http://meded.ucsd.edu/adpst/psc/articles/Mishra.pdf

Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery

Acute kidney injury

Carbamazepine and diclofenac: removal in wastewater treatment plants and occurrence in water bodies.

Biomarkers can be useful for identifying or ruling out sepsis, identifying patients who may benefit from specific therapies or assessing the response to therapy. We used an electronic search of the PubMed database using the key words "sepsis" and "biomarker" to identify clinical and experimental studies which evaluated a biomarker in sepsis. The search retrieved 3370 references covering 178 different biomarkers. Many biomarkers have been evaluated for use in sepsis. Most of the biomarkers had been tested clinically, primarily as prognostic markers in sepsis; relatively few have been used for diagnosis. None has sufficient specificity or sensitivity to be routinely employed in clinical practice. PCT and CRP have been most widely used, but even these have limited ability to distinguish sepsis from other inflammatory conditions or to predict outcome.

/pdf/sepsis-biomarkers-a-review-4665vgzfzb.pdf

Sepsis biomarkers: a review

Bordetella respiratory infections are common in people (B. pertussis) and in animals (B. bronchiseptica). During the last two decades, much has been learned about the virulence determinants, pathogenesis, and immunity of Bordetella. Clinically, the full spectrum of disease due to B. pertussis infection is now understood, and infections in adolescents and adults are recognized as the reservoir for cyclic outbreaks of disease. DTaP vaccines, which are less reactogenic than DTP vaccines, are now in general use in many developed countries, and it is expected that the expansion of their use to adolescents and adults will have a significant impact on reducing pertussis and perhaps decrease the circulation of B. pertussis. Future studies should seek to determine the cause of the unique cough which is associated with Bordetella respiratory infections. It is also hoped that data gathered from molecular Bordetella research will lead to a new generation of DTaP vaccines which provide greater efficacy than is provided by today's vaccines.

Molecular Pathogenesis, Epidemiology, and Clinical Manifestations of Respiratory Infections Due to Bordetella pertussis and Other Bordetella Subspecies

Background. Early detection of acute tubular necrosis (ATN) could permit implementation of salvage therapies and improve patient outcomes in acute renal failure (ARF). The utility of single and combined measurements of urinary tubular enzymes in predicting ARF in critically ill patients has not been evaluated using thereceiver-operatingcharacteristic(ROC)plot method. Methods. In this prospective pilot study, 26 consecutive critically ill adult patients admitted to the intensive-care unit were studied. Urine samples were collected twice daily for up to 7 days. ARF was defined as an increase in plasma creatinine of P50% and P0.15 mmolul. ROC plot analysis was applied to the tubular marker data to derive optimum cut-offs for ARF. Results. Four of the 26 study subjects (15.4%) developed ARF. Indexed to urinary creatinine concentration, c glutamyl transpeptidase (cGT), alkaline phosphatase (AP), N-acetyl-glucosaminidase (NAG), and a -a ndp-glutathione S-transferase (a -a ndp-GST) but not lactate dehydrogenase (LDH) were higher in the ARF group on admission (P-0.05). cGT, and a- and p-GST remained elevated at 24 h. The onset of ARF based on changes in plasma creatinine varied from 12 h to 4 days (median 36 h). ROC plot analysis showed that cGT, p-GST, a-GST, AP and NAG had excellent discriminating power for ARF (AUC 0.950, 0.929, 0.893, 0.863 and 0.845, respectively). The discriminating strength of creatinine clearance, while lower, was still significant (AUC 0.796). Positive and negative predictive values for ARF on admission were 67u100% for cGT, 67u90% for AP, 60u95% for a-GST, and 67u100% for p-GST indices. Positive and negative predictive values for ARF for creatinine clearance O23 mlumin were 50 and 91%, respectively. Creatinine clearances tended to be lower in ARF than in nonARF patients on admission (Ps0.06) and were significantly lower (Ps0.008) after 12 h. Plasma urea and fractional sodium excretion were unhelpful. Conclusions. Tubular enzymuria on admission to the ICU is useful in predicting ARF. The cheapness and wide availability of automated assays for cGT and AP suggests that estimation of these enzymes in random urine samples may be particularly useful for identifying patients at high risk of ARF.

