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BACKGROUND: Mannose-binding lectin (MBL) and ficolins are pattern recognition molecules (PRMs) that play an important role during infection through activation of the lectin complement pathway. We assessed whether plasma PRM levels were associated with mortality in patients with necrotizing soft tissue infection (NSTI).METHODS: We conducted a prospective, observational study over 25 months involving 135 NSTI patients with a maximum follow-up of 2.7 years. Blood samples were taken upon admission. Non-infected patients served as controls.RESULTS: PRM levels were significantly lower compared with controls. A baseline Ficolin-2 level below the median was associated with mortality at the end of follow-up (p = 0.007). No significant association was found for MBL, Ficolin-1 and Ficolin-3. A Ficolin-2 level below the median had a negative predictive value of 0.94 for 28-day mortality, and a level below the optimal cut-off was independently associated with 28-day mortality when adjusted for age, sex and chronicity [hazard ratio 6.27 (95% confidence interval 2.28-17.21), p < 0.0001], also when Simplified Acute Physiology Score II was included in the analysis [hazard ratio 3.16 (95% confidence interval 1.03-9.73), p = 0.045].CONCLUSIONS: All PRMs were significantly lower in patients with NSTI than in controls. Only baseline Ficolin-2 was associated with short- and long-term mortality. A high baseline Ficolin-2 level indicated a 94% chance of surviving the first 28 days after admission.

In this article we discuss the current level of evidence for using a high inspiratory oxygen fraction (0.60-0.90) during surgery. More than 7,000 patients have been included in randomized trials, but no significant beneficial effect was found in a recent meta-analysis as compared with 0.30-0.40 oxygen. A high oxygen fraction should be used to correct or prevent hypoxaemia in special situations, but the available studies do not allow a recommendation to use a high inspiratory oxygen fraction as a routine practice in surgical patients.

BACKGROUND: Respiratory rate is among the first vital signs to change in deteriorating patients. The aim was to investigate the agreement between respiratory rate measurements by three different methods.METHODS: This prospective observational study included acutely admitted adult patients in a medical ward. Respiratory rate was measured by three methods: a standardised approach over 60 s while patients lay still and refrained from talking, by ward staff and by a wireless electronic patch (SensiumVitals). The Bland-Altman method was used to compare measurements and three breaths per minute (BPM) was considered a clinically relevant difference.RESULTS: We included 50 patients. The mean difference between the standardised approach and the electronic measurement was 0.3 (95% CI: -1.4 to 2.0) BPM; 95% limits of agreement were -11.5 (95% CI: -14.5 to -8.6) and 12.1 (95% CI: 9.2 to 15.1) BPM. Removal of three outliers with huge differences lead to a mean difference of -0.1 (95% CI: -0.7 to 0.5) BPM and 95% limits of agreement of -4.2 (95% CI: -5.3 to -3.2) BPM and 4.0 (95% CI: 2.9 to 5.0) BPM. The mean difference between staff and electronic measurements was 1.7 (95% CI: -0.5 to 3.9) BPM; 95% limits of agreement were -13.3 (95% CI: -17.2 to -9.5) BPM and 16.8 (95% CI: 13.0 to 20.6) BPM.CONCLUSION: A concerning lack of agreement was found between a wireless monitoring system and a standardised clinical approach. Ward staff's measurements also seemed to be inaccurate.

