Efficacy and Safety of SPRINT and STAR Protocol on Malaysian Critically-ill Patients

Intensive care unit patients may have a better glycaemic management with the right control protocol. Results of virtual trial performance on Malaysian critically-ill patients adopting a model-derived and model-based control protocol known as SPRINT and STAR are presented in this paper. These ICU patients have been treated by intensive sliding-scale insulin infusion. The effectiveness and safety of glycaemic control are then analysed. Results showed that patient safety improved by 83% with SPRINT and STAR protocol as the number of hypoglycaemic patients significantly reduced (BG<;2.2 mmol/L). Percentage of time within desired bands and median BG improves in both SPRINT and STAR. However, the improvements are associated with higher number of BG measurements (workload)

Derivation of A New Bioscore for Predicting Mortality in Sepsis

Introduction: Currently, there is a lack of clinically feasible and reliable method for discriminating outcome in sepsis. We aimed to derive a new bioscore for predicting mortality in critically ill patients with sepsis using a combination of biomarkers and clinical indexes. Materials and Methods: This was a secondary analysis from a prospective study involving 159 patients with sepsis admitted to an intensive care unit (ICU). Data for key variables considered for possible inclusion in the score were collected, which included: age, sex, source of admission, comorbidities, microorganism, bacteraemia, site of infection, septic shock status, baseline Simplified Acute Physiological Score II, Sequential Organ Failure Assessment (SOFA) score (total and organ sub-scores), C-reactive protein, procalcitonin and interleukin-6 (IL-6). Approximate quintiles of each variable were given points as per the strength of their association with 30-day mortality. Results: In accordance with the statistical significance in the logistic regression analysis, the final score utilised candidate variables of age, central nervous system and liver SOFA sub-scores and IL-6. The bioscore predicted 30-day mortality with a very good performance [area under the receiver operating characteristic curve 0.814 (95% confidence interval 0.745-0.871, p&lt; 0.0001)] in our sepsis cohort. A bioscore greater than 4 predicted 30-day mortality with 80.4% sensitivity, 69.9% specificity, 2.67 positive likelihood ratio and 0.28 negative likelihood ratio. As the score increased, so did mortality rate. Conclusion: A new bioscore combining age, central nervous system and liver SOFA sub-scores and IL-6 measured on ICU admission potentially improves prediction of mortality in sepsis. Further study is warranted to prospectively validate the clinical utility of this bioscore in risk-stratifying patients with suspected sepsis

Hemorrhagic Thoracic Spinal Epidural Angiolipoma: A Case Report

Spinal epidural angiolipomas are rare benign tumors. The tumors contain both vascular and mature adipose components. Typically, they present with a progressive clinical course. Acute presentation is rare. We present a case of a fifteen-year-old girl who presented with a sudden onset of backpain followed by paraparesis with bladder and bowel incontinence. Neurological examination showed sensory loss below T10 with Grade 2 motor power. Spinal MRI showed long segment extradural lesion at T6-T9 level. Multiple laminectomy and excision of the tumor containing areas of hemorrhage was performed. Histopathology report revealed angiolipoma

Determination of favorable blood glucose target range for stochastic TARgeted (STAR) glycemic control in Malaysia

Stress-induced hyperglycemia is common in critically ill patients, but there is uncertainty about what constitutes an optimal blood glucose target range for glycemic control. Furthermore, to reduce the rate of hyperglycemic and hypoglycemic events, model-based glycemic control protocols have been introduced, such as the stochastic targeted (STAR) glycemic control protocol. This protocol has been used in the intensive care units of Christchurch and Gyulà Hospital since 2010, and in Malaysia since 2017. In this study, we analyzed the adaptability of the protocol and identified the blood glucose target range most favorable for use in the Malaysian population. Virtual simulation results are presented for two clinical cohorts: one receiving treatment by the STAR protocol itself and the other receiving intensive insulin therapy by the sliding scale method. Performance and safety were analyzed using five clinical target ranges, and best control was simulated at a target range of 6.0–10.0 mmol/L. This target range had the best balance of performance, with the lowest risk of hypoglycemia and the lowest requirement for nursing interventions. The result is encouraging as the STAR protocol is suitable to provide better and safer glycemic control while using a target range that is already widely used in Malaysian intensive care units

