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PubMed2000

An analysis of excess mortality not predicted to occur by APACHE III in an Australian level III intensive care unit.

The APACHE III derived standardized mortality ratio has been suggested as a statistic to measure intensive care unit (ICU) effectiveness. From 1991 data collected on 519 consecutive admissions to the Royal Adelaide Hospital ICU a standardized mortality ratio of 1.25 was calculated. Of the 174 deaths only 95 had a prediction of death greater than 0.5. As part of a quality assurance study we undertook a retrospective case note audit to try to identify factors that were associated with the low mortality prediction (< 0.5) in hospital deaths. Firstly we analysed the patient population that died to determine the factors that were different between patients who had a mortality prediction of greater than 0.5 versus those who had a mortality prediction of less than 0.5. Next we analysed the patient population with a mortality prediction of less than 0.5 and compared actual survivors with patients who died in hospital. Amongst low mortality prediction patients admitted to the Royal Adelaide Hospital ICU we identified age, a history of acute myocardial infarction, presentation to ICU after a cardiac arrest or with an elevated creatinine and the development of acute renal failure and septicaemia during the ICU admission as being associated with in-hospital mortality. We also documented that late hospital deaths on the ward after ICU discharge occurred more frequently with low predicted hospital mortality ICU patients. Factors other than the APACHE III score may be associated with hospital deaths of ICU patients.

APACHE↗

PubMed2002

The customization of APACHE II for patients receiving orthotopic liver transplants.

General outcome prediction models developed for use with large, multicenter databases of critically ill patients may not correctly estimate mortality if applied to a particular group of patients that was under-represented in the original database. The development of new diagnostic weights has been proposed as a method of adapting the general model - the Acute Physiology and Chronic Health Evaluation (APACHE) II in this case - to a new group of patients. Such customization must be empirically tested, because the original model cannot contain an appropriate set of predictive variables for the particular group. In this issue of Critical Care, Arabi and co-workers present the results of the validation of a modified model of the APACHE II system for patients receiving orthotopic liver transplants. The use of a highly heterogeneous database for which not all important variables were taken into account and of a sample too small to use the Hosmer-Lemeshow goodness-of-fit test appropriately makes their conclusions uncertain.

APACHE↗

PubMed2004

Pro-atrial natriuretic peptide is a prognostic marker in sepsis, similar to the APACHE II score: an observational study.

INTRODUCTION: Additional biomarkers in sepsis are needed to tackle the challenges of determining prognosis and optimizing selection of high-risk patients for application of therapy. In the present study, conducted in a cohort of medical intensive care unit patients, our aim was to compare the prognostic value of mid-regional pro-atrial natriuretic peptide (ANP) levels with those of other biomarkers and physiological scores. METHODS: Blood samples obtained in a prospective observational study conducted in 101 consecutive critically ill patients admitted to the intensive care unit were analyzed. The prognostic value of pro-ANP levels was compared with that of the Acute Physiology and Chronic Health Evaluation (APACHE) II score and with those of various biomarkers (i.e. C-reactive protein, IL-6 and procalcitonin). Mid-regional pro-ANP was detected in EDTA plasma from all patients using a new sandwich immunoassay. RESULTS: On admission, 53 patients had sepsis, severe sepsis, or septic shock, and 68 had systemic inflammatory response syndrome. The median pro-ANP value in the survivors was 194 pmol/l (range 20-2000 pmol/l), which was significantly lower than in the nonsurvivors (median 853.0 pmol/l, range 100-2000 pmol/l; P < 0.001). On the day of admission, pro-ANP levels, but not levels of other biomarkers, were significantly higher in non-surviving [corrected] than in surviving [corrected] sepsis patients (P = 0.001). In a receiver operating characteristic curve analysis for the survival of patients with sepsis, the area under the curve (AUC) for pro-ANP was 0.88, which was significantly greater than the AUCs for procalcitonin and C-reactive protein, and similar to the AUC for the APACHE II score. CONCLUSION: Pro-ANP appears to be a valuable tool for individual risk assessment in sepsis patients and for stratification of high-risk patients in future intervention trials. Further studies are needed to validate our results.

APACHE↗

PubMed2005

Resource utilization and outcome in gravely ill intensive care unit patients with predicted in-hospital mortality rates of 95% or higher by APACHE III scores: the relationship with physician and family expectations.

