Evolution of an active psychogeriatric day hospital.

A geriatric day hospital was established as part of the psychogeriatric unit of the Royal Ottawa Hospital. While initially this day hospital was integrated with day hospital programs of other units, it became apparent that a separate facility was desirable. The activities and programs of the psychogeriatric day hospital, run by one registered nurse, were integrated with those of the geriatric inpatient unit. It was found to be advantageous for inpatients and day hospital patients to share the same physical facilities. The majority of day hospital patients came from the inpatient unit; almost all had affective disorders. The emphasis was on reintegration into the community. During the 1st year of operation there were 75 patients in the program; only 3 needed admission to the inpatient unit and 1 was readmitted after discharge.     

The Planning and Operation of an Intensive Care Unit

It is desirable that every hospital of 100 beds or more should have an intensive care unit. An attempt is made to outline the more important features to be considered, including the physical aspects, when planning and establishing such a unit. The unit should contain 2-4% of the total number of hospital beds. It should be separate, centrally located and self-contained. Direct observation of all patients must be possible at all times. Efficient and specially trained personnel using modern and special equipment are required. Orientation lectures and demonstrations must be carried out frequently and regularly. The types of patients to be admitted to the unit are discussed, as well as the governing rules and regulations. All doctors should have a right to admit and look after their own patients in the unit; an Intensive Care Unit Committee made up of representatives of the major services is suggested as a means of controlling admissions and discharges and for general administration.     

Sudden Death in Hospital after Discharge from Coronary Care Unit

In a group of 339 patients with acute myocardial infarction treated in a coronary care unit, 273 left the unit while improving and were expected to leave hospital alive; 23 had a cardiac arrest or died suddenly while still in hospital—17 died immediately or after temporary resuscitation and six were resuscitated to leave hospital alive. Ventricular fibrillation was found in 13 of the 20 patients attended by the cardiac arrest team. The incidents were scattered from the 4th to the 24th day after the onset of infarction. Risk factors in these “late sudden death” patients were compared with the 250 patients who left the unit while improving and did not die or suffer cardiac arrest. The patients susceptible to late sudden death were characterized early in their hospital course by the findings of severe, predominantly anterior infarction, left ventricular failure, persistent sinus tachycardia, and frequent ventricular arrhythmias. It is suggested that such patients be chosen for prolonged observation in a second-stage coronary care unit.     

Effective use of regional intensive therapy units.

OBJECTIVE--To determine the effectiveness of regional intensive therapy units. DESIGN--Retrospective and prospective study of patients transferred to a regional intensive therapy unit over four years. SETTING--Glasgow regional intensive therapy unit. MAIN OUTCOME MEASURES--Severity of illness was assessed at the time of referral to the unit with the acute physiological and chronic health evaluation (APACHE) scoring system. Mortality was calculated. RESULTS--A significant association was found between increasing duration of illness before transfer and mortality, which was independent of the severity of illness. Mortality also varied depending on the referring hospital. CONCLUSIONS--When transfer of critically ill patients is required this should be done as early as possible to make best use of the services available. The mortality of patients transferred after 10 days casts doubt on whether further aggressive intensive therapy is appropriate.     

Health Centre X-ray Unit

An analysis of the types and numbers of x-ray films requested in the first year of a health centre x-ray unit showed that chest films represented the largest proportion of these. The unit is most valuable when it is inmediately available to the patient and general practitioner at the time of consultation, and thus it should be open for at least five sessions per week. The likely referral rate for the health centre x-ray unit is 84 patients per 1,000 at risk, and a unit functioning for five sessions a week can examine 60 patients during that time. This minimum of five sessions would be fully used by a population of 30,000 patients. The running costs were found to be about the same as those of a hospital x-ray unit.     

Does HIV status influence the outcome of patients admitted to a surgical intensive care unit? A prospective double blind study.

