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PubMed1991

Acral pseudolymphomatous angiokeratoma of children (APACHE): a case report and immunohistological study.

Acral pseudolymphomatous angiokeratoma of children (APACHE) is a new clinical entity that is characterized by angiomatous papules on the extremities. We report a case APACHE in a 14-year-old Japanese girl with asymptomatic red and violaceous papules and nodules on the ring finger of the left hand. Histological and immunohistochemical studies of our patient indicated that APACHE is a pseudolymphoma rather than an angiokeratoma.

Adolescent↗

PubMed1990

A critical study of the APACHE II scoring system using earlier data collection.

The APACHE II severity of illness scoring system was prospectively studied on 756 patients admitted to a general intensive care unit (ICU) from January 1986 to June 1988. Admission data were used. Individual and group risk of death were calculated for 3 diagnostic categories commonly seen in the A&E department and requiring admission to an ICU. The APACHE II score on admission tended to underestimate the risk of death following operative and non-operative trauma, and self-poisoning. This may have been related to the use of an analysis not yet validated against values obtained on admission to ICU. Such validation is urgently needed on a UK population if APACHE II scoring is to be of value in the A&E department.

Adolescent↗

PubMed1998

Helmet-mounted displays and facial injury in US Army AH-64A Apache accidents.

There is concern that the helmet display unit (HDU) used by AH-64 Apache helicopter pilots might contribute to facial injury in a crash. The US Army accident database was searched for HDU-related injuries in survivable Apache accidents 1985-1995. Four aviators in three crashes sustained HDU-related injury. These involved three periorbital contusions and two minor eye injuries. There were no sequelae. This equates to an incidence of 0.57 injured individuals per 100,000 flying hours or 8.0 injured aviators per 100 survivable Class A-C accidents in which the HDU was worn. Applying these data to the projected UK Army Apache flying hour programme suggests that one HDU-related injury might be encountered approximately every 10.1 years. This estimate should be interpreted with caution. Serious injury remains a possibility due to the proximity of the HDU to the eye and face.

Accidents, Aviation↗

PubMed2002

Respiratory syncytial virus infection in Navajo and White Mountain Apache children.

OBJECTIVE: The hospitalization rate for bronchiolitis of any cause among US children younger than 1 year is estimated at 31.2 per 1000. No data exist on respiratory syncytial virus (RSV)-specific hospitalization rates among high-risk Native Americans other than Alaska Natives, for whom the incidence of RSV hospitalization was estimated at 150 per 1000 among infants younger than 1 year. We aimed to estimate RSV hospitalization rates among Navajo and White Mountain Apache children younger than 2 years. METHODS: We conducted prospective population-level hospital-based surveillance to determine RSV hospitalization rates among Navajo and White Mountain Apache children younger than 2 years. From 1997 to 2000, all children who were admitted for acute lower respiratory tract infection between October 1 and March 31 had a nasopharyngeal aspirate obtained and tested for RSV by commercial enzyme immunoassay kits. We reviewed charts of children who tested positive for RSV antigen to determine disease severity. RESULTS: During 3 RSV seasons (1997-2000), 51.3% of 1837 admissions for acute lower respiratory tract infection among children younger than 2 years were attributed to RSV infection. The overall seasonal RSV hospitalization rate among children younger than 2 years was 63.6 per 1000 and 91.3 per 1000 among children younger than 1 year. In a univariate analysis, predictors of severity included age <6 months (relative risk: 6.8; 95% confidence interval: 3.1-17.0). CONCLUSIONS: Navajo and White Mountain Apache children are at high risk for RSV disease requiring hospitalization. A lower threshold for hospitalization or underlying chronic conditions that predispose to severe RSV disease do not seem to explain high RSV hospitalization rates in this population.

Hospitalization↗

PubMed2005

Involuntary eye responses as measures of fatigue in US Army Apache aviators.

