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[Dynamic monitoring of the severity of brain edema and swelling by separate impedance measurement in patients with severe craniocerebral trauma].

The dynamics of brain edema and swelling was studied according to the indices of separate impedancemetry in the early posttraumatic period in 36 patients with severe craniocerebral trauma. Swelling of the brain predominated on the 1st and 2nd days in most patients. Later, depending on the severity of the posttraumatic period, the swelling may grow or be replaced by edema with subsequent normalization. A parallelism was revealed between the severity of brain edema and swelling, the intracranial pressure value, and the severity of the patient's condition.

Acute Disease↗

Combined captopril treatment in severe and moderately severe hypertension resistant to therapy.

Combined Captopril treatment was applied in 61 patients with severe or moderately severe hypertension in patients insufficiently or not reacting to the usual combined antihypertensive therapy (3-7 kinds of drug). The combination included diuretics, beta-blockers, alpha-blockers, vasodilators, Ca-antagonists and centrally acting agents. Diuretics were used in all cases. Average duration of treatment was 8.2 months (i.e. 2-40 months). Mean systolic pressure prior to Captopril treatment was 202.4 mm Hg (S.D. +/- 27.6), while the diastolic 122.0 mm Hg (S.D. +/- 11.3). During combined Captopril treatment the average values were 154.2 mm Hg (S.D. +/- 18.8) and 97.6 mm Hg diastolic pressures (S.D. +/- 10.7), the difference being significant (p less than 0.001). Refractory hypertension occurred in three middle-aged female patients in response to combined Captopril treatments. Captopril treatment had to be discontinued for the appearance of side-effects (severe skin symptoms) only in a single case. A minor deterioration of renal functions was observed in three patients (in one bilateral renovascular, and in two essential hypertension). Serum creatinine value and renal functions of four patients showed significant improvement as a result of combined Captopril treatment. During combined Captopril treatments (also with a diuretic) two patients had so severe hypokalaemia that they needed potassium substitution or administration of a potassium-saving diuretic.

Antihypertensive Agents↗

The speed of onset and severity of acute severe asthma.

The speed of onset of attacks of acute severe asthma was prospectively studied in a total of 261 consecutive episodes. 82% of these episodes involved patients with 'extrinsic' asthma and 28% involved children. The speed of onset of an attack was rapid (defined as less than 24 hours) in 46% of episodes and was less than one hour in 13%. Rapid-onset attacks occurred more frequently in younger patients and were no more or less severe than attacks of slower evolution. Comparison of different measures of severity in our patients showed statistically significant but low correlations. Objective measures seemed no better than simple clinical assessment with the Jones index. We discuss the significance of these correlations and the place of emergency admission services for attacks of acute severe asthma of rapid speed of onset.

Acute Disease↗

Aetiology of severe aplastic anaemia and outcome after allogeneic bone marrow transplantation or immunosuppression therapy. Working Party on Severe Aplastic Anaemia of the European Blood and Marrow Transplantation Group.

This study is based on 2163 patients with severe aplastic anaemia from the European Bone Marrow Transplantation Working Party Registry on Severe Aplastic Anaemia. It was designed to define patients' characteristics according to different aetiology and to assess the impact of aetiology of the aplasia on treatment outcome. Significant differences were found in age, sex, disease severity and DR typing between idiopathic, post-hepatitis and drug-associated severe aplastic anaemia. These differences did not affect the overall outcome of patients treated with bone marrow transplantation (BMT) or immunosuppression (IS) therapy.

Adolescent↗

The clinical characteristics at the onset of a severe asthma attack and the effects of high frequency jet ventilation for severe asthmatic patients.

