitoring gadgets and investigations in critical care so that they may manage perioperative events effectively. Haemodynamic monitoring gives us warning signs about the change in the internal milieu of the patient. Point-of-care ultrasonography helps in rapid differential diagnosis. Point-of-care diagnostics give us instant bed-side information on the condition of a patient. Biomarkers help in confirming diagnosis, in monitoring, treatment, and providing prognosis. Molecular diagnostics guide anaesthesiologists in providing specific treatment to a causative agent. This article touches upon all of these management strategies in critical care and attempts to put forth the recent advancements in this speciality.

Regional Lung Perfusion Analysis in Experimental ARDS by Electrical Impedance and Computed Tomography.

Electrical impedance tomography is clinically used to trace ventilation related changes in electrical conductivity of lung tissue. Estimating regional pulmonary perfusion using electrical impedance tomography is still a matter of research. To support clinical decision making, reliable bedside information of pulmonary perfusion is needed. We introduce a method to robustly detect pulmonary perfusion based on indicator-enhanced electrical impedance tomography and validate it by dynamic multidetector computed tomography in two experimental models of acute respiratory distress syndrome. The acute injury was induced in a sublobar segment of the right lung by saline lavage or endotoxin instillation in eight anesthetized mechanically ventilated pigs. For electrical impedance tomography measurements, a conductive bolus (10% saline solution) was injected into the right ventricle during breath hold. Electrical impedance tomography perfusion images were reconstructed by linear and normalized Gauss-Newton reconstruction on a finite element mesh with subsequent element-wise signal and feature analysis. An iodinated contrast agent was used to compute pulmonary blood flow via dynamic multidetector computed tomography. Spatial perfusion was estimated based on first-pass indicator dilution for both electrical impedance and multidetector computed tomography and compared by Pearson correlation and Bland-Altman analysis. Strong correlation was found in dorsoventral (r = 0.92) and in right-to-left directions (r = 0.85) with good limits of agreement of 8.74% in eight lung segments. With a robust electrical impedance tomography perfusion estimation method, we found strong agreement between multidetector computed and electrical impedance tomography perfusion in healthy and regionally injured lungs and demonstrated feasibility of electrical impedance tomography perfusion imaging.

Enfermagem na assistência centrada ao paciente em unidade de terapia intensiva: contribuição de um display informativo

Objetivo: Analisar as metas traçadas através de um display informativo í beira leito, a partir da perspectiva da experiência do paciente e discutir as metas diárias descritas í luz do cuidado centrado no paciente. Métodos: Pesquisa qualitativa do tipo exploratória, descritiva e documental. Realizado de maio a julho de 2019, em uma Unidade de Terapia Intensiva cardí­aca de um hospital público universitário do municí­pio do Rio de Janeiro. Os dados foram coletados através de um display informativo. Resultados: Foram analisados 30 displays. A meta mais mencionada pelos pacientes esteve relacionada í alta hospitalar, saúde e bem estar, relatada por 22(78,8%) vezes no display informativo í beira leito. Conclusão: O estudo concluiu que o displayinformativo í beira leito poderá contribuir como uma ferramenta facilitadora de comunicação de metas do paciente e estabelecer estratégias para oferta do cuidado centrado no paciente. 
 Descritores: Assistência de Enfermagem . Assistência centrada no paciente. Comunicação em saúde. Segurança do paciente. Unidade de Terapia Intensiva.

Real-time effects of PEEP and tidal volume on regional ventilation and perfusion in experimental lung injury

BackgroundReal-time bedside information on regional ventilation and perfusion during mechanical ventilation (MV) may help to elucidate the physiological and pathophysiological effects of MV settings in healthy and injured lungs. We aimed to study the effects of positive end-expiratory pressure (PEEP) and tidal volume (VT) on the distributions of regional ventilation and perfusion by electrical impedance tomography (EIT) in healthy and injured lungs.MethodsOne-hit acute lung injury model was established in 6 piglets by repeated lung lavages (injured group). Four ventilated piglets served as the control group. A randomized sequence of any possible combination of three VT (7, 10, and 15 ml/kg) and four levels of PEEP (5, 8, 10, and 12 cmH2O) was performed in all animals. Ventilation and perfusion distributions were computed by EIT within three regions-of-interest (ROIs): nondependent, middle, dependent. A mixed design with one between-subjects factor (group: intervention or control), and two within-subjects factors (PEEP and VT) was used, with a three-way mixed analysis of variance (ANOVA).ResultsTwo-way interactions between PEEP and group, and VT and group, were observed for the dependent ROI (p = 0.035 and 0.012, respectively), indicating that the increase in the dependent ROI ventilation was greater at higher PEEP and VT in the injured group than in the control group. A two-way interaction between PEEP and VT was observed for perfusion distribution in each ROI: nondependent (p = 0.030), middle (p = 0.006), and dependent (p = 0.001); no interaction was observed between injured and control groups.ConclusionsLarge PEEP and VT levels were associated with greater pulmonary ventilation of the dependent lung region in experimental lung injury, whereas they affected pulmonary perfusion of all lung regions both in the control and in the experimental lung injury groups.