INTRODUCTION: AH-64 Apache helicopter pilots fly the aircraft using a monocular helmet-mounted display that provides imagery from two separate forward-looking infrared sensors mounted on the nose of the aircraft. Studies have documented complaints of fatigue, headaches, and visual problems associated with the use of this sighting system. The goals of this study were: 1) to quantify possible flight-induced fatigue in Apache aviators; and 2) to evaluate minimally intrusive neurophysiologic measures of fatigue for potential use in operational environments. METHODS: Using a pre/post design, we assessed self-reported levels of alertness, physical, cognitive, and visual fatigue, and ocular indices of fatigue obtained using an instrument specifically designed to capture various eye responses. Data were contributed to this study by 53 aviators. RESULTS: Significant differences in all pre- and postflight ocular responses were observed. Pupil size and constriction latency increased while constriction amplitude and saccadic velocity decreased. Significant pre- and postflight differences were also seen on all self-report measures. Pilots reported being less alert and more fatigued following flight. CONCLUSIONS: We found that flight in an AH-64 Apache was a significant factor in producing changes in ocular and self-report measures similar to those produced by sleep loss.

Adult↗

PubMed1985

APACHE II: a severity of disease classification system.

This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.

Acute Disease↗

PubMed1994

[Pneumonia among patients admitted to intensive care units. An epidemiological multicenter study of APACHE II score, incidence and course].

Pneumonia in patients in intensive care units (ICU) is associated with several diagnostic difficulties and high mortality. This study was conducted to describe the diagnostic procedures and clinical characteristics of the pneumonic and critically ill patient in relation to APACHE II score. The material consisted of 193 patients admitted to seven Danish ICUs and is also included in a European epidemiologic survey (EURO.NIS). Twenty-eight (14.5%) developed pneumonia and 18 (9.3%) of these were nosocomial (> 48h after admission). Patients with pneumonia had a significantly higher APACHE II score, duration of stay and mortality. The techniques used to diagnose pneumonia were mainly conventional and did not or only seldom include protected brush, bronchoalveolar lavage or pulmonary biosy. The predominant pathogens isolated in tracheal aspirate were Gram-negative bacilli (50%). The APACHE II scoring system was found to stratify patients with respect to mortality, duration of stay and pneumonia diagnosed in ICU.

Adult↗

PubMed1993

Acute physiology and chronic health evaluation (APACHE II) scoring in the Medical Intensive Care Unit, National University Hospital, Singapore.

The intensive care unit provides multisystem support and therapy to critically ill patients, and represents an expensive part of hospital medicine. This survey validates the use of APACHE II as a severity scoring system that allows reliable prediction of outcome of intensive care patients in Singapore. The mortality rate of 37.4% in our medical intensive care unit compares favourably with the other established intensive care units in the United States of America. Our results also indicate that the aged fared as well as their younger counterparts. Patients with sepsis fared poorer than expected from their APACHE II scores, and stroke patients needing intensive care admission had an extremely poor prognosis (mortality rate of 85.7%). High APACHE II scores are associated with invasive haemodynamic monitoring.

Adolescent↗

PubMed1993

Perioperative TNF alpha and IL-6 concentrations correlate with septic state, organ function, and APACHE II scores in intra-abdominal infection.

OBJECTIVE: To find out if concentrations of tumour necrosis factor a (TNF alpha) and interleukin-6 (IL-6) play a part in the pathophysiology of intra-abdominal infection, and try to identify patients who would benefit from immunotherapy against TNF alpha. DESIGN: Prospective open study. SETTING: University hospital. SUBJECTS: 19 consecutive patients (septic shock, n = 4; sepsis syndrome, n = 6; and no sepsis syndrome, n = 9, classified by the APACHE II score and the criteria of the Methyl-prednisolone Severe Sepsis Study Group) who were to undergo their first operation for intra-abdominal infection. MAIN OUTCOME MEASURES: Correlation between median (interquartile) concentrations of TNF alpha and IL-6 (pg/ml), and APACHE II score, plasma lactate concentration, and organ function. RESULTS: Perioperative concentrations of both TNF alpha (p = 0.001) and IL-6 (p = 0.006) were significantly higher in patients with septic shock. Preoperative cardiovascular and respiratory failure were associated with significantly raised TNF alpha (p < 0.001 in both cases) and IL-6 concentrations (p = 0.02 and p < 0.001, respectively). The preoperative APACHE II score correlated with the increased TNF alpha concentration (r = 0.5, p < 0.001) and plasma lactate concentration with that of IL-6 (r = 0.7, p = 0.003). CONCLUSION: Perioperative TNF alpha and IL-6 concentrations correlated with the severity of intra-abdominal infection, so it is possible that patients who present with either septic shock or the sepsis syndrome may benefit from immunotherapy against TNF alpha.

Abdomen↗

PubMed1993

[Use of the Apache II scoring system for clinical evaluation of the status of patients with gastrointestinal hemorrhage].

