Does Time of Day Affect Survival of Cardiac Arrest Patients?
Background: In-hospital cardiac arrest is a major public health problem. Small studies have demonstrated survival after cardiac arrest is worse at night as compared with all other times. Multiple hypothesis are proffered for this decreased survival, including less effective detection and treatment of the warning signs of impending arrest during the night hours.
Study design: Prospective registry.
Setting: 507 hospitals participating through the National Registry of Cardiopulmonary Resuscitation.
Synopsis: 86,748 consecutive, inpatient cardiac arrests were reported from Jan. 1, 2000, through Feb. 1, 2007, including 58,593 cases during day/evening hours and 28,155 cases during night hours.
Rates of survival to discharge (14.7 % vs. 19.8%), survival at 24 hours (28.9% vs. 35.4%), and favorable neurological outcomes (11.0% vs. 15.2%) were substantially lower during the night compared with day/evening (all p values < 0.001). The first documented rhythm at night was more frequently asystole as opposed to ventricular fibrillation during the day/evening. There also was a higher survival rate with cardiac arrests during day/evening hours occurring on weekdays compared with weekends (odds ratio [OR] 1.15). There was no difference in survival rates between weekdays or weekends among cardiac arrests occurring during the night hours.
Bottom line: Survival rates for in-hospital cardiac arrest are lower during nights and weekends, which may relate to differential physician and hospital staffing patterns during these hours.
Citation: Peberdy MA, Ornato JP, Larkin GL et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008;299:785-792.
Can CRP Identify Risk in CAP Patients?
Background: Small initial studies suggest an elevated C-reactive protein (CRP) is relatively nonspecific but may have a role in predicting disease severity in community-acquired pneumonia (CAP).
Study design: Prospective study.
Setting: Large academic center in the United Kingdom.
Synopsis: In this study of 570 patients over a two-year time period, all patients presenting to the hospital with a diagnosis of CAP and the absence of exclusion criteria were evaluated. CRP was measured on admission and repeated on day four of hospitalization.
Low CRP levels (less than 100 mg/L) were independently associated with a reduced risk of 30-day mortality (OR 0.18; p=0.03), need for invasive ventilation and/or inotropic support (OR 0.21; p=0.002), and complicated pneumonia (OR 0.05; p=0.003). In addition, the failure of CRP to fall by 50% or more at day four of hospitalization was associated with an increased risk of 30-day mortality (OR 24.5; p<0.0001), need for mechanical ventilation and/or inotropic support (OR 7.1; p<0.0001), and complicated pneumonia (OR 15.4; p<0.0001).
Patients with chronic lung disease, immunosuppression, active malignancy or hospital-acquired pneumonia were excluded from the study and the conclusions cannot be extrapolated to these higher risk populations.
Bottom line: C-reactive protein is an independent marker of severity in CAP, and low levels can be used as an adjunct to clinical judgment to help identify patients who may be safely discharged from the hospital.
Citation: Chalmers JD, Singanayagam A, Hill AT. C-reactive protein is an independent predictor of severity in community-acquired pneumonia. Am J of Med. 2008;121:219-225.
Do Aggressive Surgical Intervention and Antimicrobial Treatment Improve Outcomes in Patients Suffering PJI?
Background: Prosthetic joint infection (PJI) is a severe complication, causing significant morbidity and healthcare costs. A recent article put forth up to date guidelines for the management of PJI. The purpose of this current study was to evaluate the external clinical validity of these treatment recommendations.
Study design: Retrospective cohort analysis.
Setting: 1,000-bed tertiary care center in Switzerland.
Synopsis: 68 consecutive episodes of PJI from January 1995 through December 2004 were reviewed. Patients with polymicrobial infections and with treatment failures prior to referral to this center were included.