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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Predictive value of HbA1c-levels with regard to in-hospital mortality, length of hospital stay and intensive care utilisation versus different emergency risk scores and the Manchester Triage System in unselected medical emergency admissions


Objectives. To evaluate the predictive value of HbA1c levels in medical patients admitted to the emergency department (ED) regarding in-hospital-mortality, length of stay (LOS) and transferral to intensive care unit (ICU) and to compare them with different physiologically based emergency scoring systems and the Manchester Triage System (MTS).

Methods. In a prospective cohort-study, 1117 consecutive patients presenting to the medical ED were assessed. Data collected included age, sex, vital signs, temperature, oxygen saturation, respiratory rate, AVPU (Alert; Verbal response; response to Pain; Unresponsive)-score, MTS, different emergency scores and HbA1c. The data were correlated with LOS, hospital mortality and intensive care utilisation.

Results. HbA1c had similar accuracy in predicting LOS as most physiologically based scores (AUC=0.568, p=0.688 to 0.714) and ICU utilisation (AUC=0.525, p=0.001 compared with MTS, for all others p=0.077 to 0.830). HbA1c was positively correlated with LOS and ICU-transferral but correlated poorly with mortality, resulting in low predictive power (AUC=0.501, p=0.033 to 0.845). The subgroups with HbA1c below the median and below 6.5% had a shorter LOS (p=0.012 and p=0.004).

The differences for other subgroups were not significant.

Conclusions. HbA1c was positively correlated with LOS and ICU-referral, reflecting higher health-care utilisation, indicating that it may be a useful parameter in evaluating severity of illness in emergency patients.

Key Words: Glycated haemoglobin, Emergency score, Manchester Triage System, mortality, length of stay, ICU referral

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Osteoarticular infections in newborns: prognostic factors and outcome


Purpose: To analyze clinical, laboratory, microbiologic, imaging and therapeutic data that contribute to outcome in newborn infants with osteoarticular (OSA) infection.

Methods: Clinical course, imaging and follow-up data of 15 newborns with the diagnosis of OSA infection were retrospectively reviewed.

Results: 15 newborns with 23 acute osteoarthritis foci were included: risk factors were identified in 73%, lower extremities were affected in 8 (53%) and more than half of the children had two- or multifocal involvement. The predominant causative agent was Staphylococcus aureus. While plain radiography showed osteolytic bone lesions in only 33%, scintigraphy was consistent with osteomyelitis in 74% of study infants. Magnetic resonance imaging revealed an inflammatory process even when other imaging modalities did not detect any OSA signs. All newborns underwent surgical and antibiotic treatment; the average time from admission to surgical treatment was 3.6 days. No bone and joint deformities or limb-length disturbances were found in the mean follow-up period of 8.5 years.

Conclusion: Our study confirms that the most important prognostic factors in predicting a long-term favorable outcome are early diagnosis and therapy consisting of a combination of both surgical and appropriate antibiotic treatment.

Key words: osteoarticular infection, newborn, osteoarticular imaging, outcome

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Metronome Use Positively Affects Cardiopulmonary Resuscitation Parameters: Prospective Observational Multicenter Manikin Study


Objective: Clinical studies have shown that eliminating performer errors is important to ensure high quality cardiopulmonary resuscitation (CPR). Literature on the effects of metronome use on the quality of CPR is scarce. This study aimed to investigate the effect of metronome use on the quality of cardiopulmonary resuscitation.

Methods: Thirty volunteer emergency physicians who were divided into 15 groups participated in this prospective, observational, multi-center, manikin study. Firstly, each participant performed conventional CPR on a manikin, and then performed metronome-guided CPR after a short break. Parameters affecting CPR quality were evaluated based on the recommendations of the 2015 American Heart Association CPR and Emergency Cardiovascular Care Guideline. In addition, the fatigue levels of participants were evaluated using the Borg Fatigue Index.

Results: Metronome-guided CPR significantly improved the chest compression rate (median (Interquartile Range-IQR); 128 (22) compressions/min vs. 110 (2) compressions/min; 95%CI, p<0.001), deep compression rate (median (IQR); 95.25 (80) compressions/min vs. 72.63 (105) compressions/min; 95%CI, p<0.001), compression depth (median (IQR); 62.50 (11) mm vs. 60.25 (14) mm; 95%CI, p=0.016), ventilation number (median (IQR); 11.25 (6) ventilations/min vs. 9.50 (1) ventilations/min; 95%CI, p=0.001), high-volume ventilation count (median (IQR); 10.13 (6) ventilations/min vs. 9.50 (1) ventilations/min; 95%CI, p=0.026), minute ventilation volume (median (IQR); 11.75 (10) L/min vs. 8.03 (3) L/min; 95%CI, p<0.05), and fatigue levels (median (IQR); 3 (2) vs. 2 (2); in 95%CI, p<0.05).