AIM: To explore whether early warning score (EWS) measurements at 8h intervals is associated with better outcomes than 12h intervals. We hypothesized that the proportion of patients that deteriorated to a higher EWS at 24h after hospital admission would be lower with 8h interval than with 12h interval.METHOD: This was a pragmatic, ward-level randomized, non-blinded, controlled trial at an urban University hospital. During two six weeks periods acutely admitted surgical and medical patients, with an initial EWS of 0 or 1, were monitored either every 8th hour or every 12th hour. The primary outcome was clinical deterioration 24h post-admission, estimated by the proportion of patients with an EWS≥2 at 24h after the initial EWS on admission.RESULTS: Of 3185 patients screened for eligibility, 1346 patients were included to the trial. Forty-nine percent were allocated to the 8h group and 51% to the 12h group; of these, 23% and 20% had an elevated EWS≥2 at 24h, respectively (p=0.456), OR 1.17 (0.78-1.76); 3.4% and 2.2%, respectively had an EWS≥5 (p=0.391), and one patient in each group had an EWS≥7 at 24h (p=1.0). Multiple logistic regression analysis showed no significant interactions for the primary outcome and the predefined variables: age, gender, ward type, and inclusion period, with an adjusted OR 1.20 (0.79-1.82). There were no significant differences in regard to the secondary outcomes: cardiac arrests, ICU admissions, review by medical emergency team (MET), length of hospital stay, or elevated EWS at 48 h. Thirty-day mortality was 1.1% vs. 1.8% (p=0.357) in the 8h group and the 12h-group, respectively (OR=0.60 (0.23-1.50), p=0.279).CONCLUSION: We found no significant reduction in the proportion of clinical deterioration with monitoring frequencies of 3 vs. 2 times daily among patients acutely admitted to a surgical or medical ward and an initial EWS of 0-1.

BACKGROUND: Postoperative cognitive dysfunction is common, but it remains unclear whether there are long-term adverse cognitive effects of surgery combined with anesthesia. The authors examined the association between exposure to surgery and level of cognitive functioning in a sample of 8,503 middle-aged and elderly twins.METHODS: Results from five cognitive tests were compared in twins exposed to surgery, classified as major, minor, hip and knee replacement, or other, with those of a reference group without surgery using linear regression adjusted for sex and age. Genetic and shared environmental confounding was addressed in intrapair analyses of 87 monozygotic and 124 dizygotic same-sexed twin pairs in whom one had a history of major surgery and the other did not.RESULTS: Statistically significantly lower composite cognitive score was found in twins with at least one major surgery compared with the reference group (mean difference, -0.27; 95% CI, -0.48 to -0.06), corresponding to one tenth of an SD, that is, a negligible effect size. In the intrapair analysis, the surgery-exposed co-twin had the lower cognitive score in 49% (95% CI, 42 to 56%) of the pairs. None of the other groups differed from the reference group except the knee and hip replacement group that tended to have higher cognitive scores (mean difference, 0.35; 95% CI, -0.18 to 0.87).CONCLUSIONS: A history of major surgery was associated with a negligibly lower level of cognitive functioning. The supplementary analyses suggest that preoperative cognitive functioning and underlying diseases were more important for cognitive functioning in mid- and late life than surgery and anesthesia.

Introduction: The first Danish Helicopter Emergency Medical Service (HEMS) was introduced May 1st2010. The implementation was associated with lower 30-day mortality in severely injured patients. Theaim of this study was to assess the long-term effects of HEMS on labour market affiliation and mortalityof trauma patients.Methods: Prospective, observational study with a maximum follow-up time of 4.5 years. Traumapatients from a 5-month period prior to the implementation of HEMS (pre-HEMS) were compared withpatients from the first 12 months after implementation (post-HEMS). All analyses were adjusted for sex,age and Injury Severity Score.Results: Of the total 1994 patients, 1790 were eligible for mortality analyses and 1172 (n = 297 preHEMSand n = 875 post-HEMS) for labour market analyses. Incidence rates of involuntary earlyretirement or death were 2.40 per 100 person-years pre-HEMS and 2.00 post-HEMS; corresponding to ahazard ratio (HR) of 0.72 (95% confidence interval (CI) 0.44–1.17; p = 0.18). The HR of involuntary earlyretirement was 0.79 (95% CI 0.44–1.43; p = 0.43). The prevalence of reduced work ability after three yearswere 21.4% vs. 17.7%, odds ratio (OR) = 0.78 (CI 0.53–1.14; p = 0.20). The proportions of patients on socialtransfer payments at least half the time during the three-year period were 30.5% vs. 23.4%, OR = 0.68 (CI0.49–0.96; p = 0.03). HR for mortality was 0.92 (CI 0.62–1.35; p = 0.66).Conclusions: The implementation of HEMS was associated with a significant reduction in time on socialtransfer payments. No significant differences were found in involuntary early retirement rate, long-termmortality, or work ability.

