ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo test the hypothesis that after cecal ligation and puncture in the rat, there is increased expression of the tumor necrosis factor (TNF)/interleukin-1-dependent, acute-phase reactant alpha1-acid glycoprotein in the liver, and that this change correlates temporally with increased abundance of TNF-alpha in the hepatic parenchyma but not with circulating concentrations of TNF-alpha.DesignProspective, randomized, controlled study.SettingResearch laboratory at the University of Pennsylvania School of Medicine.SubjectsMale, adolescent Sprague-Dawley rats, weighing 200 to 300 g.InterventionsThe procedure of cecal ligation and single puncture with an 18-gauge needle was performed in one group of animals. Control animals underwent sham operation. At 0, 3, 6, 16, 24, 48, and 72 hrs after either procedure, blood was collected and the liver was isolated and perfusion-fixed with 2% paraformaldehyde. In a second group of animals, liver tissue was harvested for isolation of total hepatic RNA.Measurements and Main ResultsNorthern blot hybridization analysis demonstrated an increase in steady-state concentrations of alpha1-acid glycoprotein messenger RNA that peaked at 16 hrs after cecal ligation and puncture. The alpha1-acid glycoprotein messenger RNA was not detected in control animals. TNF-alpha concentrations in the plasma, as determined by enzyme-linked immunosorbent assay, were detected 3 and 6 hrs after cecal ligation and puncture. However, TNF-alpha concentrations were undetectable in the plasma at other time points after cecal ligation and puncture and at all time points in the sham-operated animals. Immunohistochemical staining of 7-micro m hepatic sections demonstrated a progressive increase in TNF-alpha abundance, with a peak at 16 hrs. Alterations in alpha1-acid glycoprotein gene expression correlated in time with intrahepatic TNF-alpha abundance, but not with plasma TNF-alpha concentrations.ConclusionsThe changes in TNF-alpha-dependent hepatic gene expression that accompany an animal model of the systemic inflammatory response syndrome correlate with intrahepatic, and not circulating, TNF-alpha concentrations and reflect paracrine, and not endocrine, activity. Therefore, plasma concentrations of TNF-alpha do not appropriately reflect hepatocellular responses during the systemic inflammatory response syndrome. (Crit Care Med 1996; 24:1947-1952)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesTo evaluate the pain experience of seriously ill hospitalized patients and their satisfaction with control of pain during hospitalization. To understand the relationship of level of pain and dissatisfaction with pain control to demographic, psychological, and illness-related variables.DesignProspective, cohort study.SettingFive teaching hospitals.PatientsPatients for whom interviews were available about pain (n = 5,176) from a total of 9,105 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).InterventionsNone.Measurements and Main ResultsPatients were interviewed after study enrollment about their experiences with pain. When patients could not be interviewed due to illness, we used surrogate (usually a family member) responses calibrated to patient responses (from the subset of interviews with both patient and surrogate responses). Ordinal logistic regression was used to study the association of variables with level of pain and satisfaction with its control.Nearly 50% of patients reported pain.Nearly 15% reported extremely severe pain or moderately severe pain occurring at least half of the time, and nearly 15% of those patients with pain were dissatisfied with its control. After adjustment for confounding variables, older and sicker patients reported less pain, while patients with more dependencies in activities of daily living, more comorbid conditions, more depression, more anxiety, and poor quality of life reported more pain. Patients with colon cancer reported more pain than patients in other disease categories. Levels of reported pain varied among the five hospitals and also by physician specialty. After adjustment for confounding variables, dissatisfaction with pain control was more likely among patients with more severe pain, greater anxiety, depression, and alteration of mental status, and lower reported income; dissatisfaction with pain control also varied among study hospitals and by physician specialty.ConclusionsPain is common among severely ill hospitalized patients. The most important variables associated with pain and satisfaction with pain control were patient demographics and those variables that reflected the acute illness. Pain and satisfaction with pain control varied significantly among study sites, even after adjustment for many potential confounders. Better pain management strategies are needed for patients with the serious and common illnesses studied in SUPPORT. (Crit Care Med 1996; 24:1953-1961)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesA) To examine the long-term survival of critically ill patients compared with the general population in a nationwide sample of patients requiring intensive care; and b) to analyze long-term survival stratified by specific diagnostic subgroups.DesignProspective, inception cohort study.SettingTwenty-five Finnish intensive care units (ICUs) at 17 hospitals, including 13 ICUs in five tertiary care centers.PatientsA consecutive sample of 12,180 adult patients who were admitted to ICUs in 1987. The sample was further divided into seven diagnostic subgroups.InterventionsNone.Measurements and Main ResultsVital status at 5 yrs after admission to an ICU was examined and compared to the age- and gender-adjusted survival of Finland's general population. Among ICU patients, the 5-yr mortality rate was 3.3 times that of Finland's general population (95% confidence interval 3.0 to 3.4). At 2 yrs, the survival rate