OBJECTIVE: To assess resource utilization and outcome in gravely ill patients admitted to an intensive care unit (ICU) and the potential association with health care workers' and family members' expectations. PATIENTS AND METHODS: We retrospectively evaluated ICU patients with a predicted in-hospital mortality rate of 95% or higher (PM95) using the Acute Physiology and Chronic Health Evaluation III (APACHE III) on 2 consecutive days. All patients were admitted to a single institution between September 30, 1994, and August 9, 2001. RESULTS: The APACHE III database contained data from 38,165 ICU patients during the study interval. Of these, 248 (0.65% of ICU admissions) achieved PM95 status and were included in the study. Between PM95 and hospital discharge, resource utilization (eg, blood transfusion, hemodialysis, surgery, and computed tomography or magnetic resonance imaging) was extensive. A total of 23% of patients survived to hospital discharge, yet all but 1 were moderately or severely disabled. One year after achieving PM95, 10% (95% confidence interval, 7%-15%) of patients were alive. For 229 patients, the medical records contained physician documentation that indicated a likely fatal outcome. Thirty-six of these medical records documented unrealistic family expectations of a good outcome. The latter finding correlated with increased resource utilization without significant improvement in 1-year survival. In contrast, absence of physician documentation of a likely fatal outcome In 19 patients correlated with an improved likelihood of hospital (74%) and 1-year (47%) survival. CONCLUSION: Despite better-than-predicted survival outcomes, patient functionality and 1-year survival were poor. Unrealistic family expectations were associated with increased resource utilization without significant survival benefit, whereas absence of physician documentation of likely impending death (which correlated with improved survival) may denote the prognostication skills of experienced clinicians.

APACHE↗

PubMed1999

[The clinical features of multiple-trauma patients APACHE II score system].

The clinical features of 76 multiple-trauma patients in the intensive care unit were observed with acute physiology and chronic health evaluation (APACHE II) system. The results showed that the mean value of APACHE II scores in 76 patients was 18.4; the mean duration of staying at the ICU was 91.5 hours. Six patients died in the ICU (7.9%), 13 patients were complicated with MODS (17.1%), and 10 patients developed ARDS (13.2%). As APAHCE II scores increased, the duration of the patient staying at the ICU lengthened and the mortality went up.

APACHE↗

PubMed1995

[Evaluation of the clinical status of patients with gastrointestinal hemorrhage and acute pancreatitis using the APACHE II score].

In the group of 35 patients with gastrointestinal bleeding and in the group of 15 patients with acute edematous pancreatitis before beginning of treatment Apache II score was calculated. The obtained score values ranging from 2 to 18 were subsequently compared with the duration of the interval from appearing of the clinical signs to the beginning of treatment, the way of treatment, duration of hospitalization and recurrence of the diseases during hospitalization. The relations were evaluated through correlation analysis and T-test. Although the studied relations were in our conditions statistically insignificant we suppose, that Apache II score contributes to detachment of clinical assessment of patient in correlation to its severity and prognosis.

APACHE↗

PubMed1994

Septic shock in a surgical intensive care--validation of multiorgan and APACHE II scores in predicting outcome.

We analysed retrospectively the records of 353 admissions to the National University Hospital's Surgical Intensive Care Unit over a one-year period and found 25 patients with septicaemic shock requiring vasoactive therapy. The mortality rate was 68%. Blood cultures were positive in only 36%. We validated the ability of the Acute Organ System Failure score, Multiorgan Failure score, Organ System Failure score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score to predict outcome at onset of septic shock. Only the APACHE II was a significant predictor of outcome, the rest having poor predictive ability. We conclude that the present scoring systems are too inaccurate for us to base important clinical decisions on.

APACHE↗

PubMed1997

[Correlation of carbamazepine levels in blood with clinical poisoning states, evaluated with the help of the APACHE II system and the Matthew coma scale].

Acute carbamazepine (CBZ) poisoning occurs recently quite often. Symptomatology of poisoning is variable but usually various degrees of consciousness impairment prevail. 77 patients (36 women and 41 man, mean age 31.5) were hospitalized last two years in this Centre. Clinical condition was evaluated in a regular descriptive way, classifying the degree of coma according to the Matthew scale but also by calculating the scores according to APACHE II and TOXSCORE. Serum CBZ was measured. A slight falling trend was found of the relation of the serum CBZ in the range 6-37.8 micrograms/ml (38 micrograms/ml = median) to APACHE II score and the TOXSCORE and slight rising trend of the relation of the serum CBZ to the degree of coma. The significance of this trend rose essentially at the serum CBZ levels of more than the median 38 micrograms/ml. The causes of the non significant correlation of serum CBZ (in particularly range) to the clinical condition is discussed. The individuals factors of the patient and possible effect of other, unknown drugs taken together with CBZ seem to play a minor role at the concentrations above 38 micrograms/ml. A very precise correlation has been found at the serum concentrations exceeding 40 micrograms/ml.