BACKGROUND: Available evidence on the effects of a high fraction of inspired oxygen (FIO2) of 60% to 90% compared with a routine fraction of inspired oxygen of 30% to 40%, during anaesthesia and surgery, on mortality and surgical site infection has been inconclusive. Previous trials and meta-analyses have led to different conclusions on whether a high fraction of supplemental inspired oxygen during anaesthesia may decrease or increase mortality and surgical site infections in surgical patients.OBJECTIVES: To assess the benefits and harms of an FIO2 equal to or greater than 60% compared with a control FIO2 at or below 40% in the perioperative setting in terms of mortality, surgical site infection, respiratory insufficiency, serious adverse events and length of stay during the index admission for adult surgical patients.We looked at various outcomes, conducted subgroup and sensitivity analyses, examined the role of bias and applied trial sequential analysis (TSA) to examine the level of evidence supporting or refuting a high FIO2 during surgery, anaesthesia and recovery.SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, BIOSIS, International Web of Science, the Latin American and Caribbean Health Science Information Database (LILACS), advanced Google and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) up to February 2014. We checked the references of included trials and reviews for unidentified relevant trials and reran the searches in March 2015. We will consider two studies of interest when we update the review.SELECTION CRITERIA: We included randomized clinical trials that compared a high fraction of inspired oxygen with a routine fraction of inspired oxygen during anaesthesia, surgery and recovery in individuals 18 years of age or older.DATA COLLECTION AND ANALYSIS: Two review authors extracted data independently. We conducted random-effects and fixed-effec

BACKGROUND: Handling critically ill patients is a complex task for Emergency Department (ED) personnel. Initial treatment is of major importance and requires adequately experienced ED doctors to initiate and decide for the right medical or surgical treatment. Our aim was, with regard to clinical presentation, management and mortality to describe adult non-trauma patients that upon ED arrival elicited emergency team calls.METHODS: An observational study of adult patients (≥ 18 years) admitted to a regional ED with conditions that elicited acute team activation and additional emergency team consultation calls for non-ED specialist physicians. Emergency team calls were two-tiered with 'orange' and 'red' calls. Additionally, intensive care unit (ICU) admission charts were reviewed to identify the total number of adult non-trauma and non-cardiac arrest patients admitted to the ICU from the ED during the study period.RESULTS: A total of 109 emergency team calls were triggered (79 orange and 30 red), comprising 66 (60.6 %) men and 43 women, with a median age of 64 years. Patients presented with: 4 Airway, 27 Breathing, 41 Circulation, 31 Disability, 2 Exposure and 4 Other problems. Overall, 58/109 (53.2 %) patients were admitted to the ICU, while 20/109 (18.3 %) patients were deemed ineligible for ICU admission. 30-day mortality was 34/109 (31.2 %), and circulatory problems were the most frequent cause of death (61.8 %, p = 0.02). Patients who died were significantly older than those who survived (p = 0.004). Additionally, 115 adult patients were admitted to the ICU directly from the ED without eliciting an emergency team call during the study period. These patients mainly comprised patients who were intoxicated, were unconscious or had respiratory failure.CONCLUSION: The majority of emergency team call patients presented with circulatory, disability and breathing problems. Half of the patients were admitted to the ICU, although a high rate of patie

BACKGROUND: Patient crowding in emergency departments (ED) is a common challenge and associated with worsened outcome for the patients. Previous studies on biomarkers in the ED setting has focused on identification of high risk patients, and and the ability to use biomarkers to identify low-risk patients has only been sparsely examined. The broader aims of the TRIAGE study are to develop methods to identify low-risk patients appropriate for early ED discharge by combining information from a wide range of new inflammatory biomarkers and vital signs, the present baseline article aims to describe the formation of the TRIAGE database and characteristize the included patients.METHODS: We included consecutive patients ≥ 17 years admitted to hospital after triage staging in the ED. Blood samples for a biobank were collected and plasma stored in a freezer (-80 °C). Triage was done by a trained nurse using the Danish Emergency Proces Triage (DEPT) which categorizes patients as green (not urgent), yellow (urgent), orange (emergent) or red (rescusitation). Presenting complaints, admission diagnoses, comorbidities, length of stay, and 'events' during admission (any of 20 predefined definitive treatments that necessitates in-hospital care), vital signs and routine laboratory tests taken in the ED were aslo included in the database.RESULTS: Between September 5(th) 2013 and December 6(th) 2013, 6005 patients were included in the database and the biobank (94.1 % of all admissions). Of these, 1978 (32.9 %) were categorized as green, 2386 (39.7 %) yellow, 1616 (26.9 %) orange and 25 (0.4 %) red. Median age was 62 years (IQR 46-76), 49.8 % were male and median length of stay was 1 day (IQR 0-4). No events were found in 2658 (44.2 %) and 158 (2.6 %) were admitted to intensive or intermediate-intensive care unit and 219 (3.6 %) died within 30 days. A higher triage acuity level was associated with numerous events, including acute surgery, endovascular intervention, i.v.