Prognostic utility of monocyte distribution width in critically ill patients

Background Sepsis is one of the leading causes of intensive care unit (ICU) admission and mortal- ity in Malaysia. Delayed recognition of sepsis is associated with increased morbidity and mortality. Monocyte distribution width (MDW) represents the width of a set of monocyte volume values, which increases as infection progress in severity. Its mea- surement is one of the haematologic parameter of complete blood count, hence, it does not incur added cost and is widely available. We evaluated the prognostic ac- curacy of MDW. Methods This was a prospective cohort study of 100 patients who are grouped into sepsis and non-sepsis according to the Sepsis-3 definition. This study enrolled adults, age 18 years and above, whose evaluation included a complete blood count with differ- ential upon admission to ICU. Exclusion criteria included patient refusal to join the study, readmission to ICU within 12 hours and prior study enrolment. MDW and WBC were collected on admission to ICU and for subsequent 3 days. The study had ob- tained approval from the IIUM Research Ethics Committee (Number 2020-079). Results A total of 100 patients were recruited in the study. Twenty-three patients (23%) died within 30 days of ICU admission. MDW were predictive of 30-day mortality with a cut-off point of 25.97. Patients with on admission MDW higher than this cut-off point were more likely to die with 30 days compared to those with lower value. WBC on admission and throughout 3 days were not predictive of 30-day mortality. Conclusion MDW is an effective prognosis tool of mortality upon admission to ICU. As part of the differential in CBC, MDW makes a cost effective and widely available test at present. Early prediction of death allows for risk stratification for patients admitted to the ICU

Model comparison of estimated glomerular filtration rate for acute kidney injury in intensive care unit

Acute kidney injury (AKI) is common in critically ill patients and often associated with higher mortality. It is commonly diagnosed using plasma creatinine, a fluid excreted by glomerular filtration. In this study, we analysed the highly nonlinear and complex behaviour within human systems of estimating glomerular filtration rate in critically ill patients to estimate AKI outcome by developing an application program that describes various numerical mathematical models estimated glomerular filtration rate (eGFR). The program was developed to collect numerous clinical patient data and perform computations of the governing equations that may provide clinicians with rapid estimation of GFR which allow prediction of recovery or worsening of renal function at bedside. Data collection using the application program was conducted at the intensive care unit in Kuantan, Malaysia from January to August 2016. It was found that the eGFR by CKD-EPI shows the best correlation with kinetic GFR (keGFR) equations compared to other mathematical methods for Malaysian ICU patients. It is endeavoured that more patient data would be collected using this mobile application, to develop a more accurate GFR estimation model suitable for Asian populations since creatinine based equations are often derived based on white populations

Performance of STAR virtual trials for diabetic and non-diabetic in HTAA Intensive Care Unit

Critically ill patients are commonly linked to stress-induced hyperglycaemia which relates to insulin resistance and the risk of per-diagnosed with diabetes and other metabolic illnesses. Thus, it is essential to choose the best practice of blood glucose management in order to reduce morbidity and mortality rates in intensive care unit. This study is focusing on clinical data of 210 critically ill patients in Hospital Tengku Ampuan Afzan (HTAA), Kuantan who underwent Intensive Insulin Therapy which utilized a sliding scale method. Patients were identified in two main groups of diabetic (123) and non-diabetic (87) where stochastic model is generated to observe 90% confidence interval of insulin sensitivity. Blood glucose levels comparison between these two cohorts is conducted to observe the percentage of blood glucose levels within targeted band of 4.4 – 10.0 mmol/L. It is found that 82% of BG levels are within targated band for non-diabetes cohort under stochastic targeted (STAR) glycaemic control protocol. However, only 59.6% and 70.6% BG levels are within targeted band for diabetes cohort for insulin infusion therapy used in HTAA and STAR protocols. Thus, further investigation on blood glucose control protocol for diabetes patients is required to increase the reliability and efficacy of current practice despite of patient safety

Model-based insulin-nutrition administration for glycemic control in Malaysian critical care: First pilot trial