Creating a High-Frequency Electronic Database in the PICU: The Perpetual Patient.

Our objective was to construct a prospective high-quality and high-frequency database combining patient therapeutics and clinical variables in real time, automatically fed by the information system and network architecture available through fully electronic charting in our PICU. The purpose of this article is to describe the data acquisition process from bedside to the research electronic database. Descriptive report and analysis of a prospective database. A 24-bed PICU, medical ICU, surgical ICU, and cardiac ICU in a tertiary care free-standing maternal child health center in Canada. All patients less than 18 years old were included at admission to the PICU. None. Between May 21, 2015, and December 31, 2016, 1,386 consecutive PICU stays from 1,194 patients were recorded in the database. Data were prospectively collected from admission to discharge, every 5 seconds from monitors and every 30 seconds from mechanical ventilators and infusion pumps. These data were linked to the patient's electronic medical record. The database total volume was 241 GB. The patients' median age was 2.0 years (interquartile range, 0.0-9.0). Data were available for all mechanically ventilated patients (n = 511; recorded duration, 77,678 hr), and respiratory failure was the most frequent reason for admission (n = 360). The complete pharmacologic profile was synched to database for all PICU stays. Following this implementation, a validation phase is in process and several research projects are ongoing using this high-fidelity database. Using the existing bedside information system and network architecture of our PICU, we implemented an ongoing high-fidelity prospectively collected electronic database, preventing the continuous loss of scientific information. This offers the opportunity to develop research on clinical decision support systems and computational models of cardiorespiratory physiology for example.

Contrast-Enhanced Ultrasound Imaging in Detection of Changes in Cerebral Perfusion

Contrast-enhanced ultrasonography (CEU) is a non-invasive imaging technique that provides real-time, bedside information on changes in global and segmental organ perfusion. Currently, there is a lack of data concerning changes in the distribution of segmental brain perfusion in acute ischemic stroke treated by decompressive craniectomy. The aim of our case series was to assess the role of CEU after decompressive craniectomy in patients with acute ischemic stroke. CEU was performed in 12 patients at baseline and after any one of the following interventions was performed as dictated by the patient's clinical condition: vasoactive drug administration (in order to achieve cerebral perfusion pressure ≥70 mm Hg and mean arterial pressure <100 mm Hg for management of arterial blood pressure) and mild hyperventilation (carbon dioxide arterial pressure = 30–35 mm Hg). CEU was able to detect a significant variation in cerebral contrast distribution in both normal and pathologic hemispheres after induced hyperventilation (difference in time to peak [dTTP] = −38.4%), vasodilation (dTTP = −6.6%) and vasoconstriction (dTTP = +31.2%) (p < 0.05). CEU can be useful in assessing real-time cerebral perfusion changes in neurocritical care patients.

Capnogram slope and ventilation dead space parameters: comparison of mainstream and sidestream techniques

BackgroundCapnography may provide useful non-invasive bedside information concerning heterogeneity in lung ventilation, ventilation–perfusion mismatching and metabolic status. Although the capnogram may be recorded by mainstream and sidestream techniques, the capnogram indices furnished by these approaches have not previously been compared systematically. MethodsSimultaneous mainstream and sidestream time and volumetric capnography was performed in anaesthetized, mechanically ventilated patients undergoing elective heart surgery. Time capnography was used to assess the phase II (SII,T) and III slopes (SIII,T). The volumetric method was applied to estimate phase II (SII,V) and III slopes (SIII,V), together with the dead space values according to the Fowler (VDF), Bohr (VDB), and Enghoff (VDE) methods and the volume of CO2 eliminated per breath ( VCO2). The partial pressure of end-tidal CO2 ( PETCO2) was registered. ResultsExcellent correlation and good agreement were observed in SIII,T measured by the mainstream and sidestream techniques [ratio=1.05 (sem 0.16), R2=0.92, P<0.0001]. Although the sidestream technique significantly underestimated VCO2 and overestimated SIII,V [1.32 (0.28), R2=0.93, P<0.0001], VDF, VDB, and VDE, the agreement between the mainstream and sidestream techniques in the difference between VDE and VDB, reflecting the intrapulmonary shunt, was excellent [0.97 (0.004), R2=0.92, P<0.0001]. The PETCO2 exhibited good correlation and mild differences between the mainstream and sidestream approaches [0.025 (0.005) kPa]. ConclusionsSidestream capnography provides adequate quantitative bedside information about uneven alveolar emptying and ventilation–perfusion mismatching, because it allows reliable assessments of the phase III slope, PETCO2 and intrapulmonary shunt. Reliable measurement of volumetric parameters (phase II slope, dead spaces, and eliminated CO2 volumes) requires the application of a mainstream device.

