National early warning score at Emergency Department triage may allow earlier identification of patients with severe sepsis and septic shock: a retrospective observational study.

INTRODUCTION: Severe sepsis and septic shock (SS) are time-critical medical emergencies that affect millions of people in the world. Earlier administration of antibiotics has been shown to reduce mortality from SS; however, the initiation of early resuscitation requires recognition that a patient may have sepsis. Early warning scores (EWS) are broadly used to detect patient deterioration, but to date have not been evaluated to detect patients at risk for SS. The purpose of our study was to look at the relationship between the initial national EWS (NEWS) in the emergency department (ED) and the diagnosis of SS. METHODS: We performed a retrospective, single-centre, observational study in the ED of an urban university hospital with an annual attendance of 140,000 patients. We aimed to include 500 consecutive non-trauma adult patients presenting to the ED with Manchester Triage System (MTS) category 1-3. The final diagnosis was taken from either the ED medical records or the hospital discharge summary. For all NEWS, the sensitivity and specificity to detect patients with SS was calculated. RESULTS: A total of 500 patients were included, 27 patients (5.4%) met the criteria for SS. The area under the curve (AUC) for NEWS to identify patient at risk for SS is 0.89 (95% CI 0.84 to 0.94). A NEWS of 3 or more at ED triage has a sensitivity of 92.6% (95% CI 74.2% to 98.7%) and a specificity of 77% (95% CI 72.8% to 80.6%) to detect patients at risk for SS at ED triage. CONCLUSIONS: A NEWS of 3 or more at ED triage may be the trigger to systematically screen the patient for SS, which may ultimately lead to early recognition and treatment.

Analysis of cerebrospinal fluid for xanthochromia versus modern computed tomography scanners in the diagnosis of subarachnoid haemorrhage: experience at a tertiary trauma referral centre.

BACKGROUND: Diagnosis of subarachnoid haemorrhage, a neurosurgical emergency in patients with headache remains a logistical challenge. The rationale of the traditional pathway of cerebrospinal fluid xanthochromia analysis following negative computed tomography head scans to exclude subarachnoid haemorrhage has been challenged by the increasing accuracy of modern computed tomography scanners. AIM: We set out to establish whether our xanthochromia service was adding value to the diagnostic pathway for subarachnoid haemorrhage or whether it was acting merely as a supportive test. METHOD: A retrospective audit of all cerebrospinal fluid requests received since the inception of Xanthochromia service at a tertiary trauma centre. Cases interpreted as being consistent with subarachnoid haemorrhage based on cerebrospinal fluid xanthochromia analysis were selected for in-depth review from the total number of cases. RESULTS: In total 660 requests were received for cerebrospinal fluid xanthochromia between August 2009 and July 2012. A total 28 of these were interpreted as being consistent with subarachnoid haemorrhage. Only 18 (64.3%) of requests were deemed appropriate as the clinical presentation in the remaining 10 (35.7%) was strongly suggestive of other causes of headache. A final clinical diagnosis of subarachnoid haemorrhage was made in 11 of the 18 patients who had cerebrospinal fluid xanthochromia requested appropriately. From these 11, five (45%) were deemed initially computed tomography negative and cerebrospinal fluid analysis led to final correct diagnosis of subarachnoid haemorrhage and appropriate surgical management. CONCLUSION: Despite improved computed tomography scanning technology, cerebrospinal fluid xanthochromia interpretation aids in the definitive diagnosis of subarachnoid haemorrhage. When requested appropriately cerebrospinal fluid xanthochromia analysis remains a vital service as results impact on clinical decision making, especially when computed tomography scan results are equivocal and is also important in later presenting patients when computed tomography accuracy decreases.

A cross-sectional study of knife injuries at a London major trauma centre.

INTRODUCTION: No national recording systems for knife injuries exist in the UK. Understanding the true size and nature of the problem of knife injuries is the first stage in reducing the burden of this injury. The aim of this study was to survey every knife injury seen in a single inner city emergency department (ED) over a one-year period. METHODS: A cross-sectional observational study was performed of all patients attending with a knife injury to the ED of a London major trauma centre in 2011. Demographic characteristics, patterns of injury, morbidity and mortality data were collected. RESULTS: A total of 938 knife injuries were identified from 127,191 attendances (0.77% of all visits) with a case fatality rate of 0.53%. A quarter (24%) of the major trauma team's caseload was for knife injuries. Overall, 44% of injuries were selfreported as assaults, 49% as accidents and 8% as deliberate self-harm. The highest age specific incident rate occurred in the 16-24 year age category (263/100,000). Multiple injuries were seen in 19% of cases, of which only 81% were recorded as assaults. The mean length of stay for those admitted to hospital was 3.04 days. Intrathoracic injury was seen in 26% of cases of chest trauma and 24% of abdominal injuries had a second additional chest injury. CONCLUSIONS: Violent intentional injuries are a significant contributory factor to the workload of the major trauma team at this centre. This paper contributes to a more comprehensive understanding of the nature of these injuries seen in the ED.

