There is a trend towards increasing the proportion of single rooms in new hospital builds. Coupled with the competing clinical demands for single room care, this study highlights the complexity of nursing decision-making about patient allocation to single rooms, an issue urgently requiring further attention.

No abstract

Critically ill patients with severe sepsis who had elevated troponin had increased hospital and intensive care mortality. However, cardiac troponin I did not independently predict hospital mortality.

SUMMARY. We have compared measurement of cardiac troponin T by enzyme linked immunosorbent assay with creatine kinase MB isoenzyme (CK-MB) concentration measurement in 219 Royal Marine commandos with no evidence of cardiovascular disease who have elevated creatine kinase (CK) produced by arduous physical training. CK was elevated up to 22.6 times and CK-MB mass up to 6.6 times the upper reference limit. Only two commandos had detectable cardiac troponin T, with neither exceeding the upper reference limit of 0.2 /lg/L. At decision thresholds optimized for diagnosis of acute myocardial infarction in previous published work, 58.3070 of the total CK activity, 13.8% of the CK-MB concentration/CK activity ratio and 1.6% of CK-MB concentration measurements showed elevated values but no elevations in cardiac troponin T occurred. Cardiac troponin T is currently the investigation of choice for the differential diagnosis of patients with an elevated CK due to skeletal muscle trauma to exclude myocardial damage. Additional key phrases: CK-MB mass; myocardial infarction; cardiac enzymes; relative index; skeletal muscle traumaThe differential diagnosis in patients presenting with chest pain where there may be skeletal muscle trauma creates a problem for the laboratory. A range of approaches have been suggested including creatine kinase (CK) isoenzyme separation, creatine kinase MB (CK-MB) isoenzyme/total CK activity ratio, 1 CK-MB concentration measurement and CK-MB mass/total CK activity ratio.? We have compared the diagnostic performance of proposed strategies for the differentiation of skeletal and cardiac muscle damage with measurement of cardiac troponin T (cTnT) in the situation of extreme elevation of CK due to arduous physical training. METHODSRoyal Marine recruits were studied during commando training. All had been pre-screened Correspondence: Dr P 0 Collinson. 450by full physical examination and electrocardiography both at entry, following basic training and during the training programme. None had any cardiac symptoms at any time.Two hundred and nineteen men were examined, age range 18 to 26 years, median 20.8 years, in four troops (training cohorts). Serial blood samples were obtained from individuals during training at I, 12, 19, 24 and 29 weeks. Serum was separated and stored at -70 DC prior to estimation for aspartate transaminase activity (AST), CK activity, CK-MB concentration and cTnT.AST and CK were measured on all samples. Samples for further study were selected from those periods of training corresponding to maximal physical exertion. One hundred and twenty-nine samples were selected at week 24 and 106 at week 29. On week 29 samples were taken following one of the final qualification assignments. This comprised a 30 mile route march, in full webbing, carrying a 40lb (18 kg) pack,

T he issue of glucose control for seriously ill patients in the intensive care unit (ICU) is a subject of controversy. Some studies showed improved outcomes with tight glycemic control, but others reported worse outcomes. Still others have focused on blood glucose amplitude variability (BGAV), hypothesizing that increased fluctuation of glucose levels would be associated with increased mortality. The most common measure of variability was SD, although some studies used the presence of both hypoglycemia and hyperglycemia. The Dutch National Intensive Care Evaluation registry uses glucose regulation as 1 of 11 indicators of quality of care in the ICU. All glucose values of all admitted patients are collected prospectively, which permits analysis of the relationship between BGAV and mortality. This cohort study was designed to test the hypothesis that BGAV is independently associated with hospital mortality in medical and surgical ICU patients.Patients had 24 or more hours of stay in the ICU and had 3 or more glucose measurements. Most Dutch ICUs use nursedirected insulin dosing regimens with serum glucose targets between 4.4 and 8.0 mmol/L. The SD was used as the measurement of BGAV. In addition, the mean amplitude of glycemic excursions (MAGE) was used and defined as the mean of the absolute values of any $ glucose from consecutive measurements that were higher than the SD of the entire set of glucose values. The mean absolute glucose change per hour (MAG) was defined as the sum of all absolute glucose changes divided by the time in hours. Glycemic lability index (GLI) was also determined and depends on the order and timing of the glucose measurements. The primary outcome was hospital mortality.From 20,375 patients admitted to 37 ICUs, 855,032 glucose measurements were available for analysis. Median patient age was 67 years; median APACHE IV (Acute Physiology and Chronic Health Evaluation IV) expected mortality rate was 15%; 52% of patients were medical; median glucose level was 7.3 mmol/L, and median SD was 1.73 mmol/L; 78% of patients survived. In the combined cohort of all patients, adjusted hospital mortality was associated with SD (P G 0.0001) of glucose levels and MAGE (P G 0.0012) but not with MAG (P = 0.92) and GLI (P = 0.53). In surgical patients, adjusted hospital mortality was associated with the SD (P G 0.0001), MAGE (P G 0.0001), and MAG (P = 0.04), but not with GLI (P = 0.17). In medical ICU patients, adjusted mortality was associated with SD (P G 0.0001), but not with the other assessed measures of BGAV (MAGE, MAG, GLI [P = 0.61, 0.36, 0.77, respectively]).The association between BGAV and mortality depends on the measure of BGAV and the patient population, whether surgical or medical. Glycemic lability index was not associated with mortality in either type of ICU admission. Most studies, including this one, have found SD to be an independent predictor of mortality. The presence of hypoglycemia or hyperglycemia was associated with hospital mortality, but this measure depends on only the 2 most extre...