APACHE↗

PubMed1997

[Evaluation of severity of the state of patients with peritonitis by the modified APACHE II system].

According to the APACHE II modified method 201 patient with an acute peritonitis was examined using the results of investigations available during the first 30 min after hospitalization of patient. Veritable differences of the modified APACHE II indexes were established in patients with local and diffuse peritonitis in dead and survived patients and in those who died in the first day and later after hospitalization.

APACHE↗

PubMedDate not supplied

Does the APACHE II scoring system equate with the Nottingham Patient Dependency System? Can these systems be used to determine nursing workload and skill mix?

The development of a holistic patient dependency system for intensive care in Nottingham has enabled nursing staff to analyse their patient's needs more comprehensively and relate them to existing staffing levels. A recent publication (Chellel et al., 1995) implied that some units were using medical scoring systems to predict workload and that practitioners were dissatisfied with current scoring systems. Patient dependency scores were correlated with APACHE II scores by regression analysis on 1,743 patients from the Adult Intensive. Care Unit at the University Hospital, Nottingham. Analysis revealed that APACHE II had little ability to predict patient dependency and, therefore, is unreliable at predicting nursing workload and skill mix.

APACHE↗

PubMed1978

Distribution of albumin variants Naskapi amd Mexico among Aleuts, Frobisher Bay Eskimos, and Micmac, Naskapi, Mohawk, Omaha, and Apache Indians.

In order to help define the boundaries of the distribution of the albumin variants Naskapi and Mexico which are polymorphic among several American Indian groups, we examined sera from Micmac, Mohawk, Northwest River Naskapi, Omaha and Apache Indians, and from Aleuts and Eskimos. Sera from a total of 1,524 individuals were examined. Using a cellulose acetate membrane electrophoretic system with Tris-Citric acid at pH 5.4 we were able to distinguish normal albumin and both variants in the same run. Naskapi and Mexico variants were absent from Aleut, Eskimo, Micmac, Mohawk and Omaha samples. The albumin Naskapi variant was present in an allele frequency of 0.03 in the Naskapi Indian sample. Albumin variants Naskapi and Mexico were found in the Apache sample at frequencies of 0.016 and 0.037, respectively. This report supersedes that previously published by Schell and Agarwal ('76). Generally, within an area there is a correspondence between changes in the frequency of albumin variants and changes in the ethnic background and history of the area's populations. At the same time, when viewing widely separated areas, relationships between distant groups based on linguistic and cultural similarities are paralleled on a biologic level by the distribution of normal albumin and variant albumins.

Alleles↗

PubMed2005

[Acral pseudolymphomatous angiokeratoma of children (APACHE)].

Acral pseudolymphomatous angiokeratoma of children (APACHE) is a pseudolymphoma of posttraumatic origin which was first described in 1988. We report on a female patient with APACHE following a traumatic abrasion on her foot. Reddish papules developed that histologically were characterized by a wedge-shaped inflammatory infiltrate rich in capillaries. Conservative treatment was not successful.

Adult↗

PubMed2005

A comparison of the Ranson, Glasgow, and APACHE II scoring systems to a multiple organ system score in predicting patient outcome in pancreatitis.

BACKGROUND: Systems for evaluating acute pancreatitis are useful in hospitalized patients. Traditional systems of evaluation are well established but might be outdated. We propose a Multiple Organ System Score (MOSS) containing data that are more consistently collected and which are accurate in predicting patient outcome. METHODS: A retrospective chart review of 49 patients was completed. We determined if the physician obtained all of the variables necessary to calculate Ranson, Glasgow, or APACHE II scores, if these scores were predictive of patient outcome in the form of length of hospital stay (LOS), and if new, more frequently evaluated variables could be used. RESULTS: None of the patients could be assigned complete scores. According to Spearman rank correlation, both Glasgow and MOSS showed correlation with patient outcome when APACHE II and Ranson did not. CONCLUSIONS: Although larger studies should be performed, the MOSS is useful in predicting outcomes of patients with acute pancreatitis.

Acute Disease↗

PubMed2004

D-dimer as marker for microcirculatory failure: correlation with LOD and APACHE II scores.

