Venetia Ong

The Use of Polymerase Chain Reaction Amplification for the Detection of Viruses and Bacteria in Severe Community-Acquired Pneumonia

Background: Pathogens are often not identified in severe community-acquired pneumonia (CAP), and the few studies using polymerase chain reaction (PCR) techniques for virus detection are from temperate countries. Objective: This study assesses if PCR amplification improves virus and bacteria detection, and if viral infection contributes to mortality in severe CAP in a tropical setting, where respiratory pathogens have less well-defined seasonality. Methods: In this cohort study of patients with severe CAP in an intensive care unit, endotracheal aspirates for intubated patients and nasopharyngeal swabs for non-intubated patients were sent for PCR amplification for respiratory viruses. Blood, endotracheal aspirates for intubated patients, and sputum for non-intubated patients were analysed using a multiplex PCR system for bacteria. Results: Out of 100 patients, using predominantly cultures, bacteria were identified in 42 patients; PCR amplification increased this number to 55 patients. PCR amplification identified viruses in 32 patients. In total, only bacteria, only viruses, and both bacteria and viruses were found in 37, 14, and 18 patients, respectively. The commonest viruses were influenza A H1N1/2009 and rhinovirus; the commonest bacterium was Streptococcus pneumoniae. Hospital mortality rates for patients with no pathogens, bacterial infection, viral infection, and bacterial-viral co-infection were 16.1, 24.3, 0, and 5.6%, respectively (p = 0.10). On multivariable analysis, virus detection was associated with lower mortality (adjusted odds ratio 0.12, 95% confidence interval 0.2-0.99; p = 0.049). Conclusions: Viruses and bacteria were detected in 7 of 10 patients with severe CAP with the aid of PCR amplification. Viral infection appears to be independently associated with lower mortality.

The adductor pollicis muscle: a poor predictor of clinical outcome in ICU patients

No nutrition assessment tools specifically tailored for intensive care unit (ICU) patients have been developed and validated in Singapore. Studies conducted in Brazilian populations suggest that the thickness of the adductor pollicis muscle (TAPM) may be used to assess nutritional status and predict mortality of critically ill patients. The aim of this study was to determine if TAPM can be used as a predictive indicator of mortality in Singapore ICU patients. TAPM values were obtained using skinfold calipers in 229 patients admitted to the medical ICU. TAPM measured in both hands showed no significant correlation with either the primary outcome (28-day mortality) or secondary outcomes (hospital outcome and hospital length of stay). This study demonstrated that TAPM does not predict 28-day mortality and hospital outcome, and is not correlated to length of stay in Singapore ICU patients. More studies are necessary to validate the use of TAPM as an anthropometric indicator of ICU outcome in other regions of the world.

Intravenous Thrombolysis for Acute Ischemic Stroke due to Cervical Internal Carotid Artery Occlusion.

BACKGROUND Internal carotid artery (ICA) occlusions are poorly responsive to intravenous thrombolysis with tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS). Most study populations have combined intracranial and extracranial ICA occlusions for analysis; few have studied purely cervical ICA occlusions. We evaluated AIS patients with acute cervical ICA occlusion treated with IV-tPA to identify predictors of outcomes. METHODS We studied 550 consecutive patients with AIS who received IV-tPA and identified 100 with pure acute cervical ICA occlusion. We evaluated the associations of vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and leptomeningeal collateral vessel status via 3 different grading systems, with functional recovery at 90 days, mortality, recanalization of the primary occlusion, and symptomatic intracranial hemorrhage (SICH). Modified Rankin Scale score 0-1 was defined as an excellent outcome. RESULTS The 100 patients had mean age of 67.8 (range 32-96) and median NIHSS score of 19 (range 4-33). Excellent outcomes were observed in 27% of the patients, SICH in 8%, and mortality in 21%. Up to 54% of the patients achieved recanalization at 24 hours. On ordinal regression, good collaterals showed a significant shift in favorable outcomes by Maas, Tan, or ASPECTS collateral grading systems. On multivariate analysis, good collaterals also showed reduced mortality (OR .721, 95% CI .588-.888, P = .002) and a trend to less SICH (OR .81, 95% CI .65-1.007, P = .058). Interestingly, faster treatment was also associated with favorable functional recovery (OR 1.028 per minute, 95% CI 1.010-1.047, P = .001). CONCLUSIONS Improved outcomes are seen in patients with early acute cervical ICA occlusion and better collateral circulation. This could be a valuable biomarker for decision making.

