Direct discharge from the intensive care unit improved patient flow in a resource-pressured health system

Critical care practice is constantly evolving. Pressures for bed availability in publicly funded healthcare systems have led to an increase in patients delayed in their discharge from critical care to the wards. This has resulted in more patients discharged directly home (DDH) from the intensive care unit (ICU). However, few formal pathways for DDH exist. We have performed a retrospective audit of the patients discharged home from our unit in the largest tertiary referral hospital in the Republic of Ireland from 2017 to 2022 to investigate their characteristics and the safety of this practice, given the understandable patient safety concerns raised.Results In total, 84 patients have been DDH from our unit between 2017 and 2022 from a total of 4747 patients. The overall rate of DDH increased year on year, and the vast majority of these patients were initially admitted from the emergency department or following elective major surgery. Most patients had an APACHE score of less than 11 points, and the majority were admitted for less than 3 days, with single organ failure. There was a gender divide, as greater than 60% of the patients admitted were male, with a mean age of 44.Conclusion DDH has been an important tool in improving patient flow through the hospital, avoiding unnecessary de-escalation to the ward for a select group of critical care patients. The re-admission rate in the year post-ICU discharge was very low, showing that DDH has not adversely impacted patient safety.

Comparing consumer liking of beef from three feeding systems using a combination of traditional and temporal liking sensory methods

Research on the effects of animal diet on consumer liking of beef has yielded conflicting results. Currently it is unknown whether dynamic changes occur in liking during consumption of beef. This study applied a combination of traditional and temporal (free and structured) liking methods to determine consumer liking of beef derived from animals that were fed grain (GF), grass silage plus grain (SG) or grazed grass (GG) during finishing. Three separate panels of beef eating consumers (n = 51; n = 52; n = 50) were recruited from Teagasc Food Research Centre, Dublin, Ireland to assess striploin steaks from animals fed either GF, SG, or GG. Using the free temporal liking (TL) method, results revealed that beef from GF animals was liked significantly less (p ≤ 0.05) in terms of overall liking, tenderness and juiciness, when compared to steaks from the SG and GG animals. These effects were not observed using the structured TL or traditional liking methods. Further analysis showed the evolution of scores over time was significant (p ≤ 0.05) for all attributes using the free TL method. Overall, the free TL method yielded more discriminative data and was perceived as easier to perform by consumers compared to the structured TL method. These results show that the free TL method may provide an opportunity to elicit more in-depth information regarding consumer sensory response to meat.

An observational study on passive immunity in Irish suckler beef and dairy calves: Tests for failure of passive transfer of immunity and associations with health and performance

The study objectives were to: 1) evaluate the diagnostic performance of passive immunity tests for classification of failure of passive transfer (FPT) risk, based on their relationships with calf health and performance, and 2) describe the epidemiology of morbidity and mortality in suckler beef and dairy calves under Irish conditions. A total of 1392 suckler beef calves (n = 111 farms) and 2090 dairy calves (84 farms) were included in this observational study. Blood samples were collected by jugular venipuncture. Serum samples were analysed for total IgG concentration using an ELISA assay, total protein concentration by clinical analyser (TP - CA), globulin concentration, zinc sulphate turbidity (ZST) units, total solids percentage by Brix refractometer (TS - BRIX), and total protein concentration by digital refractometer (TP - DR). Crude and cause-specific morbidity, all-cause mortality, and standardised 205-day body weight (BW) were determined. Generalised linear mixed models were used to evaluate associations between suckler beef and dairy calves for morbidity, mortality, growth and passive immunity. Receiver operating characteristic (ROC) curves were constructed to determine optimal test cut-offs for classification of health and growth outcomes. Overall, 20% of suckler beef and 30% of dairy calves were treated for at least one disease event by 6 mo. of age. Suckler beef calves had greater odds of bovine respiratory disease (BRD; odds ratio (OR), 95% confidence interval (CI): 2.8, 1.2-6.5, P = 0.01), navel infection (5.1, 1.9-13.2, P < 0.001), and joint infection/lameness (3.2, 1.3-7.8, P = 0.01) during the first 6 mo. of life than dairy calves. In addition, from birth to 6 mo. of age, suckler beef calves had greater rates of navel infection (incidence rate ratio (IRR), 95% CI: 3.3, 1.3-8.4, P = 0.01), but decreased rates of diarrhoea (0.9, 0.2-0.9, P = 0.03) compared to dairy calves. Optimal test cut-offs for classification of morbidity and mortality outcomes in suckler beef calves ranged from 8 to 9 mg/ml ELISA, 56 to 61 g/l TP - CA, 26 to 40 g/l globulin, 12 to 18 ZST units, 8.4% TS - BRIX, and 5.3 to 6.3 g/dl TP - DR. Optimal test cut-offs for classification of morbidity and growth outcomes in dairy calves ranged from 10 to 12 mg/ml ELISA, 57 to 60 g/l TP - CA, 29 to 34 g/l globulin, 19 ZST units, 7.8 to 8.4% TS - BRIX, and 5.7 to 5.9 g/dl TP - DR.