The relevance of plasma d-dimer levels as marker for morbidity and organ dysfunction in severely ill patients is largely unknown. In a prospective study we determined d-dimer plasma levels of 800 unselected patients at admission to our intensive care unit. In 91% of the patients' samples d-dimer levels were elevated, in some patients up to several hundredfold as compared to normal values. The highest mean d-dimer values were present in the patient group with thromboembolic diseases, and particularly in non-survivors of pulmonary embolism. In patients with circulatory impairment (r=0.794) and in patients with infections (r=0.487) a statistically significant correlation was present between d-dimer levels and the APACHE II score (P<0.001). The logistic organ dysfunction score (LOD, P<0.001) correlated with d-dimer levels only in patients with circulatory impairment (r=0.474). On the contrary, patients without circulatory impairment demonstrated no correlation of d-dimer levels to the APACHE II or LOD score. Taking all patients together, no correlations of d-dimer levels with single organ failure or with indicators of infection could be detected. In conclusion, d-dimer plasma levels strongly correlated with the severity of the disease and organ dysfunction in patients with circulatory impairment or infections suggesting that elevated d-dimer levels may reflect the extent of microcirculatory failure. Thus, a therapeutic strategy to improve the microcirculation in such patients may be monitored using d-dimer plasma levels.

Adolescent↗

PubMed1981

Nutrition studies with White Mountain Apache preschool children in 1976 and 1969.

Nutrition studies were undertaken with two cohorts of White Mountain Apache preschool children, first in 1969 and again in 1976. Under the direction of the same investigator, similar procedures were used in the two studies to evaluate dietary, clinical, and biochemical status. The proportion of children in 1976 with low intakes of calories and of several micronutrients (calcium, vitamin A, vitamin C, thiamin, and iron) and with abnormal biochemical values (hemoglobin, serum iron, vitamin A, and vitamin C), was about half that in 1969. Height for age and weight for age were the same in the two studies. Skinfold thickness were slightly greater in 1976. Overall, these changes in nutritional status were in keeping with changes in the environment and in the economic and health care situations on the Fort Apache Reservation.

Anthropometry↗

PubMed1990

Rotavirus diarrhoea in Apache children: a case-control study.

A case-control study of rotavirus diarrhoea in Apache children up to two years old was conducted at the White Mountain Apache reservation from 1 May through 15 December 1985 to identify risk factors for rotavirus diarrhoea. The mothers of fifty cases, forty-five hospital controls and twenty-five neighbourhood controls participated in this study. Exposure to other children with diarrhoea stood out as the single most important factor for acquiring rotavirus diarrhoea (Odds ratio = 14.0). Other significant risk factors were living in homes with septic tanks and in homes with 'poor environmental sanitation.'. Minimizing contacts of children with diarrhoea therefore would be the most effective measure in preventing the spread of this disease in the community.

Arizona↗

PubMed1975

Antibodies to heat-labile Escherichia coli enterotoxin in Apaches in Whiteriver, Arizona.

Antitoxin titers to heat-labile Escherichia coli enterotoxin were measured in Apache children hospitalized with acute diarrhea and in Apaches of different age groups without diarrhea in Whiteriver, Ariz. The study suggests that in this locale, exposure to enterotocigenic E. coli is probably widespread and occurs early in life. Antitoxin titer rises after idarrheal disease associated with enterotocigenic E. coli infection, however, were not regulary found.

Antitoxins↗

PubMed1992

Stromatolites of the Mescal Limestone (Apache Group, middle Proterozoic, central Arizona): taxonomy, biostratigraphy, and paleoenvironments.

The 25- to 30-m-thick Algal Member of the Mescal Limestone (middle Proterozoic Apache Group) contains two distinct stromatolitic units: at the base, a 2- to 3-m-thick unit composed of columnar stromatolites and above, a thicker unit of stratiform and pseudocolumnar stromatolites. Columnar forms from the first unit belong to the Group Tungussia, and two new Forms are described: T. mescalita and T. chrysotila. Among the pseudocolumnar stromatolites of the thicker unit, one distinctive new taxon, Apachina henryi, is described. Because of the low stromatolite diversity, the biostratigraphic value of this assemblage is limited. The presence of Tungussia is consistent with the generally accepted isotopic age for the Apache Group of 1200 to 1100 Ma. The Mescal stromatolites do not closely resemble any other known Proterozoic stromatolites in the southwestern United States or northwestern Mexico. Analyses of sedimentary features and stromatolite growth forms suggest deposition on a stable, flat, shallow, subtidal protected platform during phases of Tungussia growth. Current action probably influenced the development of columns, pseudocolumns, and elongate stromatolitic ridges; these conditions alternated with phases of relatively quiet water characterized by nonoriented stromatolitic domes and stratiform stromatolites. Stable conditions favorable for development of the Mescal stromatolites were short-lived and did not permit the development of thick, stromatolite-bearing units such as those characteristic of many Proterozoic sequences elsewhere.

Arizona↗