Prognostic utility of the 2011 GOLD classification and other multidimensional tools in Asian COPD patients: a prospective cohort study

Background How well the 2011 Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification prognosticates for Asian patients with COPD is unknown. Objective The authors aimed to study the predictive utility of the GOLD 2011 classification for exacerbations and mortality as compared with other multidimensional tools in an Asian population. Methods In all, 1,110 COPD patients were prospectively followed between March 2008 and March 2013. They were classified using the 2011 and 2007 GOLD guidelines, modified Medical Research Council score, St. George’s Respiratory Questionnaire (SGRQ), and Body mass index, Obstruction, Dyspnea (BOD) index. Outcome measures were exacerbations and mortality. Multivariable survival analyses and receiver operating characteristic (ROC) curves were used to assess the different classification systems. Results Time-to-event analyses demonstrated earlier exacerbations in 2011’s GOLD D when compared with GOLD A (hazard ratio [HR] 0.54, 95% confidence interval [CI]: 0.31–0.95, P=0.032) and GOLD B (HR 0.62, 95% CI: 0.45–0.85, P=0.003) and higher mortality when compared with GOLD A (HR 0.37, 95% CI: 0.16–0.88, P=0.025) and GOLD B (HR 0.46, 95% CI: 0.31–0.70, P<0.001). The areas under the ROC curve for GOLD 2011, GOLD 2007, modified Medical Research Council, St. George’s Respiratory Questionnaire, and BOD index were 0.62, 0.59, 0.61, 0.60, and 0.61, respectively, for the prediction of exacerbations and 0.71, 0.70, 0.71, 0.71, and 0.72, respectively, for the prediction of mortality (ROC comparator, P>0.05). Conclusion The 2011 GOLD classification predicts exacerbations and mortality moderately well in Asian COPD patients. Its prognostic utility is similar to that of other multidimensional systems.

External Validation of the Boston Acute Stroke Imaging Scale and M1-BASIS in Thrombolyzed Patients

Background and Purpose— Radiological findings play an essential role in therapeutic decision making and prognostication in acute ischemic stroke (AIS). The Boston Acute Stroke Imaging Scale (BASIS) and Middle Cerebral Artery-BASIS (M1-BASIS) methodologies are rapid purely radiological instruments and easily applicable for patients with AIS. We validated these methods in patients with AIS treated with intravenous tissue-type plasminogen activator. Methods— For BASIS, patients were labeled as having major stroke if there was occlusion of distal internal carotid artery, proximal (both M1 and M2 segments) of middle cerebral artery or the basilar artery, or an Alberta Stroke Program Early CT Score ⩽7. M1-BASIS differs from BASIS by classifying AIS patients with M2 occlusion as a minor stroke. We evaluated these classification systems for predicting functional outcomes (modified Rankin Scale score 0–1) at 3 months. Results— Two hundred sixty-five consecutive AIS patients treated with intravenous tissue-type plasminogen activator were included. On multivariate analysis, younger age (odds ratio, 1.039, 95% confidence interval, 1.009–1.070; P=0.011), lower National Institutes of Health Stroke Scale score (odds ratio, 1.140; 95% confidence interval, 1.073–1.210; P<0.001), and minor stroke by M1-BASIS (odds ratio, 2.376; 95% confidence interval, 1.047–5.393; P=0.039) were independent predictors of good functional outcome. When compared with National Institutes of Health Stroke Scale, the receiver operating characteristic curves for both BASIS (area under the curve, 0.721) and M1-BASIS (area under the curve, 0.795) correlated well with clinical severity scores. M1-BASIS has an additive effect with the National Institutes of Health Stroke Scale score to predict good outcomes. Conclusions— The purely radiological M1-BASIS correlates well with the clinical severity of stroke and can be a reliable prognostication tool in thrombolyzed AIS patients. This system might find an important place in the current era of telestroke.

Community-Acquired Pneumonia Case Validation in an Anonymized Electronic Medical Record–Linked Expert System

An electronic anonymized patient portal analysis using radiographic reports and admission and discharge diagnoses had sensitivity, specificity, positive predictive value, and negative predictive value of 84.7%, 78.2%, 75%, and 87%, respectively, for community-acquired pneumonia validated against a blinded expert medical review. This approach can help to track antimicrobial use and resistance.

1190: EVALUATION OF THERMOSENSOR WIRELESS SKIN-CONTACT THERMOMETER IN CRITICALLY ILL ADULTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) saturations (Sp02 <95%), low systolic blood pressure (SBP <5 percentile for age), high intracranial pressure (ICP > 20 mmHg), low cerebral perfusion pressure (CPP < 40 mmHg) and high temperature (> 38 Celsius); analysis of % time=duratrion of time below/total time monitored. Low frequency parameters such abnormal glucose (<60, >180), sodium (<140), and PaCO2 (>45) were measured as % abnormal=total number abnormal/total measurements Results: Severe TBI was met in 34 patients. Survival was 92% (31/34). The median age was 24 mo [2 mo-16 yr]. Invasive monitoring was present in 68% (23/34). One parameter or more was outside TCH clinical guidelines in 97% patients (33/34). The most common guideline deviation was low CPP in 17% of measurements, followed by low SBP (16%) abnormal sodium (14%) and low SpO2 (1.3%).Conclusions: Deviations from clinical guidelines are common. Improving compliance requires feedback to clinicians in a timely fashion. Our next phase in the QI process will focus on an intervention to improve capture with our system and to focus on easly feedback of poor compliance.