Urine proteomics--prospects for future diagnostics

This brief overview of the potential diagnostic, prognostic and pathophysiological value of studies into the urine proteome describes hypothesis-driven investigations of individual proteins and proteome-wide search for urinary biomarkers of various diseases and their progression. It is intended to illustrate the recent progress in the area of urine proteomics and proselytize for the promise of this centuries-old technique of uroscopy, yet to reveal its secrets, using modem approaches.

Characterization of urinary peptide biomarkers of acute rejection in renal allografts

We previously demonstrated that 4.7 kDa and 4.4 kDa peptides are useful in diagnosing acute rejection in renal transplant recipients. The aim of this study was to characterize these polypeptides and assess their potential as biomarkers. The polypeptides were identified as human beta-Defensin-1 (4.7 kDa) and alpha-1-antichymotrypsin (4.4 kDa), by tandem mass spectrometry and ProteinChip immunoassay. The urinary abundance of both polypeptides, assessed using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF MS), revealed a reduction in beta-Defensin-1 while alpha-1-antichymotrypsin increased in patients with rejection (p < 0.05) compared with clinically stable transplants. The area under the curve (AUC) for the receiver operator characteristic (ROC) curve for the diagnosis of rejection for the ratio of both peptides combined was 0.912. Longitudinal analysis confirmed a reduction in beta-Defensin-1 with a reciprocal increase in alpha-1-antichymotrypsin as rejection developed. The difference in urinary beta-Defensin-1 levels quantified by radioimmunoassay was 176.8 +/- 122.3 pg/mL in stable patients compared with 83.2 +/- 52.2 pg/mL in patients with acute rejection, with an ROC AUC of 0.749 (p < 0.01). Immunohistochemistry (IHC) confirmed reduced beta-Defensin-1 expression in the renal parenchyma of patients experiencing acute rejection. In conclusion, the ratio of beta-Defensin-1 and alpha-1-antichymotrypsin excretion in the urine is a novel, potentially useful candidate biomarkers of acute rejection.

Laser Doppler flowmetry detection of endothelial dysfunction in end-stage renal disease patients: correlation with cardiovascular risk

Prediction of cardiovascular (CV) complications represents the Achilles' heel of end-stage renal disease. Surrogate markers of endothelial dysfunction have been advocated as predictors of CV risk in this cohort of patients. We have recently adapted a noninvasive laser Doppler flowmetry (LDF) functional testing of endothelium-dependent microvascular reactivity and demonstrated that end-stage renal disease patients are characterized by profound alterations in thermal hyperemic responsiveness. We hypothesized that such functional assessment of the cutaneous microcirculation may offer a valid, noninvasive test of the severity of endothelial dysfunction and CV risk. To test this hypothesis, we performed a cross-sectional study, in which we compared LDF measurements to conventional risk factors, and performed a pilot longitudinal study. LDF studies were performed in 70 patients and 33 controls. Framingham and Cardiorisk scores were near equivalent for low-risk patients, but more divergent as risk increased. C reactive protein (CRP) levels and LDF parameters (amplitude of thermal hyperemia (TH), area under the curve of TH) showed significant abnormality in high-risk vs low-risk patients calculated using either Framingham or Cardiorisk scores. Patients who had abnormal LDF parameters showed increased CV mortality, however, had similar risk assessments (Framingham, Cardiorisk, CRP, and homocysteine) to those with unimpaired LDF tracings. In conclusion, LDF parameters of microvascular reactivity offer a sensitive characterization of endothelial dysfunction, which may improve CV risk assessment through incorporation into the Framingham or Cardiorisk algorithm.