PURPOSE OF REVIEW: More surgical procedures are performed on an ambulatory basis and the advantages are apparent, but outpatient surgery presents challenges because of the expectation of a fast recovery soon after termination of anaesthesia. Ambulatory surgery is a well tolerated regimen with few serious adverse outcomes, hence difficult to obtain sound scientific evidence for avoiding complications.RECENT FINDINGS: Few studies have assessed recovery of cognitive function after ambulatory surgery, but it seems that both propofol and modern volatile anaesthetics are rational choices for general anaesthesia in the outpatient setting. Cognitive complications such as delirium and postoperative cognitive dysfunction are less frequent in ambulatory surgery than with hospitalization.SUMMARY: The elderly are especially susceptible to adverse effects of the hospital environment such as immobilisation, sleep deprivation, unfamiliar surroundings, and medication errors. Enhanced recovery programmes (fast-track regimens) may allow earlier discharge which is probably beneficial for the elderly. Frailty is becoming an increasingly important concept that needs to be clinically considered in elderly patients, as well as in future studies.

BACKGROUND: Mortality may be higher for admissions at odd hours than during daytime, although for trauma patients results are conflicting. The objective of this study was to assess whether diurnal differences in mortality among severely injured trauma patients in Denmark were present.METHODS: This observational cohort study was conducted between 1 December 2009 and 30 April 2011 involving one level 1 trauma centre and seven local emergency departments in eastern Denmark. Patients were consecutively included if received by a designated trauma team. Night-time patients (20:00-07:59) were compared with daytime patients (20:00-07:59). An injury severity score (ISS) >15 defined severe injury. Patients with burns and patients who upon arrival were declared non-trauma patients were not included. The primary outcome measure was 30-day mortality.RESULTS: A total of 1985 patients were recorded, of whom 576 were admitted at night-time, 1369 at daytime and 40 not included due to missing data. There were 142 patients with ISS >15 in the daytime group and 64 at night-time. The 30-day mortality was 14.1% for admittance at night-time versus 21.3% at daytime (p=0.22). Logistic regression analysis revealed that odd-hour admission was not a significant predictor of mortality for patients with ISS >15 when adjusted for age, ISS and initial treatment facility (OR 0.71 (95% CI 0.27 to 1.90); p=0.50).CONCLUSIONS: In conclusion, we found no diurnal differences in 30-day mortality for severely injured trauma patients.

BACKGROUND: Platelet dysfunction following trauma has been identified as an independent predictor of mortality. We hypothesized that fresh frozen plasma (FFP) resuscitation would attenuate platelet dysfunction compared with 0.9% normal saline (NS).METHODS: Twelve swine were subjected to multisystem trauma (traumatic brain injury, liver injury, rib fracture, and soft tissue injury) with hemorrhagic shock (40% of estimated blood volume). Animals were left in shock (mean arterial pressure, 30-35 mm Hg) for 2 hours followed by resuscitation with three times shed volume NS (n = 6) or one times volume FFP (n = 6) and monitored for 6 hours. Platelet function was assessed by adenosine diphosphate (ADP)-induced platelet aggregation at baseline, after 2 hours of shock following resuscitation, and 6 hours after resuscitation. Fibrinogen levels and markers of platelet activation (transforming growth factor β [TGF-β], sP-Selectin, and CD40L) as well as endothelial injury (intercellular adhesion molecule 1 [ICAM-1], vascular cell adhesion molecule 1 [VCAM-1]) were also assayed. Thromboelastography was used to measure clotting activity.RESULTS: ADP-induced platelet aggregation was significantly higher in the FFP group (46.3 U vs. 25.5 U, p < 0.01) following resuscitation. This was associated with higher fibrinogen levels (202 mg/dL vs. 80 mg/dL, p < 0.01) but lower endothelial activation (VCAM-1, 1.25 ng/mL vs. 3.87 ng/mL, p = 0.05). Other markers did not differ.After 6 hours of observation, ADP-induced platelet aggregation remained higher in the FFP group (53.8 U vs. 37.0 U, p = 0.03) as was fibrinogen levels (229 mg/dL vs. 153 mg/dL, p < 0.01). Endothelial activation was lower (ICAM-1, 21.0 ng/mL vs. 24.4 ng/mL, p = 0.05), whereas TGF-β levels were higher (2,138 pg/mL vs. 1,802 pg/mL, p = 0.03) in the FFP group. Other markers did not differ. Thromboelastography revealed increased clot strength in the FFP group at both postresuscitation time points.

