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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.

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.

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.

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.

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.

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.

Summary Disseminated mucormycosis occurred in a 19 year old female following orthotopic liver transplantation for fulminant Wilson’s disease. The causative organism Cunninghamella bertholletiae has previously been described in ten clinical cases, but never before in this setting.