Both acuity and long term prognosis are important Emergency Department metrics: comparison of mobility assessment with the Emergency Severity Index.

OBJECTIVE: To compare the SUHB mobility scale (i.e., stable(S), unstable gait(U), needing help to walk(H), or bedridden(B)) and the Emergency Severity Index (ESI) associations with admission and mortality outcomes. DESIGN: Post-hoc analysis of a prospective observational study including all consenting presenting to the ED over a period of 3 weeks. Odd ratios and AUCs were calculated to assess predictive performance of SUHB and compared with ESI. RESULTS: Out of 2422 patients, 65% presented with a stable gait, 45% with an ESI level 3. With increasing mobility impairment on the SUHB scale, the probability for admission and mortality increased. SUHB had a higher AUC than ESI for 1-year mortality. CONCLUSION: SUHB was a better predictor than ESI of long-term mortality. The scale, which is rapid, requires little additional training, and no extra costs, could be used as a useful supplement to the triage process.

Evaluation of systemic vasoconstriction and prognosis using thermography: a systematic review.

PURPOSE: This systematic review investigates whether infrared thermography (IRT) can measure systemic vasoconstriction and addresses the value of IRT in assessing circulatory deficiency and prognoses. METHODS: Design was based on the PRISMA criteria and a systematic search of 6 databases was performed. RESULTS: Of 3,198 records, five articles were included. Three clinical studies were identified; two found significant correlations between IRT obtained temperatures and mortality. An experimental study found an association between peripheral temperature and stroke volume. An animal study found that central-peripheral temperature differences correlated with shock index, mean arterial pressure, and disease progression. CONCLUSIONS: Data from the most valid study suggests that central-peripheral temperature differences should be investigated further, both on its own, and integrated with other variables.

Fever increases heart rate and respiratory rate; a prospective observational study of acutely admitted medical patients.

BACKGROUND: The relationship between increase in body temperature, heart rate, and respiratory rate has only been studied in young, healthy subjects. AIM: To show the changes in heart and respiratory rate associated with fever in acutely admitted medical patients. DESIGN: A prospective observational cohort study. METHODS: Vital parameters from 4,493 patients were retrospectively extracted. Linear and multiple variable regression analysis was used to calculate the change in heart and temperature rate for every degree rise in temperature (i.e. ΔHR/°C and ΔRR/°C) in the entire study group and in those with low (<36.1°C), normal (36.1-38°C) and high (>38°C) body temperatures. RESULTS: The ΔHR/°C and ΔRR/°C was 7.2±0.4 beats per minute (bpm) and 1.4 ±0.1 (1.2 to 1.62) breaths per minute (bpm). Adjusting for age, oxygen saturation and mean blood pressure, the results were 6.4±0.4 (5.7 to 7.1) bpm and 1.2±0.1 (1.0 to 1.4) bpm. In low, normal and high body temperature the ΔHR/°C were 2.7±1.9, 6.9±1.9 and 7.4±0.9 bpm, respectively; for ΔRR/°C the values were -0.5±0.5, 1.5±0.5 and 2.3±0.3 bpm, respectively. CONCLUSIONS: We only found a modest association between fever and changes in heart rate and respiratory rate.

Differences in identification of patients' deterioration may hamper the success of clinical escalation protocols.

BACKGROUND: Timely and consistent recognition of a 'clinical crisis', a life threatening condition that demands immediate intervention, is essential to reduce 'failure to rescue' rates in general wards. AIM: To determine how different clinical caregivers define a 'clinical crisis' and how they respond to it. DESIGN: An international survey. METHODS: Clinicians working on general wards, intensive care units or emergency departments in the Netherlands, the United Kingdom and Denmark were asked to review ten scenarios based on common real-life cases. Then they were asked to grade the urgency and severity of the scenario, their degree of concern, their estimate for the risk for death and indicate their preferred action for escalation. The primary outcome was the scenarios with a National Early Warning Score (NEWS) ≥7 considered to be a 'clinical crisis'. Secondary outcomes included how often a rapid response system (RRS) was activated, and if this was influenced by the participant's professional role or experience. The data from all participants in all three countries was pooled for analysis. RESULTS: A total of 150 clinicians participated in the survey. The highest percentage of clinicians that considered one of the three scenarios with a NEWS ≥7 as a 'clinical crisis' was 52%, while a RRS was activated by <50% of participants. Professional roles and job experience only had a minor influence on the recognition of a 'clinical crisis' and how it should be responded to. CONCLUSION: This international survey indicates that clinicians differ on what they consider to be a 'clinical crisis' and on how it should be managed. Even in cases with a markedly abnormal physiology (i.e. NEWS ≥7) many clinicians do not consider immediate activation of a RRS is required.

Collaborative Audit of Risk Evaluation in Medical Emergency Treatment (CARE-MET I) - an international pilot.

