The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit.

PURPOSE: This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting. METHODS: This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed. RESULTS: Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86). CONCLUSIONS: This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores.

Employment status and health: understanding the health of the economically inactive population in Scotland.

BACKGROUND: Although the association between health and unemployment has been well examined, less attention has been paid to the health of the economically inactive (EI) population. Scotland has one of the worst health records compared to any Western European country and the EI population account for 23% of the working age population. The aim of this study is to investigate and compare the health outcomes and behaviours of the employed, unemployed and the EI populations (further subdivided into the permanently sick, looking after home and family [LAHF] and others) in Scotland. METHODS: Using data from the 2003 Scottish Health Survey, the differences in health and health behaviours among the employed, unemployed and the subgroups of the EI population were examined. RESULTS: Both low educational attainment and residence in a deprived community were more likely in the permanently sick group. The LAHF and the unemployed showed worse self-reported health and limiting longstanding illness compared to the employed but no significant differences were observed between these groups. The permanently sick group had significantly poorer health outcomes than all the other economic groups. Similar to the unemployed and LAHF they are more likely to smoke than the employed but less likely (along with LAHF and 'others') to exhibit heavy alcohol consumption. Interestingly, the LAHF showed better mental health than the rest of the EI group, but a similar mental health status to the unemployed. On the physical health element of lung function, the LAHF were no worse than the employed. CONCLUSION: While on-going health promotion and vocational rehabilitation efforts need to be directed towards all, our data suggests that the EI group is at higher risk and policies and strategies directed at this group may need particular attention.

The implementation of a bowel management protocol in an adult intensive care unit.

AIM: A study to explore the impact of implementing a bowel management protocol in a tertiary referral intensive care unit (ICU) in the West of Scotland. METHODS: A three phase study was implemented. Phase 1 - a baseline audit reviewing 26 patients' medical notes and a baseline focus group reviewing the multidisciplinary team's (MDT's) opinions with regard to bowel care management in the ICU. Phase 2 - the implementation of a protocol, updated bowel care chart and education sessions for members of the MDT. Phase 3 - an end of study audit reviewing 27 patients' notes after the implementation of phase 2. Additionally, a further focus group examined the MDT's experiences of the protocol in clinical practice. RESULTS AND FINDINGS: During the phase 1 data collection period, it was evident that there was a haphazard approach to bowel care in the ICU, resulting in poor bowel care documentation and a high incidence of constipation and diarrhoea days. After the interventions of phase 2, bowel care documentation days increased by 13% (p = 0.0003), constipation incidence decreased by 20.7% (p = 0.13) and diarrhoea days reduced by 15.2% (p = 0.18). CONCLUSION: Although further evaluation is planned, the protocol implemented in this particular study appears to be a useful tool for the delivery of bowel care in the ICU. RELEVANCE TO CLINICAL PRACTICE: Ensuring appropriate and timely bowel care in the ICU has major implications for the critically ill patients.

Social fragmentation, deprivation and urbanicity: relation to first-admission rates for psychoses.

BACKGROUND: Social disorganisation, fragmentation and isolation have long been posited as influencing the rate of psychoses at area level. Measuring such societal constructs is difficult. A census-based index measuring social fragmentation has been proposed. AIMS: To investigate the association between first-admission rates for psychosis and area-based measures of social fragmentation, deprivation and urban/rural index. METHOD: We used indirect standardisation methods and logistic regression models to examine associations of social fragmentation, deprivation and urban/rural categories with first admissions for psychoses in Scotland for the 5-year period 1989-1993. RESULTS: Areas characterised by high social fragmentation had higher first-ever admission rates for psychosis independent of deprivation and urban/rural status. There was a dose-response relationship between social fragmentation category and first-ever admission rates for psychosis. There was no statistically significant interaction between social fragmentation, deprivation and urban/rural index. CONCLUSIONS: First-admission rates are strongly associated with measures of social fragmentation, independent of material deprivation and urban/rural category.

Diamorphine for pain relief in labour : a randomised controlled trial comparing intramuscular injection and patient-controlled analgesia.

OBJECTIVES: To compare the efficacy of diamorphine administered by a patient-controlled pump (patient-controlled analgesia) with intramuscular administration for pain relief in labour. DESIGN: Randomised controlled trial. SETTING: The South Glasgow University Hospitals NHS Trust. SAMPLE: Primigravidae and multigravidae in labour at term (37-42 weeks). METHODS: Women were randomised in labour to the study (patient-controlled analgesia) or control group (intramuscular). Randomisation was achieved through a random permuted block design stratified by parity. Study group women were given a loading dose of 1.2 mg diamorphine intravenously and then attached to the pump. Control group women received intramuscular diamorphine as per hospital protocol. Participants were also given 3 mg of buccal Stemetil. Data were collected throughout labour and at six postnatal weeks. MAIN OUTCOME MEASURES: Analgesia requirements during labour and women's satisfaction with the method of pain relief. RESULTS: Women in the study group (patient-controlled analgesia) used significantly less diamorphine than women in the control group (intramuscular) but were significantly more likely to state that they were very dissatisfied with their use of diamorphine and were significantly more likely to opt out of the trial before the birth of the baby. The majority of women in both groups used other analgesia concurrent with diamorphine such as Entonox, aromatherapy or TENS. CONCLUSIONS: Patient-controlled analgesia administration of diamorphine for the relief of pain in labour offers no significant advantages over intramuscular administration. The results also suggest that diamorphine is a poor analgesic for labour pain irrespective of the mode of administration.