Spotlight on the November 24 Issue

#### Notable in Neurology This issue features an article quantifying the effects of cognitive training on behavioral outcome measures in patients with Parkinson disease and another considering the use of nonvenous drugs as first-line treatment for controlling acute convulsive seizures and status epilepticus. Another article focuses on the ability of bedside information to risk stratify stroke in acute dizziness presentations. ### Increased CSF biomarkers of angiogenesis in Parkinson disease![Graphic][1]</img> The authors analyzed angiogenesis biomarkers in Parkinson disease (PD) and their association with clinical characteristics, blood-brain barrier permeability, and cerebrovascular … [1]: /embed/inline-graphic-1.gif

Stroke risk stratification in acute dizziness presentations: A prospective imaging-based study.

To estimate the ability of bedside information to risk stratify stroke in acute dizziness presentations. Surveillance methods were used to identify patients with acute dizziness and nystagmus or imbalance, excluding those with benign paroxysmal positional vertigo, medical causes, or moderate to severe neurologic deficits. Stroke was defined as acute infarction or intracerebral hemorrhage on a clinical or research MRI performed within 14 days of dizziness onset. Bedside information comprised history of stroke, the ABCD(2) score (age, blood pressure, clinical features, duration, and diabetes), an ocular motor (OM)-based assessment (head impulse test, nystagmus pattern [central vs other], test of skew), and a general neurologic examination for other CNS features. Multivariable logistic regression was used to determine the association of the bedside information with stroke. Model calibration was assessed using low (<5%), intermediate (5% to <10%), and high (≥10%) predicted probability risk categories. Acute stroke was identified in 29 of 272 patients (10.7%). Associations with stroke were as follows: ABCD(2) score (continuous) (odds ratio [OR] 1.74; 95% confidence interval [CI] 1.20-2.51), any other CNS features (OR 2.54; 95% CI 1.06-6.08), OM assessment (OR 2.82; 95% CI 0.96-8.30), and prior stroke (OR 0.48; 95% CI 0.05-4.57). No stroke cases were in the model's low-risk probability category (0/86, 0%), whereas 9 were in the moderate-risk category (9/94, 9.6%) and 20 were in the high-risk category (20/92, 21.7%). In acute dizziness presentations, the combination of ABCD(2) score, general neurologic examination, and a specialized OM examination has the capacity to risk-stratify acute stroke on MRI.

Contrast-enhanced ultrasound: clinical applications in patients with atherosclerosis.

Contrast-enhanced ultrasound (CEUS) is increasingly being used to evaluate patients with known or suspected atherosclerosis. The administration of a microbubble contrast agent in conjunction with ultrasound results in an improved image quality and provides information that cannot be assessed with standard B-mode ultrasound. CEUS is a high-resolution, noninvasive imaging modality, which is safe and may benefit patients with coronary, carotid, or aortic atherosclerosis. CEUS allows a reliable assessment of endocardial borders, left ventricular function, intracardiac thrombus and myocardial perfusion. CEUS results in an improved detection of carotid atherosclerosis, and allows assessment of high-risk plaque characteristics including intraplaque vascularization, and ulceration. CEUS provides real-time bedside information in patients with a suspected or known abdominal aortic aneurysm or aortic dissection. The absence of ionizing radiation and safety of the contrast agent allow repetitive imaging which is particularly useful in the follow-up of patients after endovascular aneurysm repair. New developments in CEUS-based molecular imaging will improve the understanding of the pathophysiology of atherosclerosis and may in the future allow to image and directly treat cardiovascular diseases (theragnostic CEUS). Familiarity with the strengths and limitations of CEUS may have a major impact on the management of patients with atherosclerosis.

