Search

Background Hospital-based studies have reported variable associations between outcome after spontaneous intracerebral hemorrhage and peri-hematomal edema volume. Aims In a community-based study, we aimed to investigate the existence, strength, direction, and independence of associations between intracerebral hemorrhage and peri-hematomal edema volumes on diagnostic brain CT and one-year functional outcome and long-term survival. Methods We identified all adults, resident in Lothian, diagnosed with first-ever, symptomatic spontaneous intracerebral hemorrhage between June 2010 and May 2013 in a community-based, prospective inception cohort study. We defined regions of interest manually and used a semi-automated approach to measure intracerebral hemorrhage volume, peri-hematomal edema volume, and the sum of these measurements (total lesion volume) on first diagnostic brain CT performed at ≤3 days after symptom onset. The primary outcome was death or dependence (scores 3–6 on the modified Rankin Scale) at one-year after intracerebral hemorrhage. Results Two hundred ninety-two (85%) of 342 patients (median age 77.5 y, IQR 68–83, 186 (54%) female, median time from onset to CT 6.5 h (IQR 2.9–21.7)) were dead or dependent one year after intracerebral hemorrhage. Peri-hematomal edema and intracerebral hemorrhage volumes were colinear ( R2 = 0.77). In models using both intracerebral hemorrhage and peri-hematomal edema, 10 mL increments in intracerebral hemorrhage (adjusted odds ratio (aOR) 1.72 (95% CI 1.08–2.87); p = 0.029) but not peri-hematomal edema volume (aOR 0.92 (0.63–1.45); p = 0.69) were independently associated with one-year death or dependence. 10 mL increments in total lesion volume were independently associated with one-year death or dependence (aOR 1.24 (1.11–1.42); p = 0.0004). Conclusion Total volume of intracerebral hemorrhage and peri-hematomal edema, and intracerebral hemorrhage volume alone on diagnostic brain CT, undertaken at three days or sooner, are independently associated with death or dependence one-year after intracerebral hemorrhage, but peri-hematomal edema volume is not. Data access statement Anonymized summary data may be requested from the corresponding author.

IntroductionIn starting a new clinical placement, doctors in training must become aware of and apply standard operating procedures, as well as learn guidelines, simultaneously adjusting to new patient presentations, environments and personnel. This transition is thought to correlate with increased risk to patient safety, notably during the annual UK changeover. Mobile technologies are increasingly commonplace throughout the National Health Service. Clinicians at all levels are employing medical technology and applications (apps) with minimal local guidance. We set out to test the feasibility and utility of offering medical apps to out-of-hours (OOH) practitioners as an aid to clinical decision-making at point of patient contact. The theorised benefits were threefold: clinical education—real time support for clinical decision-making as one component of deliberate practice to build expert performance; decreased administrative burden–updating and accessing current guidelines; and service development—readily accessible feedback from users.MethodWe provided 32 devices in our emergency departments and OOH environments. The devices were preloaded with apps approved by our medical education department and clinical service leads to be used in support of care delivery.ResultsWe surveyed 123 clinical staff prior to the pilot discovering that 65% had used mobile apps to aid their decision-making. During our project, we saw the number of clinical users expand with our data series, suggesting the apps most useful to care delivery for this group of service providers.Future developmentsThere was huge enthusiasm for the project and we hope to maintain a clinician-led environment.

Mycoplasma genitalium is frequently associated with urogenital and rectal infections, with the number of cases of macrolide-resistant and quinolone-resistant M. genitalium infection continuing to increase. In this study, we examined the levels of resistance to these two common antibiotic treatments in geographically distinct locations in Queensland, Australia. Samples were screened for macrolide resistance-associated mutations using a commercially available kit (ResistancePlus MG; SpeeDx), and quinolone resistance-associated mutations were identified by PCR and DNA sequencing. Comparisons between antibiotic resistance mutations and location/gender were performed. The levels of M. genitalium macrolide resistance were high across both locations (62%). Quinolone resistance mutations were found in ∼10% of all samples, with a number of samples harboring mutations conferring resistance to both macrolides and quinolones. Quinolone resistance was higher in southeast Queensland than in north Queensland, and this was consistent in both males and females (P = 0.007). The M. genitalium isolates in rectal swab samples from males harbored high levels of macrolide (75.9%) and quinolone (19%) resistance, with 15.5% harboring resistance to both classes of antibiotics. Overall, the lowest observed level of resistance was to quinolones in females from north Queensland (1.6%). These data highlight the high levels of antibiotic resistance in M. genitalium isolates within Queensland and the challenges faced by sexually transmitted infection clinicians in managing these infections. The data do, however, show that the levels of antibiotic resistance may differ between populations within the same state, which has implications for clinical management and treatment guidelines. These findings also support the need for ongoing antibiotic resistance surveillance and tailored treatment.