© 2018, Springer Science+Business Media Singapore. Stress-induced hyperglycemia is prevalent in critical care, even in patients with no history of diabetes. Control of blood glucose level with tight insulin therapy has been shown to reduce incidences of hyperglycemia leading to reduced mortality and improved clinical outcomes. STAR is a tablet-based glucose control protocol with a specialized user interface into which insulin and nutrition information can be entered and predicted. This research describes the first clinical pilot trial of STAR approach in International Islamic University Hospital, Kuantan, Malaysia. The clinically specified target for blood glucose level is between 4.4 and 8.0 mmol/L. Seven episodes (of 359 h) were recruited based on the need for glucose control. Overall, 43.93% of measurement are in the range of 4.4–8.0 mmol/L band. The blood glucose median is 8.30 [6.32–10.00] mmol/L with only 1 patient having below than 2.22 mmol/L which is the guaranteed minimum risk level. This pilot study shows that STAR protocol is a patient specific approach that provides a good glycemic control in critically ill patients. Nevertheless, its implementation in Malaysian intensive care environments requires modifications and improvements in certain areas

Virtual trial of glycaemic control performance and nursing workload assessment in diabetic critically ill patients

Tight glycaemic control in critically ill patients is used to reduce mortality in intensive care units. However, its usage is debatable in reducing hypoglycaemia or accurately maintain normoglycaemia level. This paper presents the assessment for two ‘wider’ Stochastic TARgeted (STAR) glycemic controllers, namely Controller A (blood glucose (BG) target 4.4-8.0 mmol/L) and Controller B (BG target 4.4-10.0 mmol/L) with 1 to 3 hour nursing interventions. These controllers were assessed to determine the better control on diabetic and non-diabetic patients. 66 diabetic and 66 non-diabetic critically ill patient’s data from Hospital Tunku Ampuan Afzan (HTAA) were employed for virtual trial simulations with a clinically validated physiological model. Performance metrics were assessed within the percentage time in band (TIB) of 4.4 to 8.0 mmol/L, 4.4 to 10.0 mmol/L, and 6.0 to 10.0 mmol/L. Controller A shows better performance in normoglycaemic TIB of 4.4 to 10.0 mmol/L where non-diabetic and diabetic patients achieved 92.5% and 83.8% respectively. In conclusion, Controller A is higher in efficiency and safer to be used for both patients cohorts. However, higher clinical interventions in diabetic patients within this control raise the alarm to reduce nursing workload. This is believed to improve clinical interventions burnout and ensure patient’s comfortability

A study on controllable aluminium doped zinc oxide patterning by chemical etching for MEMS application

This present work reports on the study of controllable aluminium doped zinc oxide (AZO) patterning by chemical etching for MEMS application. The AZO thin film was prepared by RF magnetron sputtering as it is capable of producing uniform thin film at high deposition rates. X-Ray diffraction (XRD) and atomic force microscopy (AFM) characterization were done to characterize AZO thin film. The sputtered AZO thin film shows c-axis (002) orientation, low surface roughness and high crystalline quality. To pattern AZO thin film for MEMS application, wet etching was chosen due to its ease of processing with few controlling parameters. Four etching solutions were used namely: 10 % Nitric acid, 10 % Phosphoric acid, 10 % Acetic acid and Molybdenum etch solutions. For the first time, chemical etching using Molybdenum etch that consist of a mixture of CH3COOH, HNO3 and H3PO4 was characterized and reported. The effect of these acidic solutions on the undercut etching, vertical and lateral etch rate were studied. The etched AZO were characterized by scanning electron microscopy (SEM) and stylus profilometer. The investigations showed that the Molybdenum etch has the lowest undercut etching of 7.11 µm, and is highly effective in terms of lateral and vertical etching with an etch ratio of 1.30. Successful fine patterning of AZO thin films was demonstrated at device level on a surface acoustic wave resonator fabricated in 0.35 μm CMOS technology. The AZO thin film acts as the piezoelectric thin film for acoustic wave generation. Patterning of the AZO thin film is necessary for access to measurement probe pads. The working acoustic resonator showed resonance peak at 1.044 GHz at 45.28 dB insertion loss indicating that the proposed Molybdenum etch method does not adversely affect the device’s operating characteristic