paralleled that of the general population. At 5 yrs, the relative survival rate of the ICU patients was 66.7%. Cancer was a strong determinant of a poor outcome in multivariate analysis (relative risk 3.17; 95% confidence interval 2.86 to 3.51). The 5-yr mortality rate of the ICU patients compared with the general population was highest among patients admitted to the ICU after intoxication. Trauma victims and patients admitted to the ICU with a cardiovascular diagnosis reached the risk of death of the general population in the shortest time.ConclusionsICU patients reached a life expectancy similar to the general population, on average, 2 yrs after admission. The time after which the survival parallels that of the general population depends, however, on the diagnostic category. (Crit Care Med 1996; 24:1962-1967)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo analyze the effects of patient mix diversity on performance of an intensive care unit (ICU) severity-of-illness model.DesignMultiple patient populations were created using computer simulations. A customized version of the Mortality Probability Model (MPM) II admission model was used to ascertain probabilities of hospital mortality. Performance of the model was assessed using discrimination (area under the receiver operating characteristic curve) and calibration (goodness-of-fit testing).SettingIntensive care units.PatientsData were collected from 4,224 ICU patients from two Massachusetts hospitals (Baystate Medical Center, Springfield, MA; University of Massachusetts Medical Center, Worcester, MA) and two New York hospitals (Albany Medical Center, Albany, NY; Ellis Hospital, Schenectady, NY).InterventionsRandom samples were taken from a database. The percentage of patients with each model disease characteristic was varied by assigning weights (ranging from 0 to 10) to patients with a disease characteristic. Three simulations were run for each of 15 model variables at each of 16 weights, totaling 720 simulations.Measurements and Main ResultsThe area under the receiver operating characteristic curve and model fit were assessed in each random sample.Removing patients with a given disease characteristic did not affect discrimination or calibration.Increasing frequency of patients with each disease characteristic above the original frequency caused discrimination and calibration to deteriorate. Model fit was more robust to increases in less frequently occurring patient conditions.From the goodness-of-fit test, a critical percentage for each admission model variable was determined for each disease characteristic, defined as the percentage at which the average p value for the test over the three replications decreased to <.10.ConclusionsThe concept of critical percentages is potentially clinically important. It might provide an easy first step in checking applicability of a given severity-of-illness model and in defining a general medical-surgical ICU. If the critical percentages are exceeded, as might occur in a highly specialized ICU, the model would not be accurate. Alternative modeling approaches might be to customize the model coefficients to the population for more accurate probabilities or to develop specialized models. The MPM approach remained robust for a large variation in patient mix factors. (Crit Care Med 1996; 24:1968-1973)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo determine the role of preexisting Helicobacter pylori infection in the development of acute upper gastrointestinal (GI) hemorrhage in intensive care unit (ICU) patients in relation to other potential predisposing risk factors.DesignProspective, multicenter, cohort study.SettingMedical and surgical ICUs in six tertiary care Department of Veterans Affairs Medical Centers.PatientsEight-hundred seventy-four patients without previous GI bleeding or peptic ulcer disease who were enrolled in a multicenter, randomized, controlled trial of prophylactic intravenous immunoglobulin to prevent ICU-associated infections.InterventionsThis substudy of the larger intravenous immunoglobulin study only involved data analysis and had no intervention. All patients were enrolled in the larger study where they received intravenous immunoglobulin or placebo as intervention.Measurements and Main ResultsPatients were prospectively evaluated for the development of acute upper GI hemorrhage while in an ICU. Anti-H. pylori immunoglobulin G and immunoglobulin A concentrations were determined by enzyme immunoassay on preintervention serum samples.Seventy-six (9%) patients had overt upper GI bleeding and a mortality rate of 49%, as compared with a 15% mortality rate in patients who did not bleed (p < .001). By logistic regression analysis, the following factors were associated with an increased risk of bleeding: acute hepatic failure, prolonged duration of nasogastric tube placement, alcoholism, and an increased serum concentration of anti-H. pylori immunoglobulin A.ConclusionsIncreased anti-H. pylori immunoglobulin A concentrations, prolonged nasogastric intubation, alcoholism, and acute hepatic failure were found to be independently correlated with the development of acute GI bleeding in an ICU setting. These observations should be prospectively confirmed in an independent population before being used for treatment guidelines. (Crit Care Med 1996; 24:1974-1981)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo determine whether factors such as age, gender, and severity of injury should be considered when evaluating serum insulin-like growth factor (IGF)-1 and transthyretin concentrations as markers of nutritional status after trauma. A large, diverse group of patients was studied before the confounding effects of acute nutrient deprivation.DesignProspective, randomized, descriptive study.SettingEmergency room of a university hospital.PatientsOne hundred eight trauma patients.InterventionsNone.Measurements and