Measurement of tubular enzymuria facilitates early detection of acute renal impairment in the intensive care unit

Objective: To compare the toxicity of beta blockers in overdose and to identi@ clinical features predictive of serious toxicity. Desinn: Comparison of clinical data collected prospectively on a relational database of subjects presenting to hospital with self-poisoning, coroner's data and prescription data. Setting: Newcastle and Lake Macquarie, Australia, 1987-1995. Main Outcome Measures: Death, seizure, cardiovascular collapse, hypoglycemia, coma and respiratory depression. Subjects: Fifi-eight self-poisonings with beta blockers and two deaths inwtigated by the coroner with evidence of propranolol poisoning. Results: All patients who developed toxicity did so within sir hours of ingestion. Ihe use of ipecac was temporally associated with cardiorespiratory arrest in one patient. Propranolol was the only beta blocker associated with seizure; of those who ingested more than 2 g of propranolol, two thirdr had a seizure. mere was a signifcant association between a QRS duration of > 100 ms and risk of seizures. Propranolol was over represent4 in beta blockerpoisoning when presmption data were also euunined. Propranor01 was the only beta blocker associated with death. Propranold was taken by a younger age group. Conclusions: Propranolol should be awoided in patients at risk of self-poisoning. Propranokd poisonings should be observed closely for the first six hours post ingestion. Syrup of ipecac should nor be wed to decontaminate the gastrointestinal tract ajier beta blocker omhse.

Relative Toxicity of Beta Blockers in Overdose

Background Prediction of suicide risk is difficult in clinical practice.

Aims To identify changes in clinical presentation predictive of suicide in patients treated for repeated episodes of self-poisoning.

Method A nested case–control study used the Hunter Area Toxicology Service database to identify exposure variables and the National Death Index to identify suicide. Cases were patients who had hospital treatment on more than one occasion between 15 January 1987 and 31 December 2000.

Results There were 31 cases, for which 93 controls were selected. Study variables associated with an increased risk of subsequent suicide were an increase in the number of drugs ingested (odds ratio 2.59, 95% CI 1.48–4.51), an increase in the dose ingested (OR 1.33, 95% CI 1.01–1.76), an increase in coma score (OR 1.71, 95% CI 1.11–2.66), a decrease in Glasgow Coma Score (OR 1.21, 95% CI 1.03–1.43) and an increase in drug or alcohol misuse (OR 2.33, 95% CI 1.06–5.10).

Conclusions Patients who have escalating severity of self-poisoning episodes are at high risk of completed suicide.

/pdf/repeated-self-poisoning-increasing-severity-of-self-harm-as-1cf7qyvgml.pdf

Repeated self-poisoning: increasing severity of self-harm as a predictor of subsequent suicide.

Background: Adverse drug events (ADEs) are an important problem in all hospitalized patients as these events represent medication-related patient harm. Few epidemiologic data exist regarding ADEs in the pediatric inpatient setting and, in particular, the economic impact of such ADEs upon the healthcare sector.

Incidence, preventability, and impact of Adverse Drug Events (ADEs) and potential ADEs in hospitalized children in New Zealand: a prospective observational cohort study.

Background: Although neonates are reported to be at greater risk of medication error than infants and older children, little is known about the causes and characteristics of error in this patient group. Failure mode and effects analysis (FMEA) is a technique used in industry to evaluate system safety and identify potential hazards in advance. The aim of this study was to identify and prioritise potential failures in the neonatal intensive care unit (NICU) medication use process through application of FMEA. Methods: Using the FMEA framework and a systems-based approach, an eight-member multidisciplinary panel worked as a team to create a flow diagram of the neonatal unit medication use process. Then by brainstorming, the panel identified all potential failures, their causes and their effects at each step in the process. Each panel member independently rated failures based on occurrence, severity and likelihood of detection to allow calculation of a risk priority score (RPS). Results: The panel identified 72 failures, with 193 associated causes and effects. Vulnerabilities were found to be distributed across the entire process, but multiple failures and associated causes were possible when prescribing the medication and when preparing the drug for administration. The top ranking issue was a perceived lack of awareness of medication safety issues (RPS score 273), due to a lack of medication safety training. The next highest ranking issues were found to occur at the administration stage. Common potential failures related to errors in the dose, timing of administration, infusion pump settings and route of administration. Perceived causes were multiple, but were largely associated with unsafe systems for medication preparation and storage in the unit, variable staff skill level and lack of computerised technology. Conclusion: Interventions to decrease medication-related adverse events in the NICU should aim to increase staff awareness of medication safety issues and focus on medication administration processes.

David M. Reith

Papers

Measurement of tubular enzymuria facilitates early detection of acute renal impairment in the intensive care unit

Relative Toxicity of Beta Blockers in Overdose

Repeated self-poisoning: increasing severity of self-harm as a predictor of subsequent suicide.

Incidence, preventability, and impact of Adverse Drug Events (ADEs) and potential ADEs in hospitalized children in New Zealand: a prospective observational cohort study.

Identification of priorities for medication safety in neonatal intensive care.