The Apache II scoring system has been used to identify a clinical status of 10 patients, admitted to the intensive therapy unit with bleeding to gastrointestinal tract during the period 1. January - 30. Juni 1992. There were 9 men and 1 woman with mean age of 61.5 years (37-82). Apache II score was calculated before beginning of treatment and 4 times during following 3 days every 12 or 24 hours. The mean score before beginning of treatment was 9.7 (5-17). All the patients were treated exclusively by the conservative therapy with mean length of hospitalization 8, 1 days (4-12). The score during the therapy has had a decreasing tendency and statistically significant decrease came after 72 hours of treatment. Mortality rate at mentioned values was zero. The use of the Apache II scoring system contributes to improvement of clinical judgment of patients with gastrointestinal bleeding.

Adult↗

PubMedDate not supplied

Prognostic potential of cytokines, nitrates, and APACHE II score in sepsis.

The prognostic potentials of physiological ([Acute Physiologic and Chronic Health Evaluation] APACHE II score) and biochemical (Interleukin 6 [IL-6], Interleukin 6 soluble receptor [IL-6sR], and Interleukin 2 receptor [IL-2R], nitrates) measures were evaluated in sepsis. The APACHE II scores were calculated, and concentrations of the biochemical markers were measured, based upon information and samples obtained from 68 septic patients at time of diagnosis. Outcome (survival/non-survival) was determined at the end of the hospital stay associated with the septic episode. Statistically significant differences between survivors (S) and non-survivors (non-S) were found for APACHE II (p < 0.0001), IL-6 (p < 0.005), IL-6sR (p < 0.05), IL-2R (p < 0.02). No significant differences were found for nitrates. None of the markers could serve individually as an effective prognostic indicator. However, those markers demonstrating a significant difference between survivors and non-survivors may be able to contribute to a multi-parameter prognostic model.

Adult↗

PubMed1996

Correlation between Acute Physiology and Chronic Health Evaluation (APACHE) III score and immunological parameters in critically ill patients with sepsis.

A relationship between physiological parameters of severe sepsis and immunological function has not been established. In ten severely ill patients with sepsis physiological risk was assessed by the Acute Physiology and Chronic Health Evaluation (APACHE) III score, while one component of immunological function was evaluated using peripheral blood mononuclear cell (PBMC) cytokine production after stimulation with lipopolysaccharide (LPS) in vitro. Five of the ten patients died. Mean (s.e.m.) APACHE III scores at admission were not significantly different between survivors and non-survivors (82(13) versus 95(13)) but after 72 h they were lower in survivors (51(13) versus 111(15), P < 0.05). Downregulation of cytokine production by PBMC on LPS stimulation was a transient event in survivors. Survivors had a three-fold increase in tumour necrosis factor alpha bioactivity within 72 h, but there was no increase in non-survivors. A similar pattern was demonstrated for interleukin (IL) 1 beta (P < 0.05 between survivors and non-survivors) and IL-6 (P = 0.06) immunoactivity. Physiological as well as immunological parameters in critically ill patients with sepsis independently predicted hospital survival (r2 = 0.2). These data demonstrate a relationship between the pattern of cytokine production in vitro and survival.

APACHE↗

PubMed1995

Evaluation of severity scoring systems in ICUs--translation, conversion and definition ambiguities as a source of inter-observer variability in Apache II, SAPS and OSF.

OBJECTIVE: To explore translation, conversion and definition ambiguities, when using severity scoring systems in patients admitted to intensive care units (ICUs). DESIGN: A prospective study of the prognosis of acute renal failure in ICUs. SETTING: The study was conducted in 20 French ICUs. PATIENTS: 360 patients presenting with severe acute renal failure were studied during their ICU stay. MEASUREMENTS AND RESULTS: The inter-observer variability of Apache II (acute physiology and chronic health evaluation), SAPS (simplified acute physiology score), and OSF (organ-system failure) was considered. For Apache II, we explored the uncertainty of measurements arising from conversion into SI units, the rounding procedures used for the non-inclusive intervals defined for quantitative parameters such as age, mean arterial pressure (MAP) or serum creatinine, the absence of definition of acute renal failure (ARF) and its consequence on doubling serum creatinine values, and the absence of guidelines in the case of spontaneous ventilation when arterial blood gases (ABG) and forced inspiratory oxygen (FIO2) were not measured. The resulting variability was evaluated, calculating the lowest and the highest value of the scoring system for each patient. The mean difference by patient was greater than 1.5 (p < 0.0001). Other examples were presented and discussed for SAPS and OSF. CONCLUSIONS: Translation, conversion and definition ambiguities are a source of inter-observer variability and increase the risk of classification and/or selection biases. This gives rise to particular concern in the design and analysis of multicenter trials of meta-analysis, and improvement of these scoring systems should be envisaged in the future.