Background and Purpose— The characteristics of intracerebral hemorrhage (ICH) may vary by ICH location because of differences in the distribution of underlying cerebral small vessel diseases. Therefore, we investigated the incidence, characteristics, and outcome of lobar and nonlobar ICH. Methods— In a population-based, prospective inception cohort study of ICH, we used multiple overlapping sources of case ascertainment and follow-up to identify and validate ICH diagnoses in 2010 to 2011 in an adult population of 695 335. Results— There were 128 participants with first-ever primary ICH. The overall incidence of lobar ICH was similar to nonlobar ICH (9.8 [95% confidence interval, 7.7–12.4] versus 8.6 [95% confidence interval, 6.7–11.1] per 100 000 adults/y). At baseline, adults with lobar ICH were more likely to have preceding dementia (21% versus 5%; P =0.01), lower Glasgow Coma Scale scores (median, 13 versus 14; P =0.03), larger ICHs (median, 38 versus 11 mL; P P P =0.02) than those with nonlobar ICH. One-year case fatality was lower after lobar ICH than after nonlobar ICH (adjusted odds ratio for death at 1 year: lobar versus nonlobar ICH 0.21; 95% confidence interval, 0.07–0.63; P =0.006, after adjustment for known predictors of outcome). There were 4 recurrent ICHs, which occurred exclusively in survivors of lobar ICH (annual risk of recurrent ICH after lobar ICH, 11.8%; 95% confidence interval, 4.6%–28.5% versus 0% after nonlobar ICH; log-rank P =0.04). Conclusions— The baseline characteristics and outcome of lobar ICH differ from other locations.

A major amount of our time working in clinical practice involves thinking and decision making. Perhaps it is because decision making is such a commonplace activity that it is assumed we can all make effective decisions. However, this is not the case and the example of diagnostic error supports this assertion. Until quite recently there has been a general nihilism about the ability to change the way that we think, but it is now becoming accepted that if we can think about, and understand, our thinking processes we can improve our decision making, including diagnosis. In this paper we review the dual process model of decision making and highlight ways in which decision making can be improved through the application of this model to our day-to-day practice and by the adoption of de-biasing strategies and critical thinking.

Interruptions occur throughout clinical practice. They occur during ward rounds, procedures, discussions with relatives or specialists, while checking drugs or equipment, when prescribing and writing in notes. They can take the form of face-to-face interaction, telephone calls or text messages, pagers, alarms on monitors or equipment. They may be for mundane reasons, low priority or urgent. They may be for relaying information, to refer patients, to discuss plans, to arrange treatment or investigations. Some are unnecessary and potentially unsafe, but others are essential re-directions to more urgent clinical situations. It may be that educational interventions could be used to reduce the detrimental effects of ill-timed interruptions and to promote effective re-directional interruptions.

Extracorporeal membrane oxygenation (ECMO) is a form of life support used when conventional management with mechanical ventilation is failing. Depending on the type of ECMO support utilised, it can provide temporary lung support in neonates and children with respiratory failure (usually veno-venous access) and cardiac support (veno-arterial access) particularly around the time of corrective cardiac surgery. Unlike cardio-pulmonary bypass during cardiac surgery, ECMO support is usually provided for a number of days or even weeks. It is essential that this intense and relatively complex form of life support is free from potentially avoidable adverse incidents. We have developed a course for training in critical incident management during an ECMO ‘run’ using clinical event scenarios and based on a high-fidelity patient simulator. We present the development process and our initial thoughts about its use.

Secondary bacterial pneumonia due to community onset methicillin-resistant Staphylococcus aureus (MRSA) has become a highly publicised cause of influenza-associated death. There is a risk that case reports of fatal outcomes with post-influenza MRSA pneumonia may unduly influence antibiotic prescribing.The aim of this study was to demonstrate the incidence of community-onset MRSA pneumonia in 2009 H1N1 influenza patients.The microbiology records of patients positive for influenza A (H1N1) in 2009 were reviewed for positive blood or respiratory tract cultures and urinary pneumococcal antigen results within a Queensland database. Patients with such positive results within 48 h of hospital admission and a positive H1N1 influenza result in the prior 6 weeks were included.In 2009, 4491 laboratory-confirmed pandemic influenza A (H1N1) infections were detected. Fifty patients (1.1% of the H1N1 cohort) who were hospitalised with H1N1 and who had a bacterial respiratory tract pathogen were identified. Streptococcus pneumoniae (16 patients; 32%), Staphylococcus aureus (13 patients; 26%) and Haemophilus influenzae (9 patients; 18%) were the most commonly cultured organisms. Of the cohort of 4491 patients, MRSA was detected in only two patients, both of whom were admitted to intensive care units and survived after prolonged admissions.Influenza-associated community-onset MRSA pneumonia was infrequently identified in the 2009 H1N1 season in Queensland, despite community-onset MRSA skin and soft tissue infections being very common. Although post-influenza MRSA pneumonia is of great concern, its influence on empiric-prescribing guidelines should take into account its incidence relative to other secondary bacterial pathogens.