BACKGROUND: Traumatic brain injury (TBI) and hemorrhagic shock (HS) can be associated with coagulopathy and inflammation, but the mechanisms are poorly understood. We hypothesized that a combination of TBI and HS would disturb coagulation, damage the endothelium, and activate inflammatory and complement systems.METHODS: A total of 33 swine were allocated to either TBI + HS (n = 27, TBI and volume-controlled 40% blood loss) or controls (n = 6, anesthesia and instrumentation). TBI + HS animals were left hypotensive (mean arterial pressure, 30-35 mm Hg) for 2 hours. Blood samples were drawn at baseline, 3 minutes and 15 minutes after injury, as well as following 2 hours of hypotension. Markers of coagulation, anticoagulation, endothelial activation/glycocalyx shedding, inflammation, complement, and sympathoadrenal function were measured.RESULTS: The TBI + HS group demonstrated an immediate (3 minutes after injury) activation of coagulation (prothrombin fragment 1 + 2, 289 ng/mL vs. 232 ng/mL, p = 0.03) and complement (C5a, 2.83 ng/mL vs. 2.05 ng/mL, p = 0.05). Shedding of the endothelial glycocalyx (syndecan 1) was evident 15 minutes after injury (851.0 ng/ml vs. 715.5 ng/ml, p = 0.03) while inflammation (tumor necrosis factor α [TNF-α], 81.1 pg/mL vs. 50.8 pg/mL, p = 0.03) and activation of the protein C system (activated protein C, 56.7 ng/mL vs. 26.1 ng/mL, p = 0.01) were evident following the 2-hour hypotension phase.CONCLUSION: The combination of TBI and shock results in an immediate activation of coagulation and complement systems with subsequent endothelial shedding, protein C activation, and inflammation.

BACKGROUND: Viscoelastic hemostatic assays may provide means for earlier detection of trauma-induced coagulopathy (TIC).METHODS: This is a prospective observational study of 182 trauma patients admitted to a Level 1 trauma center. Clinical data, thrombelastography (TEG), and rotational thromboelastometry (ROTEM) parameters were recorded upon arrival. Citrated kaolin (CK), rapid TEG (rTEG), and functional fibrinogen curves were extracted, and early amplitudes A5 and A10 were registered. Patients were stratified according to international normalized ratio of 1.2 or less and international normalized ratio greater than 1.2 (TIC patients) as well as transfusion needs (no red blood cells [RBCs], 1-9 RBCs, and ≥10 RBC in 6 hours). Correlations were analyzed by Spearman's correlation.RESULTS: TIC patients had lower amplitudes than non-TIC patients in ROTEM/TEG as follows: EXTEM, INTEM, and FIBTEM: A5, A10, and maximum clot firmness (MCF); rTEG: A10; CK: maximum amplitude (MA); and functional fibrinogen: A5, A10, and MA (p < 0.05). Furthermore, A5 and A10 had a strong correlation with MA/MCF (ρ > 0.7 and p < 0.01). The A10 amplitudes were significantly lower in patients transfused with 10 or more units of RBC compared with nontransfused patients (p < 0.02). Fibrinogen concentration and platelet count had moderate correlation with A10 compared with A5 and MA/MCF (0.3 < ρ < 0.7 and p < 0.01). Time (median [interquartile range], in minutes) to obtain a reading was faster for A10 than MA/MCF (p < 0.001) (CK, 16 [15-17] vs. 27 [25-30]; rTEG, 11 [11-11] vs. 18 [17-20]; EXTEM, 11 [11-11] vs. 29 [26-31]; and INTEM 13[12-13] vs. 25 [22-29]).CONCLUSION: Early amplitudes were lower in TIC patients, had significant correlations with MA/MCF, and differentiated between nontransfused and patients receiving one to nine RBC units or 10 or more RBC units within 6 hours. A10's superior correlation with platelet count and fibrinogen concentration