APACHE↗

PubMed2003

Transthoracic echocardiography does not improve prediction of outcome over APACHE II in medical-surgical intensive care.

PURPOSE: To examine the hypothesis that transthoracic echocardiographic findings predict mortality in critically ill patients. METHODS: A retrospective analysis of concurrently collected data for consecutive patients from May 1996 to May 1998 who had transthoracic echocardiography on or within six months of admission to the medical surgical intensive care (MSICU). We examined the role of physiologic, clinical, and echocardiography variables in predicting the mortality of patients admitted to the MSICU. Three logistic regression models were developed: 1) clinical; 2) echocardiographic; and 3) combined clinical with echocardiographic. Univariate and multivariate analyses were performed and the relative strength of clinical and echocardiographic predictors was compared using odds ratio (OR) and receiver-operator-characteristic (ROC). RESULTS: Of 4,070 MSICU patient admissions, 1,093 patients had transthoracic echocardiography; the study group comprised 942 patients with complete clinical and echocardiographic data. The MSICU mortality was 28%. For the combined model, analyses identified left ventricular systolic function (LVSF), [OR 1.26; confidence interval (CI) 1.01-1.57], severe tricuspid regurgitation (TR) (OR 3.72; CI 1.04-13.24), medical diagnosis (OR 1.91; CI 1.15-3.19), and acute physiology and chronic health evaluation (APACHE) II score (OR 1.27; CI 1.23-1.31), as predictors of MSICU mortality. The combined model yielded an area under ROC curve of 0.913. For the clinical model, analyses identified age (OR 1.04; CI 1.02-1.05) and APACHE II (OR 1.32; 1.26-1.35) as predictors of mortality with an area under ROC curve of 0.917. For the echocardiography model, TR (OR 2.40; 1.08-5.38), severe aortic insufficiency (AI) (OR 4.13; CI 1.17-16.29) and pulmonary hypertension (OR 2.05; 1.01-4.09) were identified as predictors of outcome with an ROC curve of 0.536 for this model. CONCLUSION: Statistical models utilizing clinical variables are predictive of mortality in MSICU. Models that include diagnostic transthoracic echocardiography variables do not provide incremental value to predict ICU mortality. These findings may have implications for non-invasive hemodynamic assessment of critically ill patients, and raise the hypothesis that echocardiography-guided interventions may not alter outcome in ICU.

APACHE↗

PubMed2006

Impact of etiologic factors and APACHE II and POSSUM scores in management and clinical outcome of acute intestinal ischemic disorders after surgical treatment.

BACKGROUND: Acute intestinal ischemic disorder (AIID) is an uncommon vascular disease with high mortality. According to etiology, it can be categorized into three groups: arterial occlusive mesenteric ischemia (AOMI), mesenteric venous thrombosis (MVT), and nonocclusive mesenteric ischemia (NOMI). This study analyzes the effect of classification on surgical outcome. PATIENTS AND METHODS: All AIID patients who underwent operative treatment at National Cheng Kung University Hospital between January 1989 and August 2003 were enrolled in this study. Preoperative information on these patients was compared to find predictors of outcome. RESULTS: Data from 77 patients (49 men and 28 women, median age 70 years) were analyzed. The etiology was AOMI in 30 patients, MVT in 19 patients, and NOMI in 28 patients. Median age was younger in MVT (54 years) than in AOMI (70 years) or NOMI (72 years). In addition, MVT usually involved the jejunum (74%, versus 31% in AOMI and 46% in NOMI), whereas both AOMI and NOMI involved ileum and colon. The patients with AOMI had shorter duration of symptoms and higher ratio of underlying hypertension than those with MVT. The overall mortality rate was 53.2% (41/77). The day 1 and day 30 mortality were 0% and 10.5% in MVT, 16.7% and 30% in AOMI, and 42.9% and 67.9% in NOMI, respectively (P < 0.05). Both the etiology and the APACHE II scores were significant risk factors for day 30 and long-term mortality. The patients with NOMI had higher POSSUM physiologic scores than patients with MVT. The P-POSSUM regression equation can accurately predict mortality. CONCLUSIONS: Patients with MVT had a more favorable prognosis, whereas those with NOMI had the worst outlook. The APACHE II and POSSUM scoring systems are useful in predicting the clinical outcome. Early diagnosis and classification of AIID patients are useful for aggressive treatment to improve the clinical outcome.