To clarify the relationship between the clinical characteristics and the effects of high frequency jet ventilation based on the differences in the speed of deterioration in severe asthmatic patients who required intubation and mechanical ventilation, we classified 37 severe asthmatics into two groups (acute onset group: n = 20, intubated within 24 hours; slow onset group: n = 17, intubated over 3 days) and measured the arterial blood gas values, the duration of mechanical ventilation, and the peak inspiratory pressure during synchronized intermittent mechanical ventilation with or without high frequency jet ventilation. The acute onset group showed a significantly higher incidence of cyanosis (75% vs. 41%, p < 0.05), an acute loss of consciousness (90% vs. 53%, p < 0.05), severe mixed acidosis with extreme hypercapnoea (pH 7.11 +/- 0.19, PaCO2 94.1 +/- 10.7 mmHg, BE -8.3 +/- 1.7 mEq/l), and a more elevated peak inspiratory pressure (59.7 +/- 1.8 mmHg vs. 41.1 +/- 1.8 mmHg, p < 0.05) during synchronized intermittent mechanical ventilation at admission, compared with the slow onset group (p < 0.05). The slow onset group required a more prolonged mechanical ventilation than the acute onset group (5.4 +/- 4.0 vs. 3.0 +/- 2.4 days, p < 0.05), in spite of a lower peak inspiratory pressure than that observed in the acute onset group, because of either a large amount of secretion or an infection in the airway. Both the high peak inspiratory pressure and the severe mixed acidosis with markedly elevated hypercapnoea were significantly reduced by the application of high frequency jet ventilation between the intra- and the inter-groups. These findings thus indicated the existence of significant differences in the clinical features and pathogenesis of airway hyperreactivity between these two groups, and the application of high frequency jet ventilation to the status asthmaticus was thus found to be effective.

Acute Disease↗

Therapy with a severe acute respiratory syndrome-associated coronavirus-neutralizing human monoclonal antibody reduces disease severity and viral burden in golden Syrian hamsters.

BACKGROUND: Immunotherapy with monoclonal antibodies (MAbs) offers safe interventions for the prevention of infection in patients after organ transplantation and for the treatment of cancers and autoimmune diseases. MAb 201 is a severe acute respiratory syndrome-associated coronavirus (SARS-CoV)-specific MAb that prevents establishment of viral replication in vitro and prevents viral replication in vivo when administered prophylactically. The efficacy of MAb 201 in the treatment of SARS was evaluated in golden Syrian hamsters, an animal model that supports SARS-CoV replication to high levels and displays severe pathological changes associated with infection, including pneumonitis and pulmonary consolidation. METHODS: Golden Syrian hamsters that were intranasally inoculated with SARS-CoV were treated with various doses of MAb 201 or an irrelevant MAb 24 h after inoculation. Two to 7 days after infection, the hamsters were killed, and their lungs were collected for evaluation of viral titers and pathological findings. RESULTS: Postexposure treatment with MAb 201 can alleviate the viral burden and associated pathological findings in a golden Syrian hamster model of SARS-CoV infection. After a hamster is treated with MAb 201, its viral burden is reduced by 102.4-103.9 50% tissue-culture infectious doses per gram of tissue, and the severity of associated pathological findings, including interstitial pneumonitis and consolidation, is also remarkably reduced. CONCLUSIONS: The demonstration of successful postexposure MAb 201 therapy in an animal model that demonstrates viral replication and associated pulmonary pathological findings suggests that MAb 201 may be useful in the arsenal of tools to combat SARS.

Animals↗

The use of indirect calorimetry in critically ill patients--the relationship of measured energy expenditure to Injury Severity Score, Septic Severity Score, and APACHE II Score.

The nutritional needs of critically ill septic patients or patients with multiple injuries are often difficult to estimate. Indirect calorimetry can simply and accurately determine individual caloric and nutritional needs, especially in cases of critically ill patients with complicated injuries. This prospective study compared the measured energy expenditures of 30 patients using indirect calorimetry with their predicted basal energy expenditure according to the Harris-Benedict equation, or their calculated energy expenditure derived from basal energy expenditure times, an activity factor, and a stress factor. These numbers were then used to evaluate the relationship between measured energy expenditure, measured energy expenditure per kilogram, and four specific scoring systems--the Septic Severity Score (SSS), the Injury Severity Score (ISS), the Trauma Score (TS), and APACHE II. The results showed the severity of sepsis or trauma correlated with the measured energy expenditure per kilogram of body weight. Among the 15 septic patients, in whom the measured energy expenditure per kilogram was 42.2 +/- 2.6 kcal/kg, the SSS provided a better predictor of energy needs and closer correlation with measured energy expenditure per kilogram (r = 0.69, Y = 1.41 + 0.72 X). Their stress factors could be modified as "0.97 + 0.0125 x SSS" to get a more accurate Harris-Benedict calculation. For the 15 patients with multiple injuries in whom the measured energy expenditure per kilogram was 34.9 +/- 1.6 kcal/kg, the ISS offered the best correlation with measured energy expenditure per kilogram (r = 0.84, Y = -31.47 +/- 1.73 X). Their stress factors could be modified as "1.04 + 0.0077 x ISS" to get a more accurate Harris-Benedict calculation.