Mediastinal chest drain clearance for cardiac surgery

BACKGROUND

Cardiac tamponade may occur following cardiac surgery as a result of blood or fluid collecting in the pericardial space compressing the heart and reducing cardiac output. Mediastinal chest drains (including pericardial drains) are inserted as standard post-operative practice following cardiac surgery to assist the clearance of blood from the pericardial space and to prevent cardiac tamponade. To prevent chest tubes from blocking and so causing tamponade nurses manipulate them to prevent or remove clots. Manipulation methods including milking, stripping, fanfolding and tapping may be applied to the tubes to keep them from blocking. Evidence is required as to the safest and most effective means of preventing chest tube blockage and preventing cardiac tamponade.

OBJECTIVES

To compare different methods of chest drain clearance (i.e. varying levels of suction or suction in combination with milking, stripping, fanfolding and tapping of chest drains) in preventing cardiac tamponade in patients following cardiac surgery.

SEARCH STRATEGY

Over both the initial review and the 2004 revision, we searched the Cochrane Heart Group trials register, the Cochrane Controlled Trials Register (CCTR) (Issue 4, 2003) The Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effectiveness (DARE), Issue 4, 2003, MEDLINE (1966 to Nov Week 2, 2003), EMBASE (1980 to 2003 Week 47), CINAHL (1982 to Nov 2003), the Clinical Trials site of the NIH, (USA) (24.11.03) and reference lists of articles.

SELECTION CRITERIA

Randomised, quasi-randomised or systematically allocated clinical trials of chest tube manipulation methods in adults and children with mediastinal chest drains following cardiac surgery were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information where required. Adverse effects information was collected from the trials.

MAIN RESULTS

Three studies with a total of 471 participants were included. There was no data, however, which could be included in a meta-analysis. This was due to inadequate data provision by two of the studies. Where adequate data were provided there were no common interventions or outcomes to pool. On the basis of single studies there was no evidence of a difference between groups on incidence of chest tube blockage, heart rate, cardiac tamponade or incidence of surgical re-entry.

REVIEWERS' CONCLUSIONS

There are insufficient studies which compare differing methods of chest drain clearance to support or refute the relative efficacy of the various methods in preventing cardiac tamponade. Nor can the need to manipulate chest drains be supported or refuted by results from RCT's.

Variation in dialysis patient mortality by Health Authority

BACKGROUND

Maintenance dialysis is a relatively low prevalence, highly specialized, and labour-intensive treatment, which is usually delivered at regional centres serving many different health authorities. It is unknown whether a patient's health authority, in many ways an accident of birth, influences long-term dialysis outcomes.

AIM

To study survival patterns in patients starting maintenance dialysis therapy in the north-west of England between 1990 and 1999.

DESIGN

Retrospective analysis.

METHODS

We analysed data from quarterly returns submitted to the West Pennine Health Authority from 10 dialysis centres, including health authority, dialysis centre, age, gender, mode of dialysis therapy, postal code and diabetic status. Postal codes were used to compute the distance from residence to dialysis centre and Carstairs index.

RESULTS

There were 2458 patients from 18 health authorities. Survival on dialysis therapy differed by health authority (p < 0.0001). Health authorities were then grouped into socioeconomic families, using The Office of National Statistics health authority classification system (ONS1). ONS1 profiles at inception of dialysis therapy were also associated with disparities in survival, with subjects from Urban and Rural health authorities having longer survival than those from Mining and Industrial, Mature or Prospering health authorities (p < 0.0001).

DISCUSSION

Survival on dialysis varies significantly by health authority. The interface between highly specialized, centralized, medical services and the health authorities they serve may be a major outcome determinant.

Mediastinal chest drain clearance for cardiac surgery

BACKGROUND

Cardiac tamponade may occur following cardiac surgery as a result of blood or fluid collecting in the pericardial space compressing the heart and reducing cardiac output. Mediastinal chest drains (including pericardial drains) are inserted as standard post-operative practice following cardiac surgery to assist the clearance of blood from the pericardial space and to prevent cardiac tamponade. Manipulation techniques including milking, stripping, fanfolding and tapping may be applied to the tubes to keep them from blocking. Evidence is required as to the safest and most effective means of preventing chest tube blockage and preventing cardiac tamponade.

OBJECTIVES

To compare different methods of chest drain clearance (i.e. varying levels of suction or suction in combination with milking, stripping, fanfolding and tapping of chest drains) in preventing cardiac tamponade in patients following cardiac surgery.