OBJECTIVES: (a) To assess the impact of HIV status (HIV negative, HIV positive, AIDS) on the outcome of patients admitted to intensive care units for diseases unrelated to HIV; (b) to decide whether a positive test result for HIV should be a criterion for excluding patients from intensive care for diseases unrelated to HIV. DESIGN: A prospective double blind study of all admissions over six months. HIV status was determined in all patients by enzyme linked immunosorbent assay (ELISA), immunofluorescence assay, western blotting, and flow cytometry. The ethics committee considered the clinical implications of the study important enough to waive patients'' right to informed consent. Staff and patients were blinded to HIV results. On discharge patients could be advised of their HIV status if they wished. SETTING: A 16 bed surgical intensive care unit. SUBJECTS: All 267 men and 135 women admitted to the unit during the study period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: APACHE II score (acute physiological, age, and chronic health evaluation), organ failure, septic shock, durations of intensive care unit and hospital stay, and intensive care unit and hospital mortality. RESULTS: No patient had AIDS. 52 patients were tested positive for HIV and 350 patients were tested negative. The two groups were similar in sex distribution but differed significantly in age, incidence of organ failure (37 (71%) v 171 (49%) patients), and incidence of septic shock (20 (38%) v 54 (15%)). After adjustment for age there were no differences in intensive care unit or hospital mortality or in the durations of stay in the intensive care unit or hospital. CONCLUSIONS: Morbidity was higher in HIV positive patients but there was no difference in mortality. In this patient population a positive HIV test result should not be a criterion for excluding a patient from intensive care.     

Late Ventricular Dysrhythmias after Myocardial Infarction

Serious ventricular dysrhythmias occurred in hospital after discharge from a coronary intensive care unit in 11 out of 142 patients with myocardial infarction. Previous rhythm changes, hypotension, and left ventricular failure were common findings; only one of these patients had an uneventful previous course. Four patients were resuscitated and left hospital; six were resuscitated but died at varying periods up to eight days after the event; one patient could not be resuscitated. Recent coronary occlusion or further myocardial infarction was demonstrated in 7 of these 11 patients and presumably accounted for the dysrhythmia.     

Pericarditis after Acute Myocardial Infarction

Fifty-two (6·8%) of 779 patients admitted to a coronary monitoring unit with acute myocardial infarction developed a pericardial friction rub. A diagnosis of postmyocardial infarction syndrome was made in three of these.The course of the 52 patients with pericarditis was compared with that of a consecutive series of 100 patients without pericarditis. As a group those with pericarditis manifested a longer period of pyrexia, a greater rise in serum enzymes, and a higher incidence of major arrhythmias and of radiological pulmonary oedema. The Peel prognostic index, however, did not differ significantly in the two groups. The hospital mortality of the pericarditis group was not significantly different from that of the 727 non-pericarditis patients. No specially adverse features were found in a follow-up of the pericarditis group.Though the presence of a pericardial rub in the first few days after a myocardial infarction may be a sign of extensive myocardial damage and is associated with a relatively high incidence of ventricular fibrillation, it does not appear to influence the hospital mortality of patients treated in a monitoring unit.     

ICU患者呼吸道感染病原菌的分布及耐药性监测

目的了解华中科技大学同济医学院附属同济医院ICU患者呼吸道感染病原菌的分布及细菌耐药性特征,指导临床合理、科学地使用抗菌药物,为有效控制危重患者肺部感染提供依据。方法回顾分析该院2004年1月至2008年12月ICU患者呼吸道感染的病原菌分布情况,并分析其耐药性变化。结果该院ICU患者呼吸道感染病原菌主要为鲍曼不动杆菌(aba)、铜绿假单胞菌(pae)和金葡菌(sau),其中泛耐药菌株有增多趋势。耐苯唑西林金葡菌(MRSA)的检出率在77.5%~100%。药敏数据显示,pae对常用抗菌药物耐药率均较高,在25.5%~95.3%;aba仅对头孢哌酮/舒巴坦耐药率低,为12.2%,但中敏率较高,为41.7%,对其他常用抗菌药物耐药率均较高。MRSA对所有的β-内酰胺类抗菌药物均耐药,苯唑西林敏感的金葡菌(MSSA)对青霉素和红霉素耐药率较高,分别为97.1%和47.2%,对其他常用抗菌药物较敏感。结论该院ICU患者呼吸道感染以aba、pae和sau为主,且耐药现象严重,对临床常用抗菌药物有多重耐药现象,临床医生应根据药敏结果合理使用抗菌药物。     

Value of emergency toxicological investigations in differential diagnosis of coma.

Out of 208 cases of coma of unknown aetiology referred to the poisons unit of this hospital during 1978 for emergency toxicological investigations, 108 were found to be due to self-poisoning medical conditions, mainly neurological, accounted for coma in 90 patients; the cause was not ascertained in the remaining 10 cases. More than one preparation had been ingested by 58 (54%) of the poisoned patients, although barbiturates were the drugs most commonly encountered in the severe cases. Toxicological investigations should be considered in the differential diagnosis of coma when history, physical examination, and emergency biochemical measurements yield little diagnostic information.     