Circulating levels of miR-133a predict the regression potential of left ventricular hypertrophy after valve replacement surgery in patients with aortic stenosis.

BackgroundMyocardial microRNA‐133a (miR‐133a) is directly related to reverse remodeling after pressure overload release in aortic stenosis patients. Herein, we assessed the significance of plasma miR‐133a as an accessible biomarker with prognostic value in predicting the reversibility potential of LV hypertrophy after aortic valve replacement (AVR) in these patients.Methods and ResultsThe expressions of miR‐133a and its targets were measured in LV biopsies from 74 aortic stenosis patients. Circulating miR‐133a was measured in peripheral and coronary sinus blood. LV mass reduction was determined echocardiographically. Myocardial and plasma levels of miR‐133a correlated directly (r=0.46, P<0.001) supporting the myocardium as a relevant source of plasma miR‐133a. Accordingly, a significant gradient of miR‐133a was found between coronary and systemic venous blood. The preoperative plasma level of miR‐133a was higher in the patients who normalized LV mass 1 year after AVR than in those exhibiting residual hypertrophy. Logistic regression analysis identified plasma miR‐133a as a positive predictor of the hypertrophy reversibility after surgery. The discrimination of the model yielded an area under the receiver operator characteristic curve of 0.89 (P<0.001). Multiple linear regression analysis revealed plasma miR‐133a and its myocardial target Wolf‐Hirschhorn syndrome candidate 2/Negative elongation factor A as opposite predictors of the LV mass loss (g) after AVR.ConclusionsPreoperative plasma levels of miR‐133a reflect their myocardial expression and predict the regression potential of LV hypertrophy after AVR. The value of this bedside information for the surgical timing, particularly in asymptomatic aortic stenosis patients, deserves confirmation in further clinical studies.

A Novel Method for Monitoring Data Quality in Electrical Impedance Tomography

Electrical impedance tomography (EIT) has the promise to help improve care for patients undergoing ventilation therapy by providing real-time bed-side information on the distribution of ventilation in their lungs. To realise this potential, it is important for an EIT system to provide a reliable and meaningful signal at all times, or alert clinicians when this is not possible. Because the reconstructed images in EIT are sensitive to system instabilities (including electrode connection problems) and artifacts caused by e.g. movement or sweat, there is a need for EIT systems to continuously monitor, recognize and, if possible, correct for such errors. Motivated by this requirement, our paper describes a novel approach to quantitatively measure EIT data quality suitable for online and offline applications. We used a publicly available data set of ventilation data from two pediatric patients with lung disease to evaluate the data quality on clinical data. Results suggest that the developed data quality could be a useful tool for real-time assessment of the quality of EIT data and, hence, to indicate the reliability of any derived physiological information.

Abstract WP46: Blood Pressure, Clinical Improvement And Recanalization Following Acute MCA Occlusion

Background: Blood pressure (BP) drop in the first 24 hours after stroke onset may occur in response to vessel recanalization. Clinical improvement could be due to recanalization or better collateral flow with persistent occlusion. We hypothesize that patients with combination of significant improvement on the NIHSS and a drop in BP at 24hr post tPA is associated with recanalization. Methods: We included intravenous t-PA patients from the Lesion Evolution of Stroke Ischemia On Neuroimaging (LESION) registry who had pre-treatment and 24 hour MRA scan, NIHSS scores at those times and an M1 MCA occlusion at baseline, but excluded those on pressors, pre tPA SBP&lt;120 and tandem ICA occlusion. We classified recanalization status on the 24 hour MRA as none, partial or complete. We abstracted all BP measurements for the first 24 hours from the chart and calculated BP drop as the difference of the triage pre-tPA BP and the average of the last 3 hour readings preceding the 24 hour MRI. NIHSS improvement was defined as ≥4points improvement on NIHSS or NIHSS of 0 at 24hour. Patients with combination of drop in BP and NIHSS improvement were compared with others for recanalization status on 24hr MRA by Kendall Tau-b test. Results: Seventeen patients met the study criteria. There were 13 women, the mean age was 76 years and the median baseline NIHSS was 15. On the 24 hour MRA, 3, 8 and 6 patients had none, partial and complete recanalization, respectively. Patients with NIHSS improvement and a SBP drop ≥20 mmHg were more like to have recanalization at 24 hrs (57% Vs 0%, p=0.03). Similar patterns were seen for patients with NIHSS improvement and DBP drop ≥5mmHg (50% Vs 0%, p=0.04) or MAP drop ≥20mmHg (50% Vs 0%, p=0.04). Complete recanalization was only associated with the combination of NIHSS improvement with SBP drop ≥ 20mmHg (66% Vs 0%, p=0.04). A significant association was not found for recanalization with NIHSS improvement alone or drop in BP alone. Conclusion: There is an association of clinical improvement and BP drop in patients who recanalize. Bedside clinical information may be useful in the management of stroke patients.