SEARCH STRATEGY

We searched the Cochrane Heart Group specialised register, the Cochrane Controlled Trials Register (CCTR) (Issue 1, 2001) The Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effectiveness (DARE), Issue 1, 2001, MEDLINE (1966 to May Week 1, 2001), EMBASE (1980 to 2001 Week 35), CINAHL (1982 to March 2001), the Clinical Trials site of the NIH, (USA) (10.09.01) and reference lists of articles.

SELECTION CRITERIA

Randomised, quasi-randomised or systematically allocated clinical trials of chest tube manipulation techniques in adults and children with mediastinal chest drains following cardiac surgery were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information where required. Adverse effects information was collected from the trials.

MAIN RESULTS

Three studies with a total of 471 participants were included. There was no data, however, which could be included in a meta-analysis. This was due to inadequate data provision by two of the studies and where adequate data were provided there were no common interventions or outcomes to pool. On the basis of single studies there was no difference between groups on incidence of chest tube blockage, heart rate, cardiac tamponade or incidence of surgical re-entry.

REVIEWER'S CONCLUSIONS

There are insufficient studies which compare differing methods of chest drain clearance to support or refute the relative efficacy of the various techniques in preventing cardiac tamponade. Nor can the need to manipulate chest drains be supported or refuted by results from RCT's.

Isolated sarcoid granulomatous interstitial nephritis: review of five cases at one center

AIMS

To identify any clinical or biochemical parameters which determine prognostic outcome in isolated sarcoid granulomatous interstitial nephritis presenting with renal failure.

METHODS

A review of five cases of renal failure due to isolated sarcoid granulomatous interstitial nephritis, which presented to Hope Hospital over the 7-year period 1994 to 2000. Follow-up averaged 35 months with a range of 11 to 73 months.

RESULTS

Only one patient had an elevated serum ACE at presentation, reflecting the suboptimal sensitivity of this test as a marker in sarcoidosis and the limited extent of disease in these patients. Four of the five cases had a marked improvement in creatinine clearance within 10 days of starting oral prednisolone. Two patients required acute hemodialysis on presentation. Their renal failure responded to treatment with steroids, enabling withdrawal of dialysis within 10 days. All patients remained dialysis-independent although serum creatinine levels rose during follow-up. One patient experienced a relapse that responded to an increased dose of steroid.

CONCLUSIONS

Serum ACE is not reliable in the diagnosis of renal failure due to sarcoid interstitial nephritis and the diagnosis can only be made on renal biopsy. First-line treatment with oral prednisolone results in a rapid improvement in creatinine clearance although prolonged treatment may be needed to prevent a relapse.

Effects of anaemia on cardiovascular status

Cardiomyopathy is a common, heterogeneous and important cause of cardiac morbidity and mortality in uraemic patients. The risks of ischaemic heart disease, cardiac failure, and death increase progressively from lowest risk in patients with concentric left-ventricular hypertrophy, to medium risk in patients with left-ventricular dilatation but intact systolic function, to highest risk in patients with systolic dysfunction. Anaemia and hypertension are the reversible risk factors most consistently linked with the development of cardiomyopathy in these patients. Longitudinal data show that anaemia predisposes individuals to initial left ventricular dilatation, with compensatory hypertrophy, which may progress to systolic dysfunction. This process typically begins at glomerular filtration rates between 25 and 50 ml/min, and haemoglobin concentrations that are even slightly below normal are associated with progressive cardiac enlargement. Several observational studies have suggested that the correction of anaemia may reduce mortality and hospitalization rates in dialysis patients. The available evidence supports maintaining haemoglobin concentrations to greater than 11 g/dl. Whether a haemoglobin threshold exists above which no further benefit is seen remains controversial, partially because recent randomized controlled trials have intervened relatively late in the anaemia cardiomyopathy cardiac failure death continuum. One large randomized controlled trial showed no benefit from normalizing the haemoglobin concentration in haemodialysis patients with well-established cardiac disease; however, these patients had been exposed to anaemia for long periods of time and were at the extreme end of the cardiorenal disease spectrum. Other researchers have demonstrated a protective effect of normalizing the haemoglobin concentration in patients with asymptomatic, and hence presumably early, cardiomyopathy. The psychological benefits and improvements in exercise tolerance and quality of life resulting from normalization of the haemoglobin concentration are becoming clearer. However, conclusive evidence of the cardiovascular benefits of earlier, more aggressive treatment of renal anaemia as well as of the exact target haemoglobin concentration at which risk begins to develop is still lacking. The results of ongoing trials should help to clarify both of these issues within the next 5 years.