The haemodynamic effects of intermittent high volume venovenous haemofiltration were studied in 13 critically ill patients. The mean negative fluid balance during filtration was 1.21 and the mean duration of treatment 3 h 40 min. The cardiac index fell initially (4.5 +/- 0.2 to 3.8 +/- 0.21/min/m2; p less than 0.05) but then remained stable throughout treatment before returning to baseline at the end of haemofiltration. The mean arterial pressure was unchanged with an increase in the systemic vascular resistance (651 +/- 33 to 765 +/- 65 dyne.s/cm5; p less than 0.05) suggesting that vascular responsiveness is maintained during haemofiltration.

A national collaborative study involving the laboratories of 17 Australian hospitals examined the in vitro activity of loracarbef, cefaclor, cephalexin, amoxycillin and amoxycillin/clavulanate against 2661 recently isolated common bacterial pathogens. Loracarbef was the most active agent against Escherichia coli (MIC90 = 1 mg/l) and had activity comparable to other agents against Klebsiella pneumoniae and Proteus mirabilis. Like the oral cephalosporins, it had no activity against species of Enterobacter and Serratia. beta-lactamase-producing Staphylococcus aureus and Haemophilus influenzae were moderately sensitive to loracarbef (MIC90 = 8 mg/l for both species). Streptococcus pneumoniae was moderately sensitive to loracarbef (MIC90 = 2 mg/l) but strains which were insensitive to penicillin were often highly resistant.

Summary Back pain and minor neurological symptoms are commonly experienced postpartum, often being attributed to non-specific causes such as maternal obstetric factors, or the use of epidural analgesia. We report a case in which neurological problems associated with a prolapsed intervertebral disc occurred after epidural analgesia in labour and a normal vaginal delivery.

To assess the changes in antibiotic resistances in Staphylococcus aureus, both methicillin-susceptible and methicillin-resistant strains, in Australia.Retrospective review of data collected annually.Twenty metropolitan teaching hospitals in the six States of Australia and the Australian Capital Territory from 1988 to 1994.Changes in prevalence and resistance rates of methicillin-resistant S. aureus (MRSA) and methicillin-susceptible strains, based on antibiotic susceptibility testing of clinical isolates of S. aureus.Prevalence of MRSA has remained constant on the eastern seaboard of Australia. A distinctive strain of MRSA emerged in Western Australia which had different antimicrobial susceptibilities. Resistances emerged in MRSA strains from eastern Australia, principally to ciprofloxacin and rifampicin, while resistance to fusidic acid remained stable and resistance to chloramphenicol significantly declined. Resistances in methicillin-susceptible strains remained fairly stable, except for a decline in resistance levels for tetracycline. High levels of resistance were seen to penicillin, moderate levels to erythromycin and low levels to trimethoprim and fusidic acid in methicillin-susceptible strains.The continued high prevalence of and increasing resistance in MRSA in some Australian hospitals have meant that some strains are now untreatable with oral antibiotics.

A national study was conducted to determine the in vitro activity of 2 newer macrolides, dirithromycin and erythromycylamine compared with that of erythromycin, tetracycline and penicillin. Nineteen major teaching hospitals participated in the study. Minimal Inhibitory Concentrations (MICs) were determined by agar dilution, mostly using Iso-Sensitest Agar and an inoculum of 10(4) cells per spot. 2284 clinically significant strains were isolated in late 1991 and early 1992, comprising 1736 Gram-positive cocci, 355 Haemophilus influenzae, 97 Moraxella catarrhalis, 32 Listeria monocytogenes, 25 Neisseria meningitidis and 39 Neisseria gonorrhoeae were tested. The study indicates that dirithromycin and erythromycylamine possess antibacterial activity equivalent to that of erythromycin against most Gram-positive cocci and M. catarrhalis. Strains resistant to erythromycin were also resistant to dirithromycin and to erythromycylamine. Tetracycline was as active as the macrolides against both penicillin-resistant and penicillin-susceptible strains of Staphylococcus aureus. Coagulase-negative penicillin-resistant staphylococci, compared with tetracycline, were relatively resistant to the macrolides. H. influenzae was less susceptible than the Gram-positive cocci.