Lymphangiosarcoma associated with lymphedema in a man with Maffucci's syndrome.

A man with Maffucci's syndrome and lifelong lymphedema in the right lower extremity had a lymphangiosarcoma in the same extremity. Despite amputation of the limb and radiotherapy, he died several months later of pulmonary metastases. Malignancies of vascular origin rarely have been reported in this syndrome. Our patient's features suggest that lymphedema may predispose patients with Maffucci's syndrome to the development of lymphangiosarcoma.

Polyomavirus infection versus high-grade bladder carcinoma. The importance of cytologic and comparative morphometric studies of plastic-embedded voided urine sediments.

The cytodiagnostic criteria of polyomavirus infection of the urinary tract versus high-grade bladder carcinoma in Cytospin and plastic-embedded preparations of voided urine samples are presented. In Cytospin preparations, the polyomavirus infection and the high-grade bladder carcinoma could not always be distinguished from each other. The diagnosis was facilitated when plastic-embedded specimens were used for cytologic study. On the basis of the comparison of morphometric data from the two types of specimens, it is postulated that the physical properties of the cancer cell nuclei differ from those of the virocytes.

Aluminum affects interconnections between aggregates of cultured hippocampal neurons. Neurotoxicity of aluminum in vitro.

The effect of aluminum (Al) was studied in an in vitro system of cultured hippocampal neurons from fetal rats in a chemically defined medium. Neuronal aggregates interconnected by neurites were detected light and electron microscopically in control and Al-treated cultures. In the Al-treated cultures disruptions of the fibers were observed proximal to the aggregates; the number of disruptions increased with The Al concentration applied. It is concluded that interference of intracellular Al with the neuronal skeleton occurs, leading to an enhanced fragility of the interconnecting neurites. The concentration-dependent Al-induced disruption of interconnecting neurites may serve as an in vitro model for further research in Al neurotoxicity.

Invasive carcinomas of the urinary bladder. Evaluation of tunica muscularis mucosae involvement.

Awareness of the existence of a tunica muscularis mucosae in the urinary bladder complicates the assessment of muscle invasive carcinomas on bladder biopsy. Sixty cystectomy specimens and select bladder biopsies were reviewed to analyze this problem. The patterns of development of the tunica muscularis mucosae were categorized as continuous, interrupted, scattered, or absent. Most bladders demonstrated several patterns of development rather than a uniform appearance. The most frequently observed pattern was that of scattered smooth muscle fibers seen in 33 of 40 (82.5%) cases. The rarity of carcinomatous invasion limited to the tunica muscularis mucosae is emphasized. The authors conclude that the potential for overstaging bladder carcinomas because of misinterpretation of this structure is small.

Immunophenotypic analysis of colorectal carcinomas with monoclonal antibodies 47D10 and anti-carcinoembryonic antigen.

A series of 80 colorectal adenocarcinomas were analyzed immunohistochemically for the antigen recognized by a new monoclonal antibody (MCA) 47D10. These antigens are part of a complex family of substances similar to, yet distinct from carcinoembryonic antigen (CEA), and are termed nonspecific cross-reacting antigens (NCA). Formalin-fixed paraffin-embedded sections of colorectal adenocarcinomas were evaluated for the expression of these antigens and compared to the expression of CEA. Our study shows that 83.8% of the cases were positively stained for NCA while 91.3% were positive for CEA. Both antigens were coexpressed in 80% of the cases. No correlation was found between MCA 47D10 immunoreactivity and tumor grade, stage, size or location within the colon. In 25 cases, the benign colonic mucosa adjacent to the carcinoma stained positively with MCA 47D10. Normal colon does not express NCA as recognized by MCA 47D10, except in rare cells. Forty-eight of these cases had serum available for study. Both NCA and CEA were determined in these serum samples. Forty-two of these sera demonstrated elevated CEA levels, whereas only 8 showed increased levels of the 47D10 antigen(s). These findings suggest that the gene product(s) recognized by MCA 47D10 can be independently expressed or, more commonly, coexpressed with CEA in these tissues.

Hazards of domestic pets. Ringworm and other skin conditions.

Domestic pets may be responsible for a number of skin eruptions in man. Whilst ringworm due to Microsporum canis is one of the most common of these conditions in this country, trichophyton infection, flea bite dermatitis, cheyletiella dermatitis, canine scabies and traumatic dermatitis are by no means rare. Less frequently encountered conditions include creeping eruption, favus, fowl-mite dermatitis and allergic dermatitis.