Adult↗

Impaired self-awareness after moderately severe to severe traumatic brain injury.

Patients with moderately severe to severe traumatic brain injury (TBI) can demonstrate disturbances in self-awareness several months or years after injury. Patients may underreport cognitive and behavioral difficulties, which are the true residuals of their brain injury. Increasingly, research indicates that the residuals of these disturbances in consciousness greatly affect the process and outcome of rehabilitation. A recent model for conceptualizing disturbances of self-awareness after various forms of brain injury is reviewed.

Awareness↗

Progress toward a new injury severity characterization: severity profiles.

Presented is a new seven-dimensional injury severity profile. The profile includes three physiologic assessments and four variables which express the number, location, and severity of a patient's injuries in terms of 'Abbreviated injury scale' values. The physiologic assessments are coded values for the 'Glasgow coma scale', systolic blood pressure, and respiratory rate. Also presented are survival-death predictive values of a cluster model based on survival rates of clusters of profiles of 2569 blunt-injured and penetrating-injured patients. The cluster model has a relative information gain (R) of 0.90. R is a measure of predictive value relative to an infallible predictor. It varies from 0 to 1, the higher the value the better the predictive value. The model had 26 false negatives (deaths predicted to survive) and 35 false positives (survivors predicted to die) giving rise to a false negative rate of 9.3%, a false positive rate of 1.4% and a misclassification rate of 2.4%. The R value and false negative rate are particularly noteworthy, the R value being higher than, and the false negative rate much lower than typical values of 30-40% achieved by TRISS (a combination index based on trauma score, injury severity score and patient age). Also noteworthy is that the clustering was independent of survival/death outcome information and that the good results were achieved even though patient age has not yet been incorporated into the model.

Actuarial Analysis↗

Parent-completed scales for measuring seizure severity and severity of side-effects of antiepileptic drugs in childhood epilepsy: development and psychometric analysis.

We have developed two outcome measures for childhood epilepsy: a seizure severity (SS) scale and a side-effects (SE) scale. Both scales have been designed for completion by parents. The scales were tested in two pilot phases and the results of this stepwise analysis are described here. The final scales' psychometric properties were assessed in a group of 80 children with active epilepsy, representative of the population at whom the scales were aimed: children with chronic epilepsy, aged 4-16 years, including all seizure types and epilepsies, as well as children with neurological comorbidity. The SS scale and SE scale showed good internal consistency and test-retest stability. Although there was a significant positive correlation between the SS scale and the SE scale, this was low, indicating that the scales measure a different clinical trait. The SE scale consisted of two subscales: a Toxic subscale, measuring the severity of dose-related side-effects, and a Chronic subscale, measuring the severity of long-term behavioural and cognitive side-effects. These subscales for side-effects showed a high correlation and can be used as a joint scale. These scales have the potential to improve outcome assessment in childhood epilepsy and they can be used to assess important aspects of quality of life in this population.

Adolescent↗

Computed tomography severity index is a predictor of outcomes for severe pancreatitis.