We aimed to elucidate platelet function in trauma patients, as it is pivotal for hemostasis yet remains scarcely investigated in this population. We conducted a prospective observational study of platelet aggregation capacity in 213 adult trauma patients on admission to an emergency department (ED). Inclusion criteria were trauma team activation and arterial cannula insertion on arrival. Blood samples were analyzed by multiple electrode aggregometry initiated by thrombin receptor agonist peptide 6 (TRAP) or collagen using a Multiplate device. Blood was sampled median 65 min after injury; median injury severity score (ISS) was 17; 14 (7%) patients received 10 or more units of red blood cells in the ED (massive transfusion); 24 (11%) patients died within 28 days of trauma: 17 due to cerebral injuries, four due to exsanguination, and three from other causes. No significant association was found between aggregation response and ISS. Higher TRAP values were associated with death due to cerebral injuries (P < 0.01, when corrected for ISS and platelet counts), whereas lower platelet counts were associated with massive transfusion (P < 0.01, when corrected for ISS and aggregation). An aggregation value of 145 IU by TRAP significantly identified death due to cerebral injury (sensitivity 71% and specificity 76%, P < 0.01) by receiver operating characteristic-curve analysis; the corresponding value of platelet counts for massive transfusion was 189 × 10/l (sensitivity 86%, specificity 75%, P < 0.01). We concluded there was no simple relationship between platelet aggregation and injury severity. Our results indicate that high platelet aggregation values are associated with fatality of cerebral injury.

INTRODUCTION: Correct estimation of the severity of burns is important to obtain the right treatment of the patient and to avoid over- and undertriage. In this study we aimed to assess how often the guidelines for referral of burn injured patients are met at the national burn centre (NBC), Denmark.METHODS: We included burn patients referred to the NBC in a three-months period. Patient records were systematically analyzed and compared with the national guidelines for referral of burn injured patients.RESULTS: A total of 97 burn injured patients were transferred for treatment at the NBC and the most common reason for referral was partial thickness burn exceeding 3% estimated area of burn (55% of the patients) while facial burns (32%) and inhalational injury (25%) were other common reasons. We found that 29 (30%) of the referrals were considered potentially unnecessary according to the guidelines. The overtriage was highest among patients suffering of burns due to scalding and these were mostly children below 2 years of age.CONCLUSION: An overtriage of referred burn injured patient was found and 30% of the referred patients were treated as outpatients. A telemedicine solution may be useful in the evaluation of burn injured patients before transfer.

Depression, anxiety and sleep disturbances are known problems in patients with breast cancer. The effect of melatonin as an antidepressant in humans with cancer has not been investigated. We investigated whether melatonin could lower the risk of depressive symptoms in women with breast cancer in a three-month period after surgery and assessed the effect of melatonin on subjective parameters: anxiety, sleep, general well-being, fatigue, pain and sleepiness. Randomized, double-blind, placebo-controlled trial undertaken from July 2011 to December 2012 at a department of breast surgery in Copenhagen, Denmark. Women, 30-75 years, undergoing surgery for breast cancer and without signs of depression on Major Depression Inventory (MDI) were included 1 week before surgery and received 6 mg oral melatonin or placebo for 3 months. The primary outcome was the incidence of depressive symptoms measured by MDI. The secondary outcomes were area under the curve (AUC) for the subjective parameters. 54 patients were randomized to melatonin (n = 28) or placebo (n = 26) and 11 withdrew from the study (10 placebo group and 1 melatonin group, P = 0.002). The risk of developing depressive symptoms was significantly lower with melatonin than with placebo (3 [11 %] of 27 vs. 9 [45 %] of 20; relative risk 0.25 [95 % CI 0.077-0.80]), giving a NNT of 3.0 [95 % CI 1.7-11.0]. No significant differences were found between AUC for the subjective parameters. No differences in side effects were found (P = 0.78). Melatonin significantly reduced the risk of depressive symptoms in women with breast cancer during a three-month period after surgery.

