RESUMEN
BACKGROUND: An important element in improving the care of patients with sepsis is early identification and early intervention. Early warning score (EWS) systems allow earlier identification of physiological deterioration. A standardised national EWS (NEWS) has been proposed for use across the National Health Service in the UK. AIM: To determine whether a single NEWS on emergency department (ED) arrival is a predictor of outcome, either in-hospital death within 30â days or intensive care unit (ICU) admission within 2â days, in patients with sepsis. METHODS: Data were collected over a 3-month period as part of a national audit in 20 EDs in Scotland. All adult patients who were admitted for at least 2â days or who died within 2â days were screened for sepsis criteria. Patients with systemic inflammatory response syndrome criteria were included. An EWS was calculated based on initial physiological observations made in the ED using the NEWS. RESULTS: Complete data were available for 2003 patients. Each rise in NEWS category was associated with an increased risk of mortality when compared to the lowest category (5-6: OR 1.95, 95% CI 1.21 to 3.14), (7-8: OR 2.26, 95% CI 1.42 to 3.61), (9-20: OR 5.64, 95% CI 3.70 to 8.60). This was also the case for the combined outcome (ICU and/or mortality). CONCLUSIONS: An increased NEWS on arrival at ED is associated with higher odds of adverse outcome among patients with sepsis. The use of NEWS could facilitate patient pathways to ensure triage to a high acuity area of the ED and senior clinician involvement at an early stage.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Sepsis/diagnóstico , Índice de Severidad de la Enfermedad , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Femenino , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Curva ROC , Escocia/epidemiología , Sensibilidad y Especificidad , Medicina Estatal , Adulto JovenRESUMEN
BACKGROUND: The Surviving Sepsis Campaign (SSC) promotes a bundle approach to the care of septic patients to improve outcome. Some have questioned the capability of delivering the bundle in emergency departments (EDs). The authors report the epidemiology and 6 h bundle compliance of patients with severe sepsis/septic shock presenting to Scottish EDs. METHODS: Analysis of the previously reported Scottish Trauma Audit Group sepsis database was performed including 20 mainland Scottish EDs. A total of 308,910 attendances were screened (between 2 March and 31 May 2009), and 5285 of 27,046 patients were identified after case note review and included on the database. This analysis includes patients who had severe sepsis/septic shock before leaving the ED. Epidemiological, severity of illness criteria, and ED management data were analysed. RESULTS: 626 patients (median age 73; M/F ratio 1:1; 637 presentations) met entrance criteria. The median number of cases per site was 16 (range 3-103). 561 (88.1%) patients arrived by ambulance. The most common source of infection was the respiratory tract (n=411, 64.5%) The most common physiological derangements were heart rate (n=523, 82.1%), respiratory rate (n=452, 71%) and white cell count (n=432, 67.8%). The median hospital stay was 9 days (IQR 4-17 days). 201 (31.6%) patients were admitted to critical care within 2 days, 130 (20.4%) directly from the ED. 180 patients (28.3%) died. There was poor compliance with all aspect of the SSC resuscitation bundle. CONCLUSIONS: Sepsis presentations are of variable frequency but have typical epidemiology and clinical outcomes. SSC bundle resuscitation uptake is poor in Scottish EDs.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Sepsis/epidemiología , Adolescente , Adulto , Anciano , Femenino , Adhesión a Directriz , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Prevalencia , Estudios Prospectivos , Resucitación/normas , Estudios Retrospectivos , Escocia/epidemiología , Sepsis/fisiopatología , Sepsis/terapia , Choque Séptico/epidemiología , Choque Séptico/fisiopatología , Choque Séptico/terapia , Adulto JovenRESUMEN
BACKGROUND: The aim of this study was to investigate the delivery of procedural sedation and analgesia (PSA) in an urban teaching hospital Emergency Department (ED) over a 2-year period, and identify factors associated with complications. METHODS: Consecutive ED patients requiring PSA were prospectively enrolled onto the Registry of Emergency Procedural Sedation. Data collected included: patient and procedural characteristics; process times; physiological parameters; agents; sedation depth; and composition of staff team and complications. Multivariable binary logistic regression was used to identify factors associated with an increased risk of complications. RESULTS: 1402 patents required PSA during the study period. 1345 (95.9%) underwent orthopaedic manipulations. 597 (42.6%) received moderate sedation. 401 (28.6%) were sedated to deeper levels. Complications occurred in 49 (3.5%) cases. Deeper levels of sedation and the procedure occurring overnight were identified as risk factors for complications. Procedure type, patient age, grade of doctor and choice of drug were not found to be associated with an increased risk of complications. CONCLUSIONS: Procedural sedation and analgesia by Emergency Physicians is safe and effective; however, complications do happen. Complications are more likely at deeper levels of sedation and at night. Emergency Physicians must have the necessary skills and equipment to deal with such complications when they arise. EDs must be adequately staffed with trained clinicians 24 h a day to provide PSA.