BACKGROUND: In a small group of patients with acute pancreatitis, Balthazar and Ranson demonstrated the applicability of computed tomography (CT) criteria to predict mortality. Building upon their work with a larger group of patients with acute pancreatitis, we set out not only to demonstrate that the CT severity index can predict death, but also length of hospital stay and need for necrosectomy. METHODS: We reviewed all patients admitted to our hospital in the years 1992 to 1997 with a primary diagnosis of acute pancreatitis. Entrance criteria required that a CT scan had been performed during the hospitalization. The index CT scan was used to determine a CT severity index (the CTSI of Balthazar and Ranson). Outcomes measured were death, length of stay (LOS), and need for necrosectomy (NEC). Statistical analysis was performed using Fisher's exact and chi-square tests where appropriate. RESULTS: Between the years 1992 to 1997, 886 patients had 1,774 admissions for acute pancreatitis, of which 268 had a CT scan performed and were entered into our study. These 268 patients had a mean age of 57 years, a mean LOS of 16 days (1 to 118), and a mean CTSI of 3.9 (0 to 10). Overall mortality was 4% (n = 11). A CTSI >5 significantly correlated with death (P = 0.0005), prolonged hospital stay (P <0.0001), and need for necrosectomy (P <0.0001). Patients with a CTSI >5 were 8 times more likely to die, 17 times more likely to have a prolonged hospital course, and 10 times more likely to undergo necrosectomy than their counterparts with CT scores <5. CONCLUSIONS: These data show that the CTSI is an applicable and comparable predictor of outcomes in severe pancreatitis.

APACHE↗

Severe congenital myotonic dystrophy and severe anaemia of prematurity in an infant of Jehovah's Witness parents.

Severe congenital myotonic dystrophy (CMD) is an autosomal dominant condition characterized by hypotonia and respiratory insufficiency at birth. Terminal outcome has been reported in infants requiring ventilation for longer than 30 days. The case is reported of an infant born at 34 weeks' gestation with severe CMD. Infant survived following ventilatory support from birth until day 67 of life. Subcutaneous erythropoietin (600 units, three times weekly) was commenced on day 6 as the Jehovah's Witness parents were strongly opposed to blood transfusions. Haemoglobin fell to 5.8 g/dL without adverse effects and then progressively rose to 15.4 g/dL. No blood transfusions were necessary. This case illustrates that infants with severe CMD requiring ventilation for more than 30 days do not have a universally fatal outcome. Low haemoglobin was well tolerated which calls for re-examination of the indications for blood transfusions in ventilated neonates.

Adult↗

Scoring the severity of atopic dermatitis: three item severity score as a rough system for daily practice and as a pre-screening tool for studies.

Different scoring systems have been developed to determine the severity of atopic dermatitis. The SCORAD (SCORing Atopic Dermatitis), one of the best validated systems, is suited for clinical trials, but is too complicated and time consuming for routine clinical use. The TIS score (Three Item Severity score), a simplified system, is based on the evaluation of erythema, oedema/papulation and excoriation on a scale from 0 to 3. In order to determine the value of the TIS score we conducted a prospective study in 126 children with mild to severe atopic dermatitis. Both the TIS score and the SCORAD were assessed by trained investigators. Interobserver agreement was investigated in 20 children by comparing the independently performed scores of three investigators. A positive correlation was found between the TIS score and the SCORAD (Rank Spearman r(s)=0.86; p<0.0005). The item which correlated best with the SCORAD was excoriation (r(s)=0.72; p<0.0005) followed by oedema/papulations (r(s)=0.66; p<0.0005). Interobserver agreement which was calculated by Cohen's kappa (kappa) was "excellent" for SCORAD (kappa=0.82; p<0.001) and "fair" for TIS score (kappa=0.58; p<0.01). We conclude that the TIS score is a rough, though reliable and simple system for scoring atopic dermatitis. It is particularly suitable in general practice, for routine clinical use and for screening purposes in clinical trials. For research purposes, the objective SCORAD offers a more detailed and comprehensive assessment.

Adolescent↗

Serum total antioxidant status in severe exacerbation of asthma: correlation with the severity of the disease.