Unlocking the Potential of Electronic Health Records for Translational Research

To review current excellent research and trend in the field of bioinformatics and translational informatics with direct application in the medical domain. Synopsis of the articles selected for the IMIA Yearbook 2012. Six excellent articles were selected in this Yearbook's section on Bioinformatics and Translational Informatics. They exemplify current key advances in the use of patient information for translational research and health surveillance. First, two proof-of-concept studies demonstrated the cross-institutional and -geographic use of Electronic Health Records (EHR) for clinical trial subjects identification and drug safety signals detection. These reports pave ways to global large-scale population monitoring. Second, there is further evidence on the importance of coupling phenotypic information in EHR with genotypic information (either in biobank or in gene association studies) for new biomedical knowledge discovery. Third, patient data gathered via social media and self-reporting was found to be comparable to existent data and less labor intensive. This alternative means could potentially overcome data collection challenge in cohort and prospective studies. Finally, it can be noted that metagenomic studies are gaining momentum in bioinformatics and system-level analysis of human microbiome sheds important light on certain human diseases. The current literature showed that the traditional bench to bedside translational research is increasing being complemented by the reverse approach, in which bedside information can be used to provide novel biomedical insights.

Bedside information technology to support patient-centered care

PurposePatients and health care providers often lack real time access to information at the bedside required to provide safe patient-centered care. Both groups identified pertinent information needed at the patient's bedside. The purpose of our research was to identify the essential data elements that will be used to define requirements for a useful bedside communication tool in the acute care hospital setting. MethodsDescriptive research methods were used to identify bedside information requirements through group and individual interviews. Data from patients and health care providers were analyzed to identify common themes, compiled into a survey, and validated by both groups. ResultsThirty-seven information requirements were identified and classified under five themes: (1) plan of care, (2) patient education, (3) communication of safety alerts, (4) diet, and (5) medications. A survey completed by 30 patients and 30 health care providers confirmed 36 specific bedside information requirements (mean≥5 on an 11-point scale). Patients and health providers each identified 24 specific information requirements that were similar in importance. When compared with nurses, significant differences were noted in the degree to which patients identified knowing the “daily routine schedule,” e.g. when their doctor typically sees patients as a key requirement for the electronic bedside communication tool, t=3.52, p=.001. ConclusionPatients and health care providers identified information requirements at the bedside to promote self-care management of healthcare needs and an understanding of the hospital environment. Accurate, easily accessed information at the bedside is needed for providing safe patient-centered care.

Prospective pilot study of a tablet computer in an Emergency Department

BackgroundThe recent availability of low-cost tablet computers can facilitate bedside information retrieval by clinicians. ObjectiveTo evaluate the effect of physician tablet use in the Emergency Department. DesignProspective cohort study comparing physician workstation usage with and without a tablet. Setting55,000 visits/year Level 1 Emergency Department at a tertiary academic teaching hospital. Participants13 emergency physicians (7 Attendings, 4 EM3s, and 2 EM1s) worked a total of 168 scheduled shifts (130 without and 38 with tablets) during the study period. InterventionPhysician use of a tablet computer while delivering direct patient care in the Emergency Department. Main Outcome MeasuresThe primary outcome measure was the time spent using the Emergency Department Information System (EDIS) at a computer workstation per shift. The secondary outcome measure was the number of EDIS logins at a computer workstation per shift. ResultsClinician use of a tablet was associated with a 38min (17–59) decrease in time spent per shift using the EDIS at a computer workstation (p<0.001) after adjusting for clinical role, location, and shift length. The number of logins was also associated with a 5-login (2.2–7.9) decrease per shift (p<0.001) after adjusting for other covariates. ConclusionClinical use of a tablet computer was associated with a reduction in the number of times physicians logged into a computer workstation and a reduction in the amount of time they spent there using the EDIS. The presumed benefit is that decreasing time at a computer workstation increases physician availability at the bedside. However, this association will require further investigation.