二尖瓣置换术后左心室破裂2例并文献复习

目的：总结二尖瓣置换术后左心室破裂2例临床经验教训,方法：回顾性分析我院2006,1．2009,12二尖瓣置换术后左心室破裂2例的临床资料,两例均在监护室里发生突然大出血,紧急输血,输液,机械呼吸,抗休克治疗,并行开胸手术。结果：一例心外修补抢救成功,术后2周顺利出院,一例CPB下心内外修补,因低心排综合症死亡。结论：左心室破裂是二尖瓣置换术最严重的并发症,一旦发生死亡率极高,因此预防,避免其相关因素更关键：     

Candida colonization in intensive care unit patients' urine

The objective of this study was to identify possible predisposing factors for candiduria in intensive care unit (ICU) patients from Hospital das Clínicas, Universidade Federal de Goiás, Goiania, Brazil, during one year. Urine samples from 153 ICU patients were obtained by catheterization on admission day and every seven days. Data such as sex, age, antifungal therapy, and variables as antibiotics, underlying diseases or comorbid conditions and stay in the hospital, were collected from patients who had at least one urine culture that yielded > 10(3) yeast colonies/ml. Candiduria was recovered in 68 patients and the commonest predisposing factors were antibiotic therapy (100%) and indwelling urinary catheter (92.6%). The percentage of Candida spp. isolation increased during the extended periods in which patients remained in the ICU. C. albicans was isolated in 69.1%, and the other species non-albicans as C. glabrata, C. kefyr, C. parapsilosis, C. famata, C. guilliermondii, C. krusei, and C. tropicalis were isolated in lower percentage. The high frequency of candiduria and the possible predisposing factors found in ICU patients show that candiduria surveillance should be performed to help reducing nosocomial infections.     

Fungal colonization in patients with cancer of the upper respiratory tract

Fungal opportunistic infections are a danger for immunocompromised hosts, such as patients with malignancies, especially in a hospital environment. We studied a group of patients with solid tumors of the respiratory tract on admission and after twenty days of hospitalization. Colonization by moulds and/or yeasts was frequently found.Preventive measures should be applied to avoid colonization inside the hospital. The importance of overcrowding, sanitation and diet is pointed out.     

Comprehensive care of patients with head injuries.

The comprehensive head injury service run by the neurosurgeons at the Hull Royal Infirmary for the surrounding population of one million was analysed. The analysis showed that all patients with either a fractured skull or a lowered level of consciousness should be admitted to a district general hospital because the associated risk of their having a major head injury is over 20%. Those patients with both a fractured skull and a lowered level of consciousness have a 60% likelihood of a major head injury and should be transferred immediately to the neurosurgical unit. Patients with compound or complicated fractures of the skull and those without fractured skulls but with neurological impairment persisting for four hours or more, should also be transferred to the neurosurgical unit. If these guidelines are followed about 200 patients/million population will be referred to the neurosurgical centre. Patients with a minor head injury and none of the clinical risk factors may safely be sent home. This should reduce the rate of admissions to hospital for head injuries by 60%.     

Effects of self poisoning with maprotiline.

Self poisoning with maprotiline was studied in 41 patients (43 episodes) consecutively admitted to an intensive care unit. Thirty five patients had taken more than one drug or alcohol. Fifteen patients were in coma grade III or IV; 17 patients were still not conscious after 24 hours in the intensive care unit. Among six patients given ventilation the mean duration of ventilation in the five who recovered was 36 hours. Three patients had a cardiorespiratory arrest, and one patient died. Twenty eight patients had a QRS interval of 100 ms or more, and 15 patients had seizures. In six patients seizures were precipitated by physostigmine. Cardiotoxicity after overdosage of maprotiline is equal to if not greater than that found after overdosage of conventional tricyclic antidepressants. Overdosage of maprotiline is more often associated with seizures than overdosage with tricyclic antidepressants. Physostigmine further increases the risk of seizures and should not be used in cases of overdosage of maprotiline.     

Improved prognosis since 1969 of myocardial infarction treated in a coronary care unit: lack of relation with changes in severity.