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Analgesia/efectos adversos , Sedación Consciente/efectos adversos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Analgesia/métodos , Sedación Consciente/métodos , Femenino , Hospitales de Enseñanza , Hospitales Urbanos , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Factores de Riesgo , Reino Unido , Adulto JovenRESUMEN
PURPOSE: To describe cases of postoperative endophthalmitis in the European Society of Cataract & Refractive Surgeons (ESCRS) study of the prophylaxis of endophthalmitis, compare characteristics of unproven cases and cases proven by culture or polymerase chain reaction, and compare the characteristics with those in other reported series. SETTING: Twenty-four ophthalmology units in Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey, and the United Kingdom. METHODS: Univariable and multivariable logistic regression models were used to analyze data for statistical association of signs and symptoms in cases with proven or unproven endophthalmitis. Specific data describing characteristics of the cases were compared between the 2 types of cases. RESULTS: Data from 29 endophthalmitis cases were analyzed. Swollen lids and pain were statistically associated with proven cases of endophthalmitis on univariable regression analysis. Multivariable analysis indicated that swollen lids and an opaque vitreous were associated with proven cases. Five cases of endophthalmitis occurred in the cefuroxime-treated groups. No case of streptococcal infection occurred in the cefuroxime-treated groups. However, cases of infection due to streptococci showed striking differences in visual acuity and were associated with earlier onset. Characteristics in the 29 cases parallel results in previous studies, such as the Endophthalmitis Vitrectomy Study, although the addition of a control group in the ESCRS study elicited additional findings. CONCLUSION: Swollen lids, pain, and an opaque vitreous were statistically associated with proven endophthalmitis cases in the ESCRS study.
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Endoftalmitis/diagnóstico , Oftalmopatías/diagnóstico , Infecciones Bacterianas del Ojo/diagnóstico , Enfermedades de los Párpados/diagnóstico , Dolor/diagnóstico , Complicaciones Posoperatorias , Cuerpo Vítreo/patología , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Cefuroxima/uso terapéutico , Endoftalmitis/tratamiento farmacológico , Endoftalmitis/microbiología , Infecciones Bacterianas del Ojo/tratamiento farmacológico , Infecciones Bacterianas del Ojo/microbiología , Femenino , Humanos , Implantación de Lentes Intraoculares , Masculino , Persona de Mediana Edad , Facoemulsificación , Reacción en Cadena de la Polimerasa , Factores de Tiempo , Agudeza VisualRESUMEN
BACKGROUND: Infestations of the parasitic copepod Lepeophtheirus salmonis, commonly referred to as sea lice, represent a major challenge to commercial salmon aquaculture. Dependence on a limited number of theraputants to control such infestations has led to concerns of reduced sensitivity in some sea lice populations. This study investigates trends in the efficacy of the in-feed treatment emamectin benzoate in Scotland, the active ingredient most widely used across all salmon producing regions. METHODOLOGY/PRINCIPAL FINDINGS: Study data were drawn from over 50 commercial Atlantic salmon farms on the west coast of Scotland between 2002 and 2006. An epi-informatics approach was adopted whereby available farm records, descriptive epidemiological summaries and statistical linear modelling methods were used to identify factors that significantly affect sea lice abundance following treatment with emamectin benzoate (SLICE(R), Schering Plough Animal Health). The results show that although sea lice infestations are reduced following the application of emamectin benzoate, not all treatments are effective. Specifically there is evidence of variation across geographical regions and a reduction in efficacy over time. CONCLUSIONS/SIGNIFICANCE: Reduced sensitivity and potential resistance to currently available medicines are constant threats to maintaining control of sea lice populations on Atlantic salmon farms. There is a need for on-going monitoring of emamectin benzoate treatment efficacy together with reasons for any apparent reduction in performance. In addition, strategic rotation of medicines should be encouraged and empirical evidence for the benefit of such strategies more fully evaluated.