A comparison of answer retrieval through four evidence-based textbooks (ACP PIER, Essential Evidence Plus, First Consult, and UpToDate): A randomized controlled trial

Background: The efficacy of bedside information products has not been properly evaluated, particularly in developing countries.Aim: To compare four evidence-based textbooks by comparing efficacy of their use by clinical residents, as measured by the proportion of questions for which relevant answers could be obtained within 20 min, the time to reach the answer and user satisfaction.Methods: One hundred and twelve residents were taught information mastery basics and were randomly allocated to four groups to use: (1) ACP PIER, (2) Essential Evidence Plus (formerly InfoRetriever), (3) First Consult, and (4) UpToDate. Participants received 3 of 24 questions randomly to retrieve the answers from the assigned textbook. Retrieved answers and time-to-answers were recorded by special designed software, and the researchers determined if each recorded answer was relevant.Results: The rate of answer retrieval was 86% in UpToDate, 69% in First Consult, 49% in ACP PIER, and 45% in Essential Evidence Plus (p < 0.001). The mean time-to-answer was 14.6 min using UpToDate, 15.9 min using First Consult, 16.3 min using Essential Evidence Plus, and 17.3 min using ACP PIER (p < 0.001).Conclusion: UpToDate seems more comprehensive in content and also faster than the other three evidence-based textbooks. Thus, it may be considered as one of the best sources for answering clinicians’ questions at the point of care.

Factors Predicting and Reducing Mortality in Patients with Invasive Staphylococcus aureus Disease in a Developing Country

BackgroundInvasive Staphylococcus aureus infection is increasingly recognised as an important cause of serious sepsis across the developing world, with mortality rates higher than those in the developed world. The factors determining mortality in developing countries have not been identified.MethodsA prospective, observational study of invasive S. aureus disease was conducted at a provincial hospital in northeast Thailand over a 1-year period. All-cause and S. aureus-attributable mortality rates were determined, and the relationship was assessed between death and patient characteristics, clinical presentations, antibiotic therapy and resistance, drainage of pus and carriage of genes encoding Panton-Valentine Leukocidin (PVL).Principal FindingsA total of 270 patients with invasive S. aureus infection were recruited. The range of clinical manifestations was broad and comparable to that described in developed countries. All-cause and S. aureus-attributable mortality rates were 26% and 20%, respectively. Early antibiotic therapy and drainage of pus were associated with a survival advantage (both p<0.001) on univariate analysis. Patients infected by a PVL gene-positive isolate (122/248 tested, 49%) had a strong survival advantage compared with patients infected by a PVL gene-negative isolate (all-cause mortality 11% versus 39% respectively, p<0.001). Multiple logistic regression analysis using all variables significant on univariate analysis revealed that age, underlying cardiac disease and respiratory infection were risk factors for all-cause and S. aureus-attributable mortality, while one or more abscesses as the presenting clinical feature and procedures for infectious source control were associated with survival.ConclusionsDrainage of pus and timely antibiotic therapy are key to the successful management of S. aureus infection in the developing world. Defining the presence of genes encoding PVL provides no practical bedside information and draws attention away from identifying verified clinical risk factors and those interventions that save lives.

Custom‐Made Raster Method for Fistula and Graft

SUMMARY Unfamiliarity with fistula and graft characteristics can lead to failed punctures, haematomas and sometimes access occlusion. The Custom-made Raster Method provides detailed shunt visualisation and angiographic images by using photo-editing software. Access veins of an individual shunt and an adapted raster are projected on a digital picture of the arm. During angiography the shunt arm is fixated and a digital picture is taken from a fixed vertical angle and distance. Reference points are marked on the shunt arm, which serves as a fixation to draw a raster with coordination points. In this way a picture is created similar to a roadmap with veins. There is complete integration of digital and radiological images by using software programmes Adobe Photoshop® + Illustrator® or Agfa Web 1000® under Windows XP®. All illustrations fit 1:1 by scaling up or down without distortion. Editing with Photoshop® gives a precise projection of shunt veins on the real coloured background of the digital photograph. In this projection the grey angiography background is made completely transparent. The system can contain more detailed information in combination with echo (duplex) images of depth and diameter. This visualisation method is a useful tool for multi disciplinary access meetings with intervention radiologists, access surgeons and nephrologists. Access malfunction, aneurysms and stenosis can be projected at the exact location. The system leads to clear and concrete puncture advice. Transfer of access information and communication to other dialysis centres is facilitated.