We have studied the acid-base and cardiorespiratory effects of intermittent pumped high-volume venovenous haemofiltration (HVHF) using replacement fluid containing lactate as the source of bicarbonate in critically ill patients. We demonstrated significant hyperlactataemia throughout the procedure, but there was no deterioration in acid-base status, haemodynamics, or oxygen delivery. These observations suggest that the worsening of acidosis and the hypotension that have been described with this technique can be avoided by appropriate monitoring and resuscitation prior to haemofiltration, and may be due to unrecognized inadequacies in the oxygen transport system.

Summary Tissue hypoxia is thought to be pivotal to the development of multiple organ failure, but cannot be measured directly in clinical practice. We assessed the relationship between initial arterial blood lactate concentrations and the presence of the phenomenon of delivery-dependent oxygen consumption, both of which may indicate tissue hypoxia. Twenty-three critically ill patients with septic shock and adult respiratory distress syndrome were studied prospectively and allocated to one of two groups according to blood lactate concentrations. In group 1, blood lactate concentration was less than the level widely accepted as significant (2 mmol.l−1); in group 2, the concentration exceeded 2 mmol.l−1. In both groups, resuscitation with colloid, blood and vasoactive drugs resulted in significant increases in oxygen delivery; in group 1 (n = 13), mean (SEM) oxygen delivery increased from 484 (36) to 730 (44) ml.min−1.m−2 (p < 0.005) and in group 2 (n = 10) from 550 (54) to 780 (54) ml.min−1.m−2 (p < 0.05). In neither group was there a significant change in oxygen consumption. However, there were individuals in both groups who exhibited pathological delivery dependence. This suggests that the absence of hyperlactataemia does not preclude delivery dependence of oxygen consumption with the attendant potential for tissue hypoxia.

The protease inhibitor aprotinin was given a) in experimental septic shock, and b) in patients with hepatic cirrhosis and ascites, since in both conditions, activation of the plasma kallikrein-kinin system is associated with pathological systemic vasodilatation, which may trigger reflex neuroendocrine activation and renal solute retention. Given early in experimental sepsis, aprotinin maintained the arterial pressure, systemic vascular resistance (SVR), creatinine clearance and sodium excretion, all of which fell in controls. Aprotinin also blocked increases in pulmonary artery pressure and plasma renin activity (PRA). Given late in sepsis, aprotinin caused a rapid rise in arterial pressure and SVR towards baseline levels. In cirrhosis, aprotinin increased SVR in patients with low baseline values, and improved glomerular filtration rate, renal plasma flow and sodium excretion in all subjects; PRA was suppressed by aprotinin. Aprotinin reverses pathological systemic vasodilatation in these two conditions, and this is associated with a reduction in renin release and improved renal function.

Training students and doctors to deal with medical emergencies is problematic. Patients present sporadically at uncontrolled times. Learning by trial and error is unacceptable. In Anaesthesia and Surgery many of the core skills and emergency routines can be learned under direct senior supervision but the same is often not the case in Medicine. There is also a distinct gap between possession of knowledge and skills and their application: adequate knowledge in theory may not be translated into effective patient management. In order to address these issues a Medical Emergencies Teaching Programme has been developed for final year Medical Students and new-start Medical Senior House Officers (SHO). This consists of a series of tutorials, skills stations and simulated acutely ill patient management scenarios which are filmed and used for debriefing. A Medical Emergencies Handbook has been written and provides the core materials for the course. Tutorials are all interactive and based on real cases. They are organized through the seven weeks of the student course and are condensed in the SHO 2-day course. They include ‘Initial Assessment and Management of the Acutely Ill Adult’, LVF, shock, haemorrhage, anaphylaxis, acute coronary syndromes, respiratory emergencies, basic and advanced life support, prescribing drugs and talking to bereaved relatives. Practical skill stations run in the 2nd and 3rd weeks of the student course. These cover airway support, how to administer oxygen and nebulisers, rapid infusion, using monitoring (ECG, pulse oximetry, cuff BP), the cardiac arrest trolley, basic and advanced life support and defibrillation. Simulated patient management. Once the above skills have been learned the students then manage emergencies in real-time as a team of four, with access to all of the equipment and communications they would have in an acute clinical area, working on a ‘low-tech’ simulator. This is video-recorded and a debriefing teaching session immediately follows the case. Scottish Clinical Simulation Centre. The final full day of the course involves real-time emergency patient management in teams using a high fidelity clinical simulator with video-recording and debriefing. Summary This course combines cognitive and practical training early. The core philosophy of the management of the acutely ill patient is emphasized and standard core material issued from the start. There is early inclusion of real-time, hands-on patient management using a ‘low-tech’ system with video recording. These structured, sequential elements ensure that the students are familiar with the management of the acutely ill and with the teaching processes such that they gain maximally from the exposure to the high tech simulator. Feedback from the first 140 students completing the course has been unanimously positive. The next step is to evaluate the influence this teaching has on clinical management.