Oxidative processes, mediated by oxygen free radicals are recognized to contribute significantly to the inflammatory pathology of bronchial asthma. An imbalance between oxidants and antioxidants has also been proposed in this disease. This study examines the serum total antioxidant status (TAS) in asthmatic patients with severe exacerbation of their disease and the probable correlation with clinical or laboratory findings. The TAS was measured in 20 patients (10 men and 10 women, with a mean age of 41.95 +/- 20.75 years), using a colorimetric method. On the days of admission and discharge, the forced expiratory volume in 1 sec (FEV1), the partial arterial oxygen pressure (PaO2), and severity criteria were recorded and correlated with TAS at the same time. The TAS was also measured in 10 healthy subjects (8 men and 2 women, mean age of 39 +/- 9 years). A statistically significant decrease of TAS was observed on admission day compared to that on discharge day (0.98 +/- 0.08 vs. 1.12 +/- 0.17 mmol/L, p < 0.001, respectively, paired t-test) suggesting the presence of oxidative stress during an asthma attack. The TAS on admission was also statistically significantly decreased compared to that of normal subjects (0.98 +/- 0.08 vs. 1.19 +/- 0.09 mmo/L, p < 0.001, respectively, paired t-test). A statistically significant correlation was observed between FEV1 change and TAS change, from admission to discharge day (r = 0.58, p = 0.007, Pearson correlation). Finally, a statistically significant correlation was found between FEV1 change and TAS on discharge day (r = 0.65, p = 0.002). Decreased TAS was found during an asthma attack, probably as a consequence of increased oxidative stress. The TAS change was correlated with severity criteria, such as FEV1. Therefore, it seems that measurement of TAS could be a simple and useful tool in the evaluation of an asthma attack. The supplementary administration of antioxidants in future needs further clarification.

Adult↗

Provocative hypothalamopituitary axis tests in severe head injury: correlations with severity and prognosis.

OBJECTIVE: To evaluate the effect of severe head injury on both the secretion of basal pituitary hormones and the response to exogenous synthetic hypothalamic releasing factors administration. DESIGN: Prospective, clinical study. SETTING: General intensive care unit in a university teaching hospital, Italy. PATIENTS: Comatose, head-injured patients (n = 22), all intubated and mechanically ventilated, invasively monitored without previous endocrinologic problems and substitutive therapies. INTERVENTIONS: Routine neuroemergency procedures; administration of exogenous, synthetic hypothalamic releasing hormones. MEASUREMENTS AND MAIN RESULTS: Determinations of basal concentrations of growth hormone (GH), prolactin (PRL), thyroid-stimulating hormone (TSH), triiodothyronine, and thyroxine were performed daily in the first week and on days 15 and 16 after the trauma. Plasma insulin-like growth factor-I and cortisol were also determined on days 2, 7, and 15. We carried out a thyrotropin-releasing hormone (TRH) test for the evaluation of the PRL, TSH, and GH responses on days 1 and 16 after the trauma and a growth hormone-releasing hormone (GHRH) test for the evaluation of GH and PRL responses on days 2, 7, and 15 after the trauma. Outcome was evaluated at 6 mos with the GOS. Triiodothyronine showed low values, even if in the normal range; thyroxine remained in the normal range. Significant increases in insulin-like growth factor-I concentrations were observed on both days 7 and 15 compared with day 2 (p = .024 and p = .034, respectively). The GH response to GHRH was significantly greater on days 7 and 15 than in the very acute phase (p< .01 comparing days 7 and 15 vs. day 2). We found a higher GH response to GHRH on day 7 in group 1 vs. group 2 (as both peak and area under the curve, p = .018 and p = .015, respectively). No difference in GH response was detected on days 2 and 15. A "paradoxical" response of GH to TRH was observed on the day after the head trauma (basal vs. peak, p = .002) but not on day 16. The GH peak response to TRH was greater on day 1 in those patients with an unfavorable course (group 1 vs. group 2, p < .05). The TSH response to TRH was not significantly correlated to the severity of trauma, but it was significantly (p < .04) higher in group 1 than in group 2. Finally, a "paradoxical" PRL response to GHRH administration was present on day 2 (basal vs. peak, p=.0003), day 7 (basal vs. peak, p = .01), and on day 15 after the trauma (basal vs. peak, p = .04). CONCLUSIONS: Some of the responses to provocative tests have been identified as "paradoxical" and seem to have a great importance in the definition of prognosis in severe head-injured patients, specifically the GH response to TRH and the PRL response to GHRH that are significantly correlated with outcome.

Adolescent↗

Distinguishing illness severity from tic severity in children and adolescents with Tourette's disorder.