BACKGROUND: Helicopters are widely used for interhospital transfers of stroke patients, but the benefit is sparsely documented. We hypothesised that helicopter transport would reduce system delay to thrombolytic treatment at the regional stroke centre.METHODS: In this prospective controlled observational study, we included patients referred to a stroke centre if their ground transport time exceeded 30 min, or they were transported by a secondarily dispatched, physician-staffed helicopter. The primary endpoint was time from telephone contact to triaging neurologist to arrival in the stroke centre. Secondary endpoints included modified Rankin Scale at 3 months, 30-day and 1-year mortality.RESULTS: A total of 330 patients were included; 265 with ground transport and 65 with helicopter, of which 87 (33%) and 22 (34%), received thrombolysis, respectively (p=0.88). Time from contact to triaging neurologist to arrival in the regional stroke centre was significantly shorter in the ground group (55 (34-85) vs 68 (40-85) min, p<0.01). The distance from scene to stroke centre was shorter in the ground group (67 (42-136) km) than in the helicopter group (83 (46-143) km) (p<0.01). We did not detect significant differences in modified Rankin Scale at 3 months, in 30-day (9.4% vs 0%; p=0.20) nor 1-year (18.8% vs 13.6%; p=0.76) mortality between ground and helicopter transport.CONCLUSIONS: We found significantly shorter time from contact to triaging neurologist to arrival in the regional stroke centre if stroke patients were transported by primarily dispatched ground ambulance compared with a secondarily dispatched helicopter.

OBJECTIVES: Telemedicine is gaining ground in the treatment of patients with chronic obstructive pulmonary disease (COPD). Because telemedicine often requires both participation and engagement of the patients, it is important to take differences in cognitive ability into account, as there is evidence that cognitive dysfunction may be a limitation in patients with severe COPD. The aim of this study was to investigate whether cognitive performance is better after telemedicine-based treatment than after conventional hospitalization in patients with severe COPD and a mild to moderate exacerbation.MATERIALS AND METHODS: This randomized study was a substudy of the "Virtual Hospital," a multicenter, randomized controlled trial. The primary outcome in this substudy was cognitive function, evaluated 3 days and 6 weeks after discharge using a neuropsychological test battery comprising four tests and seven variables.RESULTS: We included 44 patients consecutively. Baseline characteristics were as follows: mean age, 70 (standard deviation [SD] 10) years; mean forced expiratory volume in 1 s, 1.0 (SD 0.55) L (42% of predicted); mean hemoglobin oxygen saturation, 95 (SD 2.0) percent; and mean Mini Mental State Examination score, 27.5 (SD 1.6) points. The performance in all seven neuropsychological test variables tended to be better in the group allocated to virtual admission 3 days and 6 weeks after discharge, but the difference was not significant after Bonferroni's correction for multiple comparisons.CONCLUSIONS: There were no significant differences in cognitive performance between the telemedicine-based group and the conventional hospital group. Patients with severe COPD suffering from mild to moderate exacerbations were able to manage the telemedicine-based treatment despite the reduced cognitive function often seen in COPD patients.