Metabolic acidosis and hyperlactataemia are important, independent findings in acute illness, and the combination of these abnormalities carries a grave prognosis. Despite this there is still controversy about the most appropriate therapy of lactic acidosis, and the relationship of commonly used acid base measurements to blood lactate levels. This paper details studies in shock and multiple organ failure examining these issues. Shocked patients were studied during catecholamine therapy and showed improvements in acidosis and hyperlactataemia in conjunction with cardiorespiratory improvement. This supports a beneficial role for these agents in appropriately monitored, volume resuscitated and oxygenated patients with shock and lactic acidosis. Assessment of differences in mixed venous and arterial acid base status was performed in 32 patients. The relationship of blood lactate to acid base measurements was examined. There were no significant differences in [H+], [HCO3] or base excess. There was no significant correlation between any of these in arterial or mixed venous samples and arterial whole blood lactate. Mixed venous PCO2 was significantly higher than arterial PCO2. Haemodynamic, oxygen transport and acid base changes were documented in eight patients with multiple organ failure being treated by intermittent high volume haemofiltration (Gambro AK10 system) with lactate buffered replacement fluid PCO2 (Gambro haemofiltrasol). Cardiac output and oxygen delivery fell significantly during therapy but blood pressure was maintained by an increase in systemic vascular resistance as we have shown previously. Serious acid base derangements were not seen. Significant hyperlactataemia was present throughout haemofiltration as a result of the infusion of replacement fluid containing 45 mmol/l lactate. The only alterations in acid base status were transient falls in arterial bicarbonate and base excess at one hour.

The effects of adrenaline on haemodynamics and oxygen transport were studied in 13 patients with septic shock persisting after optimal fluid loading. adrenaline was administered by intravenous infusion at an increasing dose until no further benefit was seen. There were significant increases in mean arterial pressure, cardiac index, left ventricular stroke work index and oxygen delivery index. There was no significant change in oxygen consumption although the trend was towards an increase. There was a significant reduction in oxygen extraction ratio, but no change in shunt fraction. Adrenaline would appear to have beneficial haemodynamic effects in septic shock.

It was with some surprise that we read “Tips on... Effective time management” in BMJ Careers on 26 March 2006. This advocates doing “two things at the same time,” in particular, “prescribing drugs and filling in forms during the ward round,” as a means …

The effects of a sedative infusion of propofol on haemodynamics and oxygen transport were examined in critically ill adult patients. Ten patients receiving mechanical ventilation for treatment of septic shock and respiratory failure were given a decreasing rate propofol infusion designed to achieve and maintain a stable sedation level. Full cardiovascular and oxygen transport variables, arterial blood lactate concentrations and sedation scores were measured before infusion and at 1, 3 and 6 h after starting the infusion. There were significant reductions in mean (SEM) heart rate (97.3 (2.9) to 85.7 (3.9) beat.min-1 p < 0.05), mean arterial pressure (87.6 (3.7) to 76.2 (4.1) mmHg P < 0.05) and systemic vascular resistance index (1461 (137) to 1327 (141) dyne.s.cm-5.m-2 p < 0.05), with no significant change in cardiac filling pressures. There were no significant changes in cardiac output, oxygen delivery, oxygen consumption or arterial blood lactate concentrations. Controlled propofol sedation is well tolerated in appropriately monitored and resuscitated critically ill adult patients, and appears to have no major effects on whole-body oxygen transport.

Three cases of pyogenic Haemophilus influenzae meningitis in adults have been diagnosed within the Brisbane Metropolitan area in the last twelve months. This had been considered a very unusual cause of meningitis in adults which has not previously been recorded in the Australian literature, and should alert clinicians to a possible alteration in the age specificity of this disease. Two of the three isolates proved resistant to ampicillin; this emphasizes the need to exclude beta lactamase production in all Haemophilus isolates from critical infections. All three patients recovered without significant sequelae but the choice of primary antimicrobial in adult meningitis remains open to question.

Recently, the problems associated with crush injury have recently been highlighted [1]. The association between major urological surgery and severe muscle damage is well recognised [2]. We report a case of myoglobinuric acute renal failure following radical cystectomy and suggest possible prevention.