BACKGROUND: The absence of an accepted model for risk-adjustment of acute medical admissions leads to suboptimal clinical triage and serves as a disincentive to compare outcomes in different hospitals. The Simple Clinical Score (SCS) is a model based on 16 clinical parameters affecting hospital mortality. METHODS: We undertook a feasibility pilot in 21 hospitals in Europe and New Zealand each collecting data for 12 or more consecutive medical emergency admissions. Data from 281 patients was analysed. RESULTS: Severity of illness as estimated by SCS was related to risk of admission to the Intensive Care Unit (p<0.001) but not to the Coronary Care Unit. Mortality increased from 0% in the Very Low Risk group to 22% in the Very High Risk Group (p<0.0001). Very low scores were associated with earlier discharge as opposed to very high scores (mean length of stay of 2.4 days vs 5.6 days, p<0.001). There were differences in the pattern of discharges in different hospitals with comparable SCS data. Clinicians reported no significant problems with the collection of data for the score in a number of different health care settings. CONCLUSION: The SCS appears to be a feasible tool to assist clinical triage of medical emergency admissions. The ability to view the profile of the SCS for different clinical centres opens up the possibility of accurate comparison of outcomes across clinical centres without distortion by different regional standards of health care. This pilot study demonstrates that the adoption of the SCS is practical across an international range of hospitals.

Whither the rationale for thrombolytic agent administration? A retrospective review of traditional intuitive decision-making using a decision analysis model.

Of 50 consecutive patients admitted to Nenagh Hospital coronary care unit 50 per cent did not develop a myocardial infarction. Only 10 patients had definite evidence of infarction on admission. Of the 40 remaining patients, only 15 subsequently developed electrocardiographic and enzymatic confirmation of infarction. Streptokinase was administered to 5 patients who did not infarct, and was not given to 10 patients who did. These decisions to use or withhold thrombolytic therapy were retrospectively reviewed using a computer programme incorporating a decision analysis of the benefits and risks of thrombolysis. The programme examined four scenarios that used different estimates of the chance of death from infarction (pdiMI), and different safety profiles of thrombolytics. The scenario that assumed the worst safety profile and estimated pdiMI from patient age would have recommended thrombolytic treatment to the most with, and to the least without, acute infarction (i.e. 60 per cent of patients with an infarct and 8 per cent without an infarct would have been treated). Depending on the scenario assumed, the traditional intuitive method of decision-making gained from 0.08 and 0.25 quality adjusted life years (QALY's) for the average patient. Had decision analysis been used to guide these decisions these gains would have been enhanced by from 0.21 to 0.28 QALY's per patient, regardless of scenario used.

A thrombolytic decision tree.

We constructed a decision analysis model based on data in the medical literature to estimate the possible outcomes of thrombolytic therapy in patients 50 to 80 years old with possible myocardial infarction. We used the model to test the most likely effects of treatment (determined by averaging the values in reports of large studies) and the worst effects reported so far. The program begins by asking the patient's age, the hours from the onset of pain, and the probability of acute myocardial infarction. It then provides an opportunity to perform sensitivity analyses by changing the values for these variables and for the probability of death in the absence of thrombolytic therapy, as well as for the probability of major stroke and hemorrhage. The counterintuitive findings observed with this program are that the benefits of thrombolytic therapy increase with age and that young patients derive surprisingly little benefit from it.

The effect of growth hormone treatment on somatomedin levels in growth hormone-deficient children.

Serum levels of immunoreactive somatomedin (IRSM) and insulin-like activity (ILAs) by receptor assay have been measured in 177 GH-deficient (GHD) children treated with 2 U GH three times weekly for 6-10 months. The overall mean (+/- SD) pretreatment IRSM and ILAs levels were 0.21 +/- 0.30 and 0.39 +/- 0.25 U/ml, respectively. Pretreatment IRSM and ILAs levels were in the normal range for chronological age and sex in 15.8% and 33% of these GHD children. Mean IRSM and ILAs levels increased after 1 month of therapy to 0.36 +/- 0.51 and 0.62 +/- 0.33 U/ml, respectively (P less than .0001). The increase in serum IRSM levels (from 0.2 to 2.0 U/ml) that normally occurs from 1-16 yr of age is also evident in untreated GHD children, albeit to a lesser extent. In addition, the mean increase in IRSM after GH was greater in older patients. However, individual responses varied greatly. An increase in IRSM or ILAs with an increase in height velocity (HV) was observed in the majority of children, but all other combinations occurred, including increased SM with decreased HV, decreased SM with increased HV, and decreased SM with decreased HV. In summary 1) age-dependent factors in GHD children importantly influence basal and treatment SM leels; 2) a basal SM level is not a very sensitive diagnostic test, since a significant proportion of GHD children have SM levels in the normal range; and, 3) SM levels in individual patients may not increase with GH therapy and, thus, cannot be used to predict a clinical response to GH therapy.

The characterization of growth factor activity in human brain.

The purification of fibroblast growth factor from bovine brain has been reported (Gospodarowicz, D., Bialecki, H., and Greenberg, G. (1978) J. Biol. Chem. 253, 3736-3743). Westall et al. (Westall, F. C., Lennon, V. A., and Gospodarowicz, D. (1978) Proc. Natl. Acad. Sci. U. S. A. 75, 4675-4678) showed that bovine brain fibroblast growth factor was composed of three fragments derived by limited proteolysis from myelin basic protein. In the present study using similar purification methods, we isolated a fraction enriched in growth factor activity from human brain. The mitogenic activity could not be resolved from myelin basic protein by chromatographic procedures but, upon isoelectric focusing, the mitogen and myelin basic protein were readily dissociated. At least two potent growth factors (pI values 7.2 to 7.4 and 8.1 to 8.6) were identified. Studies of a relatively crude basic extract of human brain suggested that the brain may contain a number of growth factors.