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Copépodos/efectos de los fármacos , Ivermectina/análogos & derivados , Salmo salar/parasitología , Animales , Acuicultura , Enfermedades de los Peces/tratamiento farmacológico , Enfermedades de los Peces/epidemiología , Geografía , Ivermectina/farmacología , Ivermectina/uso terapéutico , Resultado del TratamientoRESUMEN
PURPOSE: To present the development and design of the European Society of Cataract & Refractive Surgeons multicenter study of the prevention of postsurgical infective endophthalmitis after phacoemulsification and to describe the process for its successful implementation and conduct. SETTING: Twenty-four ophthalmology units and eye clinics in Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey, and the United Kingdom, with an administrative office in Ireland, coordinating center in England, and data management and statistical unit in Scotland. METHODS: This partially masked randomized placebo-controlled multinational clinical study was designed to evaluate prospectively the prophylactic effect of intracameral cefuroxime and/or perioperative topical levofloxacin on postoperative endophthalmitis after cataract surgery. Random allocation was based on a 2 x 2 factorial design that included participating centers as a class variable. Real-time electronic data collection monitored study progress and provided weekly outcome tables, monthly recruitment summaries, and quarterly analytical reports for the study's Data Monitoring Committee, which evaluated the safety and efficacy by Internet-based conferences. RESULTS: A 2-year lead time was required to meet harmonized standards of clinical research in the European Union, obtain ministerial authorization in 3 countries, gain institutional approvals at 24 hospitals, and procure indemnity insurance for surgical centers. Informed consent instruments, designed to comply with national health policies, were translated into 8 languages. The use of information technology to collect study data enabled the organizers to evaluate individual eligibility at enrollment, adherence with study medications during and after surgery, and postoperative status during follow-up. CONCLUSION: This international cooperative study provided the opportunity to estimate the current incidence of endophthalmitis after cataract surgery in Europe and determine whether 1 or both of 2 antimicrobial regimens reduces the risk for postsurgical intraocular infection.
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Antibacterianos/uso terapéutico , Profilaxis Antibiótica , Extracción de Catarata , Endoftalmitis/prevención & control , Infecciones Bacterianas del Ojo/prevención & control , Complicaciones Posoperatorias/prevención & control , Administración Tópica , Cámara Anterior/efectos de los fármacos , Cefuroxima/uso terapéutico , Método Doble Ciego , Endoftalmitis/microbiología , Infecciones Bacterianas del Ojo/microbiología , Humanos , Inyecciones , Levofloxacino , Ofloxacino/uso terapéutico , Complicaciones Posoperatorias/microbiología , Estudios ProspectivosRESUMEN
PURPOSE: To report results in the European Society of Cataract & Refractive Surgeons (ESCRS) multicenter study of the prophylaxis of endophthalmitis after cataract surgery. SETTING: Twenty-four ophthalmology units and eye clinics in Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey, and the United Kingdom, with an administrative office in Ireland, coordinating center in England, and data management and statistical unit in Scotland. METHODS: This partially masked randomized placebo-controlled multinational clinical study to evaluate prospectively the prophylactic effect of intracameral cefuroxime injection and/or perioperative levofloxacin eyedrops on the incidence of endophthalmitis after phacoemulsification cataract surgery began in September 2003 and was terminated early in January 2006. The study used random allocation of patients in a 2 x 2 factorial design. RESULTS: By the end of 2005, complete follow-up records had been received for 13 698 study patients. Such a clear beneficial effect from the use of intracameral cefuroxime had been observed that it was agreed it would be unethical to continue the study and to wait for the completion of all follow-up procedures before reporting this important result. If total reported cases of endophthalmitis are considered, the incidence rate observed in those treatment groups not receiving cefuroxime prophylaxis (23 cases in 6862 patients) was almost 5 times as high (odds ratio [OR], 4.59; 95% confidence interval [CI], 1.74-12.08; P = .002) as that in the groups receiving this treatment (5 cases in 6836 patients). If only cases proved to be due to infection are considered, the rate was more than 5 times as high (OR, 5.32; 95% CI, 1.55-18.26; P = .008) in the treatment groups not receiving cefuroxime. Although the use of perioperative levofloxacin eyedrops as prophylaxis was also associated with a reduction in the observed incidence rate of postoperative endophthalmitis, this effect was smaller and was not statistically significant, whether total reported cases or only cases proven to be due to infection are used in calculating the rates. As not all follow-up procedures are complete, it is possible that further cases of endophthalmitis may be reported; however, it is not expected that this will alter the main conclusion. Nevertheless, it is anticipated that successful completion of follow-up procedures in all patients will increase the total number in the study to approximately 16,000. CONCLUSION: Intracameral cefuroxime administered at the time of surgery significantly reduced the risk for developing endophthalmitis after cataract surgery.