BACKGROUND: A number of perioperative risk factors may suppress the immune system and contribute to the development of post-operative complications. The association between surgical site infection (SSI) and other wound-related complications resulting from immunosuppression through either perioperative administration of dexamethasone, pre-operative smoking or alcohol abuse is, however, uncertain.METHODS: This study was a post hoc analysis of data from the PROXI randomized trial in 1386 patients who underwent emergency or elective laparotomy. We assessed the associations of use of dexamethasone, smoking status and alcohol abuse with the primary outcome, being a composite of SSI, anastomotic leak, wound dehiscence, burst abdomen and 30-day mortality.RESULTS: The primary outcome occurred in 21% of patients receiving dexamethasone versus 28% of patients not receiving dexamethasone, and this was not statistically significant when adjusting for stratification variables originally used in the PROXI trial [OR 0.90, 95% CI (0.65-1.24)]. In smokers, the primary outcome occurred in 32%, compared with 23% of non-smokers (P = 0.0001). Smokers also had a higher frequency of SSI (25% vs 17%, P < 0.0001) and burst abdomen (3.8% vs 2.4%, P = 0.04). In alcohol abusers, the primary outcome occurred in 48%, compared with 25% in patients who did not abuse alcohol (P = 0.0006). Burst abdomen occurred more commonly in alcohol abusers (15% vs 2.3%, P < 0.0001).CONCLUSION: Perioperative administration of dexamethasone was not significantly associated with SSI or other wound-related complications. Conversely, smoking and alcohol abuse were both significant predictors of the primary outcome consisting of wound-related complications and mortality.

BACKGROUND: Laparoscopic cholecystectomy performed during low intraabdominal pressure (<12 mm Hg) is associated with significantly less postoperative pain than standard pressure (≥12 mm Hg). The impact on surgical space conditions and safety of operating at lower pressures has not been adequately described, but deep neuromuscular blockade may be beneficial. We investigated if deep muscle relaxation would be associated with a higher proportion of procedures with "optimal" surgical space conditions compared with moderate relaxation during low-pressure (8 mm Hg) laparoscopic cholecystectomy.METHODS: In this assessor-blinded study, 48 patients undergoing elective laparoscopic cholecystectomy were administered rocuronium for neuromuscular blockade and randomized to either deep neuromuscular blockade (rocuronium bolus plus infusion maintaining a posttetanic count 0-1) or moderate neuromuscular blockade (rocuronium repeat bolus only for inadequate surgical conditions with spontaneous recovery of neuromuscular function). Patients received anesthesia with propofol, remifentanil, and rocuronium. The primary outcome was the proportion of procedures with optimal surgical space conditions (assessed by the surgeon as 1 on a 4-point scale). Secondary outcomes included the proportion of procedures completed at pneumoperitoneum 8 mm Hg and surgical space conditions on dissection of the gallbladder (numeric rating scale 0-100; 0 = optimal surgical space conditions; 100 = unacceptable surgical space conditions).RESULTS: Optimal surgical space conditions during the entire procedure were observed in 7 of 25 patients allocated to deep neuromuscular blockade and in 1 of 23 patients allocated to moderate blockade (P = 0.05) with an absolute difference of 24% between the groups (95% confidence interval, 4%-43%). Laparoscopic cholecystectomy was completed at pneumoperitoneum 8 mm Hg in 15 of 25 and 8 of 23 patients in the deep and moderate group, respectively (95% confide

BACKGROUND: Transfusion with red blood cells (RBC) may be needed during hip revision surgery but the appropriate haemoglobin concentration (Hb) threshold for transfusion has not been well established. We hypothesized that a higher transfusion threshold would improve ambulation after hip revision surgery.METHODS: The trial was registered at Clinicaltrials.gov ( NCT00906295). Sixty-six patients aged 18 years or older undergoing hip revision surgery were randomized to receive RBC at a Hb threshold of either 7.3 g/dL (restrictive group) or 8.9 g/dL (liberal group). Postoperative ambulation was assessed using Timed Up and Go-test (TUG) and ability to walk was also assessed daily by a physiotherapist blinded to the allocation.RESULTS: Fifty-three patients were able to perform the TUG and included in the analysis. The TUG could be completed in a median of 36 sec vs. 30 sec in the restrictive group and the liberal group, respectively (P = 0.02). The mean difference in TUG was 14.5 sec (95% CI 2.8-26.2 sec). No difference was found in the day patients could perform TUG or walk 10 meters. The Hb at the day of testing was 10.2 g/dL in the restrictive group and 9.9 g/dL in the liberal group. Only 26 patients received RBC.CONCLUSIONS: A Hb transfusion threshold of 8.9 g/dL was associated with a statistically significantly faster TUG after hip revision surgery compared to a threshold of 7.3 g/dL but the clinical importance is questionable and the groups did not differ in Hb at the time of testing.