Changes in lipid profiles in non diabetic, non nephrotic patients commencing continuous ambulatory peritoneal dialysis

This study examined the effect on patient lipid profile of commencing continuous ambulatory peritoneal dialysis (CAPD). We followed eighteen non diabetic, non nephrotic patients for 9 months before and after dialysis commencement and compared lipid profiles. Mean cholesterol levels rose from 4.98 mmol/L to 5.42 mmol/L (p < 0.05). This change was chiefly due to a rise in low density lipoprotein (LDL) cholesterol. The LDL cholesterol rose after dialysis commencement and continued to rise up to 9 months later. High-density lipoprotein (HDL) cholesterol remained stable. Serum albumin and body weight fell during follow-up, suggesting that the rise in cholesterol was not a reflection of enhanced nutritional status. This study highlights the pro-atherogenic change in lipids that results from commencing CAPD. This phenomenon is not seen in hemodialysis, and it should be considered when selecting a dialysis modality, given the increased risk of cardiovascular disease in the dialysis population.

Dual phase hepatic CT: influence of scanning direction on liver attenuation

OBJECTIVE

We measured changes in hepatic attenuation during arterial and portal phase acquisition of hepatic CT in the craniocaudal and caudocranial directions.

SUBJECTS AND METHODS

In 10 of 20 patients undergoing dual phase helical CT during staging for colorectal cancer, images in both phases were obtained in the craniocaudal direction. Ten patients underwent imaging in the caudocranial direction. Attenuation values in the aorta and in the peripheral and central liver regions of interest were measured on each slice. Central and peripheral liver attenuation was also measured in 10 additional patients undergoing unenhanced CT.

RESULTS

Both peripheral and central regions of interest revealed progressively increasing attenuation during the arterial phase, irrespective of scanning direction. During the portal phase, hepatic attenuation was stable in the craniocaudal direction but decreased in the caudocranial direction (p < 0.05, Wilcoxon's signed rank sum test). Central hepatic attenuation was lower than peripheral attenuation in unenhanced livers and in enhanced livers during both phases of caudocranial acquisition. We determined no significant difference during the arterial phase of enhancement in the craniocaudal direction.

CONCLUSION

The direction of acquisition does not influence sequential liver enhancement during the arterial phase. Craniocaudal acquisition produces more stable enhancement during the portal phase. Differences in attenuation between the central and peripheral areas of the liver are probably unrelated to contrast administration.

New insights into the epidemiologic and clinical manifestations of atherosclerotic renovascular disease

Atherosclerotic renovascular disease (ARVD) continues to challenge the clinician as we enter the third millenium. ARVD frequently complicates patients with other vascular pathological states, and it is an increasingly common cause of end-stage renal failure. Although renovascular interventional procedures are now widely available and are of benefit to some patients with ARVD, a large proportion still progress to dialysis. Recent epidemiological investigations have emphasized the relationship between ARVD and other vascular diseases, and these are notable in patients with coronary artery disease and/or cardiac failure. Increased awareness of the possible coexistence of ARVD in patients with these latter conditions may allow earlier diagnosis and a minimization of complications (eg, angiotensin-converting enzyme inhibitor-related uremia or flash pulmonary edema). Contemporary studies also highlight the importance of intrarenal vascular and parenchymal injury in the cause of chronic renal failure in many patients with ARVD. Severe renal structural damage often coexists with proximal renal arterial narrowing, and this can explain the variability of renal functional outcomes known to accompany revascularization procedures. More appropriate selection of those patients likely to benefit from renovascular revascularization is now required. Large-scale trials that will identify the optimal approach to improving renal functional and survival outcomes in this high-risk group of patients are now long overdue.

Haemodialysis catheter bacteraemia: evolving strategies

This article reviews the new trends in the diagnosis, treatment and prevention of catheter-related bacteraemia in clinical nephrology. Among these are the newer diagnostic techniques of evaluating and obtaining culture specimens from central lines, such as timed cultures and use of the endoluminal brush. In general, attempts to salvage infected haemodialysis lines are unsuccessful. We review the data that pertain to the use of antibiotic-coated catheters in non-dialysis patients and discuss how these observations may be applied to end-stage renal disease patients.