APACHE↗

PubMed2002

Procalcitonin, C-reactive protein and APACHE II score for risk evaluation in patients with severe pneumonia.

OBJECTIVE: Procalcitonin (PCT) is a peptide that is found elevated in patients with sepsis and severe infections. In healthy persons PCT serum levels are below 0.1 ng/mL. The aim of this study was to investigate the value of serum PCT determination for risk evaluation in patients with pneumonia. METHODS: We focused on the correlation of PCT with the clinical status of the patient and prognosis of the disease. In a prospective study, in a nonsurgical intensive care unit the following parameters were assessed regularly in 93 patients with documented pneumonia: C-reactive protein (CRP), white blood cell count (WBC), body temperature, PCT and Acute Physiology and Chronic Health Evaluation (APACHE) II score. RESULTS: At the onset of infection 50% of the patients had elevated PCT levels above 2 ng/mL. The model of multivariate analysis of all tested parameters on days 0-5 stratified for clinical outcome (change in clinical classification or death) showed local significance for APACHE II score only. None of the other parameters in this model serves as an isolated indicator for change of clinical status or death. An intra-individual change of body temperature or CRP was never significantly associated with a change in the clinical status of the patient. CONCLUSION: Change in PCT on admission and at the end of the observation period significantly indicated a clinical change.

APACHE↗

PubMed2003

A randomised clinical trial to assess the effect of total enteral and total parenteral nutritional support on metabolic, inflammatory and oxidative markers in patients with predicted severe acute pancreatitis (APACHE II > or =6).

BACKGROUND: Total enteral nutrition (TEN) within 48 h of admission has recently been shown to be safe and efficacious as part of the management of severe acute pancreatitis. Our aim was to ascertain the safety of immediate TEN in these patients and the effect of TEN on systemic inflammation, psychological state, oxidative stress, plasma glutamine levels and endotoxaemia. METHODS: Patients admitted with predicted severe acute pancreatitis(APACHE II score >5) were randomised to total enteral (TEN; n = 8) or total parenteral nutrition (TPN; n = 9). Measurements of systemic inflammation (C-reactive protein), fatigue (visual analogue scale), oxidative stress (plasma thiobarbituric acid-reactive substances), plasma glutamine and anti-endotoxin IgG and IgM antibody concentrations were made on admission and repeated on days 3 and 7 thereafter. Clinical progress was monitored using APACHE II score. Organ failure and complications were recorded. RESULTS: All patients tolerated the feeding regime well with few nutrition-related complications. Fatigue improved in both groups but more rapidly in the TEN group. Oxidative stress was high on admission and rose by similar amounts in both groups. Plasma glutamine concentrations did not change significantly in either group. In the TPN group, 3 patients developed respiratory failure and 3 developed non-respiratory single organ failure. There were no such complications in the TEN group. Hospital stay was shorter in the TEN group [7(4-14) vs. 10 (7-26) days; p = 0.05] as was time to passing flatus and time to opening bowels [1 (0-2) vs. 2 (1-5)days; p = 0.01]. The cost of TEN was considerably less than of TPN. CONCLUSION: Immediate institution of nutritional support in the form of TEN is safe in predicted severe acute pancreatitis. It is as safe and as efficacious as TPN and may be beneficial in the clinical course of this disease.

APACHE↗

PubMed2001

The role of APACHE-II triaging in optimum management of small bowel perforations.

Small bowel perforations with peritonitis pose a serious problem to an emergency surgeon because of the lack of any uniformity of opinion regarding the optimum surgical treatment to be performed. This may be attributed to lack of any common and reliable scoring system. A prospective study to discover the utility of APACHE-II triaging in small bowel perforations was conducted over a period of 14 months on 51 patients with small bowel perforations of various aetiologies. The triaging facilitated definitive surgical treatments based on the predictive value of APACHE-II scoring. The classification of patients into three groups, effectively brought uniformity in the management. A significant reduction in mortality and cost-effective utilization of scarce intensive care unit resources were the dominant outcomes of this study conducted at a busy tertiary centre.

APACHE↗