OBJECTIVE--To study changes from 1969 to 1983 in the prognosis of patients with acute myocardial infarction treated in a coronary care unit. DESIGN--Mortality follow up of all patients with definite acute myocardial infarction. SETTING--The coronary care unit of the Royal Melbourne Hospital, a tertiary referral centre. SUBJECTS--4253 Patients (3366 men, 887 women) admitted from 1969 to 1983. MAIN OUTCOME MEASURE--Mortality recorded at discharge from hospital and 12 months after admission. RESULTS--Details of clinical findings, history, electrocardiograms, arrhythmias, and radiological findings were recorded on admission. Mean ages were 63 for women and 57 for men, and women had haemodynamically more severe infarcts than men. In the later years patients were older and had less severe infarcts. Overall, hospital mortality in men was 16.7% in 1969-73 and 8.5% in 1979-83 and declined in all grades of the Norris and Killip infarct severity indices compared with a constant 19.2% in women. Even after adjustment for age and severity by logistic regression, hospital mortality fell in men by an average of 8% (95% confidence interval 4% to 11%) a year but remained constant in women. By 1983 male mortality was 60% that of women of similar age and comparable severity of infarction. Mortality of hospital survivors at 12 months declined by 7% (4% to 9%) a year in both sexes, even after adjustment for age and severity, with a male to female mortality ratio of about 0.8. New indices were derived to predict mortality in hospital and at 12 months. CONCLUSION--The observed declines in mortality cannot be explained by changes in severity of infarction or in prognostic characteristics of patients.     

A different kind of day hospital--for patients with preterminal cancer and chronic disease.

A new day hospital has been set up in Sheffield for patients with preterminal cancer and chronic disease. During the first 26 months 197 patients with cancer and 66 chronically sick patients attended. Of the 2701 attendances by patients with cancer, breast cancer accounted for 38%. One hundred and forty of the patients with cancer died, 83% in the terminal-care unit and 12% at home. Ninety per cent of respondents to a questionnaire thought that the support provided was of great importance to both patient and family; and over two-thirds of the patients were said to have benefited from improved control of symptoms. A similar facility could be developed within existing day hospitals without major revenue consequences, and should produce a genuine improvement in care. This study suggests, however, that it would not shorten the terminal stay in hospital.     

Defibrillators in general practice.

After a successful pilot scheme introduced in 1975, when six portable defibrillators were provided for health centres, an additional 50 defibrillators were provided in February 1982 for general practitioners to use. Between December 1975 and February 1984 defibrillation was attempted in 54 patients who collapsed with clinical cardiac arrest in the presence of general practitioners or less than five minutes before their arrival. A cardiac output was achieved in 32 patients, 28 survived to reach hospital via a mobile coronary care unit, and 22 were discharged alive. Of the 28 admitted to hospital, 24 were found to have myocardial infarction. If all general practitioners carried defibrillators they might make an important dent in the early mortality from myocardial infarction in addition to that achieved by a mobile coronary care unit.     

综合性医院重症监护病房病原菌分离情况分析

目的探讨重症监护病房（Icu）医院内感染的临床特点及病原菌种类、分布情况,为临床合理使用抗菌药物、预防和控制医院感染提供参考和依据。方法采用前瞻性监测与回顾性调查相结合的方法,对ICU患者的临床资料进行统计分析。结果ICU病人标本中分离出病原菌593株,得出菌种分布与感染情况。结论重症监护病房医院内感染发生率高,以呼吸道感染为主,主要病原菌以革兰阴性非发酵菌为主,加强ICU患者感染的控制,可减少ICU医院内感染的发生。     

Mobile Intensive Care in Myocardial Infarction

In the first six months of its existence a mobile intensive care unit was used to admit 95 patients with definite or probable myocardial infarction to the local district hospital. Though the area served was a rural one, with a radius of about 25 miles from the hospital, the average interval between receiving a call and starting intensive care was less than 30 minutes. Five patients with ventricular fibrillation were successfully resuscitated by the mobile team outside hospital. The mobile unit has made it possible to admit many more patients with myocardial infarction to hospital than before, and we believe its cost and use of skilled staff are justified by the results. The unit reduces the delay between the onset of symptoms and initiation of intensive care and thus diminishes the risk of primary ventricular fibrillation, which is maximal soon after the onset of symptoms. Since mobile intensive care removes the risk of transport it allows concentration of cases of acute myocardial infarction in the larger hospitals.