OBJECTIVE: To examine whether tic severity, comorbid disorders, or both are associated with illness morbidity in youths with Tourette's disorder (TD). METHOD: Subjects were 156 consecutively referred youths (aged 5-20 years) who met DSM-III-R criteria for Tourette's disorder at a major academic medical center. All subjects were evaluated with a clinical interview by a child and adolescent psychiatrist and an assessment battery that included the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version. Statistical analysis used chi 2 and multivariate logistic regression. RESULTS: Nineteen (12%) of the 156 youths with TD required psychiatric hospitalization. Current age, TD severity, TD duration, obsessive-compulsive disorder, psychosis, major depression, bipolar disorder, panic disorder, and overanxious disorder were significant univariate predictors of psychiatric hospitalization (p < .01). While tic severity was marginally significant as a predictor of psychiatric hospitalization (p < .05), major depression (p < .016) and bipolar disorder (p < .001) were robust predictors of psychiatric hospitalization, even after statistical adjustment for collinearity and correction for all other variables assessed. CONCLUSION: The findings indicate that comorbid mood disorders are strongly associated with illness morbidity in youths with TD, highlighting the importance of attention to comorbidity in patients with TD.

Adolescent↗

Severe skiing injuries: a retrospective analysis of 361 patients including mechanism of trauma, severity of injury, and mortality.

All ski accident patients requiring an inhospital treatment at our institute from 1984 to 1992 (n = 2,053) were analyzed retrospectively. The incidence, pattern, and severity of the injuries, as well as the 30-day mortality comparing two time slots (1984 to 1988 and 1989 to 1992) were analyzed for the 361 cases classified as "serious" injuries according to the following definitions and groupings: group 1, multiple trauma (Injury Severity Score > or = 18) and patients with multiple fractures (n = 179; group 2, abdominal or thoracic single trauma (Abbreviated Injury Scale (AIS) score > or = 2, n = 58); and group 3, isolated head injuries (AIS score > or = 2, n = 124). Serious injuries were observed in 19% in the first period compared to 16% in the second period (not significant). Two hundred thirty-eight of 361 patients injured themselves by just falling, while 117 collided with some sort of obstacle like other skiers (45), trees or rocks (27), posts, pylons, barriers (20), and moving objects (25) such as piste machines, ski lifts, automobiles, and in one case a helicopter. Six skiers were caught on the ski run by an avalanche. Comparing the two time periods, trauma circumstances did not change significantly. The number of most severe head injuries (AIS score > or = 4) increased from 11.6 to 19.3% (p < 0.05). The overall mortality increased from 2 to 7% (p < 0.05). Group 2 had the best prognosis with no mortality, while group 3 was rated worst with 8%. Skiing remains a major source of serious trauma in winter resort areas.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

A study examining inter- and intrarater reliability of three scales for measuring severity of psoriasis: Psoriasis Area and Severity Index, Physician's Global Assessment and Lattice System Physician's Global Assessment.

BACKGROUND: There is a lack of consensus as to the best way of monitoring psoriasis severity in clinical trials. The Psoriasis Area and Severity Index (PASI) is the most frequently used system and the Physician's Global Assessment (PGA) is also often used. However, both instruments have some drawbacks and neither has been fully evaluated in terms of 'validity' and 'reliability' as a psoriasis rating scale. The Lattice System Physician's Global Assessment (LS-PGA) scale has recently been developed to address some disadvantages of the PASI and PGA. OBJECTIVES: To evaluate the inter-rater and intrarater reliability of the PASI, PGA and LS-PGA. METHODS: On the day before the study, 14 dermatologists (raters), with varied experience of assessing psoriasis, received detailed training (2.5 h) on use of the scales. On the study day, each rater evaluated 16 adults with chronic plaque psoriasis in the morning and again in the afternoon. Raters were randomly assigned to assess subjects using the scales in a specific sequence, either PGA, LS-PGA, PASI or PGA, PASI, LS-PGA. Each rater used one sequence in the morning and the other in the afternoon. The primary endpoint was the inter-rater and intrarater reliability as determined by intraclass correlation coefficients (ICCs). RESULTS: All three scales demonstrated 'substantial' (a priori defined as ICC > 80%) intrarater reliability. The inter-rater reliability for each of the PASI and LS-PGA was also 'substantial' and for the PGA was 'moderate' (ICC 75%). CONCLUSIONS: Each one of the three scales provided reproducible psoriasis severity assessments. In terms of both intrarater and inter-rater reliability values, the three scales can be ranked from highest to lowest as follows: PASI, LS-PGA and PGA.

Adult↗