Conclusions: Our study showed that metronome is a useful device for reaching effective CPR. Metronome guidance may change the CPR parameters positively. This study is in accordance with previous studies which have investigated the effect of metronome-guided CPR on survival.

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Comparative analysis of injury severity caused by traffic accidents classified as severe injury in police database vs. MAIS 3+ injury in hospital database – first pilot research in Serbia


Objective. Conduct a comparative analysis of injury severity (IS) caused by traffic accidents (TA) and classified as severe injury (SI) in police database vs. MAIS 3+ injury in hospital database, and determine correction factor (CF).

Methods. Data were collected prospectively on the injured in TA examined by Emergency medical services. The numbers of fatalities, the numbers of patients transported to hospitals, and those examined at the scene of TA who refused further medical treatment and transport were identified. IS was asssessed in hospital according to ICD, AIS and MAIS for each patient. The data on SBI were compared vs. MAIS 3+ and CF was determined.

Results. 134 respondents were included: 55 drivers, 37 passengers, 23 pedestrians, 17 motorcyclists and 2 cyclists. 12% out of 17% of MAIS 3+ patients were hospitalized. One patient with MAIS 5 died during hospitalization. The comparative analyisis of IS as assessed in the police vs hospital database showed the ratio SI : MAIS 3+ to be 1.2. Eighteen SIs belonged to MAIS 3+, one to MAIS 1 and one to MAIS 2. Four patients with MAIS 1 and 2 score sustained no injuries, according to the police report. Six moderate IS according to police data were classified as MAIS 3 in hospital registers. CF for MAIS 3+ was 0.316 and for minor IS was 0.016.

Conclusion. The results confirm that there are discrepancies in assessments of IS between police and hospital records and that it is neccessary to form a common database.

Key words: traffic accident, severe injury, MAIS

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Authors´ reply to Discernment of mortality predictors in patients with major injuries-direct trauma impact or systemic complications

Dear Editor

We wanted to thank Dobrić´ s interest in the article published in your journal a few months ago (Prognosis value of lactate in prehospital care as a predictor of mortality and high patients in trauma). The main objective of the article was to assess the utility of prehospital lactic acid (PLA) in predicting mortality at 2, 7 and 30 days (1). Dr. Dobrić makes some reflections that we would like to comment. First of all, one of the elements that we do not value in our work is the cause of death or the injury mechanism, we believe that with a sample size larger than ours, conclusions could be reached on these aspects, but our work is based on assessing the association of the PLA with any cause of death and the bad prognosis globally, as well as for any lesion mechanism which also allows us to extrapolate our results to any serious trauma; on the other hand, it is worth remembering that in many cases the cause of death of these patients it is difficult to know.

However, the article we present affects the evaluation of the traumatic patient in the prehospital field in which any tool that supposes an aid for the sanitary professionals must be taken into account. In that sense, we believe that our results guarantee the use of this biomarker as an aid in decision-making regarding the prognostic assessment of these patients (2-4). Focusing on the assessment of mortality within 2 days, it is obtained that the PLA has a predictive capacity to determine mortality from any cause or mechanism of 81% (95% CI 65.5-97.1%) which gives the test a large ability to predict poor prognosis; on the other hand, a PLA greater than, or equal to 5.9 mmol / mL has an LR (+) of 5.20 (95% CI 2.60-10.39) which means that this test globally can be considered as good (5), and also has an excellent negative predictive value of 95.6% (95% CI 89.1-98.3%). In any case, as indicated in the conclusions of our study, we believe that objective and structured evaluation should be the fundamental basis for the evaluation of critical patients and. in particular. of patients with severe trauma and that decision-making should not be based on the determination of the PLA only, but on a set of elements.


  1. Martin-Rodriguez F, Lopez-Izquierdo R. Prognostic value of lactate in prehospital care as a predictor of mortality and high-risk patients with trauma. Signa vitae 2019;15(1):59-61.
  2. Parsikia A, Bones K, Kaplan M, Strain J, Leung PS, Ortiz J, et al. The predictive value of initial serum lactate in trauma patients. Shock 2014; 42(3):199-204.
  3. Baxter J. Do lactate levels in the emergency department predict outcome in adult trauma patients? A systematic review. J Trauma Acute Care Surg 2016; 81(3):555-66.
  4. Lewis CT, Naumann DN, Crombie N, Midwinter MJ. Prehospital point-of-care lactate following trauma: A systematic review. J Trauma Acute Care Surg 2016; 81(4):748-55.
  5. Aznar-Oroval A, Marcheño-Alvaro A, García_lozano T, Sánchez-Yepes M. Likelihood ratio and Fagan’s nomogram: 2 basic tools for the rational use of clinical laboratory tests. Rev Calid Asist 2013;28(6):390-1 . doi: 10.1016/j.cali.2013.04.002. Epub 2013 Jun 17

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