Main ResultsIn this heterogeneous group of patients, Injury Severity Score ranged from 1 to 45 (11.5 +/- 10.3 [SD]), age ranged from 18 to 77 yrs (35 +/- 15.3 [SD]), and 68% were male and 32% were female. A venous blood sample was collected on admission and analyzed for serum IGF-1, transthyretin, albumin, and C-reactive protein concentrations. Relationships among variables were tested with multiple regression, Pearson's correlation coefficients, and analysis of variance.Gender, age, and severity of injury demonstrated strong and interactive effects on serum IGF-1 concentrations. IGF-1 concentrations were predicted with the following equations in women and men, respectively: y = 414 - 10.87(age) + 1.19(Injury Severity Score) + .09(age2); y = 454 - 10.87(age) - 2.57(Injury Severity Score) + .09(age sup 2); (R2= .35, p < .0001). The relationship between age and IGF-1 was curvilinear in both men and women. IGF-1 concentrations increased with age until [approximately]57 yrs, and then decreased with increasing age. In women, IGF-1 concentrations increased with increasing severity of injury. In men, IGF-1 concentrations decreased with increasing Injury Severity Scores. This dissimilar response to injury between men and women was also seen in the significant interaction between gender and Injury Severity Score in predicting transthyretin concentrations (R2= .32, p < .05). In men, transthyretin concentrations decreased significantly with severe injury; in women, transthyretin concentrations remained stable with severe injury. Albumin concentrations were predicted by injury severity and serum osmolality, but not gender. C-reactive protein, and time postinjury did not significantly influence the serum proteins (serum IGF-1, transthyretin, or albumin). Without consideration of age or severity of injury, mean concentrations of IGF-1, transthyretin, albumin, and C-reactive protein were not different between men and women, and were within normal expected ranges.ConclusionsSerum IGF-1 and transthyretin concentrations, measured without the confounding effects of acute nutrient deprivation, were influenced by the severity of the injury in patients suffering traumatic injury. Age was an important determinant of serum IGF-1 in men and women even in severe trauma. The present study indicated that men and women demonstrate different physiologic responses to trauma. Women responded to increasing severity of injury with increased serum IGF-1 and little change in transthyretin concentrations. In men, both IGF-1 and transthyretin concentrations decreased with severe injury. Interpretation of serum concentrations of IGF-1 and transthyretin as markers of nutritional status after trauma should include consideration of age, gender, and severity of injury. (Crit Care Med 1996; 24:1982-1987)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectivesInsulin-like growth factor-1 (IGF-1) has been studied as a marker of nutrition in critical illness, but there is little research on IGF-binding protein-3, which regulates the bioactivity of IGF-1. The objectives of the present study were to measure serum IGF-binding protein-3 concentrations in trauma patients and to determine whether factors such as age, gender, and severity of injury should be considered when evaluating serum IGF-binding protein-3 concentrations as a marker of nutritional or clinical status.DesignProspective, randomized, descriptive study.SettingEmergency room of a university hospital.PatientsOne hundred eight trauma patients.InterventionsNone.Measurements and Main ResultsIn this diverse group of patients, Injury Severity Score ranged from 1 to 45 (11.5 +/- 10.3 [SD]), age ranged from 18 to 77 yrs (35 +/- 15.3), and 68% were male. A venous blood sample was collected at the time of admission into the study and was analyzed for serum IGF-binding protein-3 concentration (by radioimmunoassay), serum osmolality, IGF-1 concentration, and C-reactive protein concentration. Relationships between variables were tested using Pearson's correlation coefficients and multiple regression analysis.Age, Injury Severity Score, serum osmolality, time since injury, and gender were not significant predictors of serum IGF-binding protein-3 concentrations when all patients were analyzed together. However, when men and women were analyzed separately, notable gender differences were observed. In women, serum IGF-binding protein-3 concentrations were increased with increasing severity of injury (beta = 0.52, R2= .33, p < .01). In men, the opposite relationship was observed (beta = -0.29, R2= .17, p < .01). Other predictors in the model (age, serum osmolality, and time since injury) were not significant. Variability in IGF-binding protein-3 concentration could not be explained by differences in body mass index or acute-phase response (serum C-reactive protein). Serum IGF-1 concentrations changed coordinately with IGF-binding protein-3 concentrations in females and males (r = .62, p < .001 and r = .54, p < .001, respectively). IGF-binding protein-3 concentration at the time of admission into the study could not predict mortality, but this value was correlated with length of hospitalization in women (r = .37, p < .05).ConclusionsDetermination of the specificity and sensitivity of IGF-binding protein-3 as an index of nutrition or anabolism requires knowledge of its relationship to nonnutritional factors. These factors are most discernible before the confounding effects of treatments, absence of feeding, and complications. The present study demonstrated that gender and severity of injury must be considered when interpreting serum IGF-binding protein-3 concentrations in trauma patients. In a much wider context, the present findings suggest that the study of the metabolic response to stress requires separate analyses, based on gender. (Crit Care Med 1996; 24:1988-1992)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID