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R J Gemke

Publications and source records attributed to R J Gemke.

34 records · Page 2Linked to original sources
PubMed1997

Health status prediction in critically ill children: a pilot study introducing Standardized Health Ratios.

Performance of intensive care is usually quantified by means of standardized mortality rates, where standardization is directed towards the severity of illness on admission. However, as more critically ill patients survive, functional outcome and quality of life of these patients becomes more important. In a prospective study in a 10-bed tertiary paediatric intensive care unit (ICU), admission and follow-up health status were collected for 209 surviving patients. For this cohort of patients, health status 1 year after admission was also predicted, using the quantified health-utility-index (HUI), as a value between 0 and 1. For this purpose, two alternative multiple regression models were constructed. The most important predictors of 1-year health status were the level of sensation, mobility and cognition on admission to which self-care, systolic blood pressure, oxygen, Glascow Coma Scale, glucose and age may be added. The two alternative predictive models performed equally well (R2 = 0.83 and 0.84 respectively), indicating that health status could be predicted to a significant degree. The concept of relating expected future health status (based on base-line health status), with actual (observed) health status is denoted with the Standardized Health Ratio (SHR). In combination with the Standardized Mortality Ratios (SMR), such a ratio may become a new comprehensive indicator of performance in intensive care medicine.

Adolescent↗
PubMed1996

Reliability and validity of a comprehensive health status measure in a heterogeneous population of children admitted to intensive care.

This study assesses psychometric and empirical characteristics of the Multi-Attribute Health Status Classification (MAHSC) in a heterogeneous population of children admitted to intensive care. The MAHSC encompasses six health domains (sensation, mobility, emotion, cognition, self-care, and pain), each with four or five hierarchic levels of dysfunction. The health status of 254 consecutively admitted children was determined independently by 3 different observers (parents, attending clinicians, and investigators). The proportion of children with health impairment varied between 13% (in sensation) and 58.7% (in mobility). Interrater reliability of domain scores, as analyzed by Spearman's rank, Pearson product moment, and intraclass correlations, was high, generally exceeding 0.80 for all pairs of observers. Intraclass correlation appeared to be highest in nonsurgical patients (range, 0.89-0.98) and lowest in cardiovascular surgery patients (range, 0.50-0.84). The validity of the classification was supported by (1) the presence of expected specific health status impairment in patient suffering from diseases with an acknowledged impact on specific domains and (2) the presence of a relation between health impairment and medical consumption. The absence of a relation between the average (chronic) health status preceding admission and the acute risk of mortality precipitating the admission confirmed their independent prominence in outcome assessment. We conclude that the MAHSC is a feasible, reliable, and valid measure for outcome assessment in a heterogeneous population of children within a demanding clinical situation. Excellent interrater reliability allows the use of various raters, adjusted to practical requirements.

Adolescent↗
PubMed1995

Comparative assessment of pediatric intensive care: a national multicenter study. Pediatric Intensive Care Assessment of Outcome (PICASSO) Study Group.

OBJECTIVE: Comparative assessment of performance of pediatric intensive care. DESIGN: Open, prospective multicenter study. SETTING: All pediatric intensive care units (n = 10; six tertiary and four nontertiary) in the Netherlands. PATIENTS: 1063 consecutive unselected admissions, < or = 18 yrs old, during a 4-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Effectiveness was defined as the ratio of observed to expected (Pediatric Risk of Mortality-score-derived) mortality. Efficiency was determined by two objective criteria: mortality risk of > 1%, or administration of at least one intensive care unit (ICU)-dependent therapy. In the total population, observed and expected mortality rates were similar. Between hospitals, crude mortality showed wide variations (mean 7.1%, range 1% to 10%). However, in each center, observed and expected mortality rates were similar (mean ratio of observed/expected mortality 0.99, range 0.8 to 1.5). In tertiary care centers, severity of illness-corrected mortality rates in high-risk patients were less than in a United States reference population. Paradoxically, in low-risk tertiary care patients, the observed mortality rate was higher than expected. The relatively high mortality rate in this group is probably the result of the large number of low-risk tertiary care patients suffering from severe, incurable chronic disease. The average number of efficient ICU days was 72%, although large fluctuations between units were found (range 22% to 95%), suggesting that in several centers efficiency rates might be improved by a better selection of high-risk patients requiring ICU-dependent therapies. CONCLUSIONS: Differences in mortality rates among pediatric ICUs were largely explained by differences in severity of illness. High efficiency rates combined with adequate effectiveness were found in several centers, indicating that admission and discharge decisions might be improved in less efficient centers.

Child, Preschool↗
PubMed1995

Long-term survival and state of health after paediatric intensive care.

Survival and state of health were assessed one year after discharge in 468 children admitted to an intensive care unit (ICU). ICU mortality was 7.5%, cumulative hospital mortality 8.3%, and one year mortality 10.5%. An established six domain health status classification was used, comprising sensation, mobility, emotion, cognition, self care, and pain to determine the presence, type, and severity of chronic health impairment. This classification has not been validated for infants, who were therefore excluded. After one year, of the 254 patients eligible for analysis, 80 (31.5%) had no overall health impairment (no affected domains) preceding admission; of these, 11 had died in ICU and 69 were long-term survivors, among whom 45 recovered to perfect health. There was overall health impairment (> or = 1 affected domain) preceding admission in 174 of 254 patients (68.5%). However, after one year, overall state of health was improved or equal to the preadmission state in 164 of 226 survivors (72.6%). In domain-specific health, the proportion improving or remaining unchanged varied from 77.9% (emotional functions) to 89.4% (mobility and pain). Consequently, despite the large number with health impairment before admission, cumulative one year survival was favourable and health status in three quarters of the population was preserved.

Child↗
PubMed1994

[Submersion in children; the role of hypothermia and development of adult respiratory distress syndrome].

OBJECTIVE: To evaluate the occurrence of the adult respiratory distress syndrome (ARDS), and of hypothermia as a predictor of outcome in cases of submersion injury in children. DESIGN: Retrospective analysis. PATIENTS: All drowning cases admitted to the Intensive Care Unit of the Wilhelmina Children's Hospital in Utrecht between January 1986 and January 1993. RESULTS: There were 45 patients, 29 boys and 16 girls, aged 0-13 years. Hypothermia was related to the duration of submersion and did not correlate with a good outcome. Asystole on arrival at the hospital was associated with demise in all but one patient, who was left with severe neurological impairment. ARDS occurred in 27/45 patients (60%), all within 6 h following admission. Of the 45 patients treated, 11 died. Of the 34 survivors, 7 were discharged from the Intensive Care Unit with neurological sequelae (2 with mild, 5 with serious sequelae). CONCLUSION: In our patients with drowning accidents, hypothermia did not appear to provide any protective effect. ARDS, if it occurred, became evident within 6 h after admission.

Adolescent↗
PubMed1994

Effectiveness and efficiency of a Dutch pediatric intensive care unit: validity and application of the Pediatric Risk of Mortality score.

OBJECTIVE: To assess the performance of pediatric intensive care by an international standard. DESIGN: Prospective, cohort study. SETTING: Nine-bed multidisciplinary pediatric intensive care unit (ICU) within a 174-bed, tertiary care children's hospital. PATIENTS: Consecutive, unselected patients (n = 612) during a 16-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Collected data included age, major diagnostic category, primary clinical specialty, severity of illness (daily Pediatric Risk of Mortality [PRISM] score), administration of ICU-dependent therapy (daily), and vital status at discharge. The PRISM score allowed the calculation of overall and daily mortality risk. After testing the applicability of the predictive model, effectiveness was determined by comparing severity of illness-based predicted mortality rate with vital status at discharge. Efficiency was defined by two criteria: a) the administration of at least one ICU-dependent therapy; or b) a mortality risk of > 1%. Five-hundred ninety-three patients were included (19 survivors were excluded because of incomplete data). Mean age was 55.0 months (median 24). Mean length of stay was 4.4 days (median 2). Overall ICU mortality rate was 8.4%. The overall performance of the PRISM score-based predictive model was found to be good (goodness-of-fit test chi 2[5] = 5.49; p = .35; area under receiver operating characteristic curve 0.92). Subgroup analysis showed that the best model performance was in nonoperative patients. Decreased performance was found in operative patients. In cardiovascular patients, the mortality rate was higher. In other surgical patients, the mortality rate was lower than expected. Of 593 patients, 489 (82.5%) admissions were efficient, as were 2,393 (76.5%) of 3,130 patient days in the ICU. The ranking of daily efficiency according to clinical specialty was as follows: postoperative cardiovascular surgical patients (86.3%); nonsurgical patients (76.6%); and other postoperative patients (49.6%). CONCLUSIONS: In our setting, effectiveness and efficiency of pediatric intensive care appeared to be validly determined using explicit criteria (mortality risk, administration of ICU-dependent therapy). Overall effectiveness met the standard set forth in an American study; validity in stratified analysis of diagnostic subgroups remains to be further established. Efficiency showed marked, specialty-related differences. The low efficiency in other (noncardiovascular) surgical patients was probably caused by the recovery function of the ICU. A more general application of these criteria might be considered in modifying admission and discharge policy, as well as in quality control.

Child↗
PubMed1994

Patient characteristics and resource utilisation in paediatric intensive care.

To determine the relation between basic clinical characteristics and resource utilisation in paediatric intensive care, an open prospective study was performed. Resource utilisation was expressed using the therapeutic intervention score system (TISS) and length of stay (LOS), from which total resource utilisation per admission (TISSTOT) and average daily resource utilisation (TISSMEAN = TISSTOT/LOS) were obtained. Overall 593 admissions, totalling 3130 days, were included. Mortality was 8.4% and non-survivors accounted for 14.1% of overall resource utilisation. In non-survivors, TISSTOT and TISSMEAN were higher, whereas LOS was not different from survivors'. Severity of illness, surgical status, significant chronic comorbidity, emergency admission, and transfer status constituted the major predictive determinants of TISSTOT (r2 = 0.19) and TISSMEAN (r2 = 0.45) in multiple regression analysis. High resource utilisation in high risk patients was probably warranted, as effectiveness of prolonged intensive treatment was demonstrated. It is concluded that TISSTOT and TISSMEAN are appropriate, non-monetary measures of resource utilisation, a considerable proportion of which are determined by a concise set of basic clinical characteristics.

Analysis of Variance↗
PubMed1991

[Shock in children; no child's play].

Shock comprises of circulatory insufficiency accompanied by a discrepancy between oxygen demand and supply at tissue level. This results in tissue hypoxia, which when persisting, can lead to (severe) organ failure. In this article we will discuss pathophysiologic backgrounds of shock following the mechanisms that cause hemodynamic deterioration and tissue hypoxia. Subsequently the role of various cytokines in the pathogenesis of septic shock, which occurs relatively frequent in childhood, are discussed. As far as fluid substitution and vasoactive medication is concerned, therapeutic strategies can be chosen more rationally these days. This is mainly due to the availability of smaller i.v. cannula, central venous catheters and advances in (non) invasive hemodynamic measurements in childhood e.g. central venous pressure, cardiac output, peripheral vascular resistance and left ventricular shortening fraction. Despite these developments, shock (in particular septic shock) remains to have a high mortality, also in childhood.

Child↗
PubMed1990

[Congenital laryngeal stenosis; a rare cause of dyspnea in the newborn infant].

Congenital laryngeal obstruction is a rare but serious cause of severe, often fatal, post partum asphyxia. The condition should be recognized and in most cases an artificial airway has to be established immediately because hypoxia allows little time for extensive evaluation. Thereafter a further diagnostic procedure by means of laryngobronchoscopy and contrast laryngography should be performed. The clinical picture of two cases with a congenital laryngeal stenosis is described and the initial therapeutic approach is discussed.

Abnormalities, Multiple↗
PubMed1989

[Prenatal fetal blood group determination using chorionic villi biopsy].

The presence or absence of Rhesus D, c and Kell antigens on foetal red blood cells was determined in the first trimester of pregnancy on erythrocytes obtained by chorionic villi sampling. Pregnancies in 15 severely sensitized women (9 Rh D, 5 Kell and I Rh c) with a poor obstetric history and a partner heterozygous for the offending antigen were examined. A conclusive diagnosis could be made in 13 of the 15 cases studied.

Blood Group Antigens↗
PubMed1989

Early onset agammaglobulinaemia with monoclonal IgG production.

Two patients are described with X-linked agammaglobulinaemia (XLA). After a period of gammaglobulin infusions endogenous IgG production appeared to resume and gammaglobulin therapy was gradually stopped. However, bacterial respiratory tract infections recurred. Immunological evaluation showed normal levels of serum IgG with mono/oligoclonal IgG m-bands, while B lymphocytes and plasma cells were absent from the peripheral blood and bone marrow. Endogenous IgG was synthesized in plasma cells in the submucosa of the gastrointestinal tract. Renewed high doses of exogenous gammaglobulin led to the reduction of infections and the disappearance of mono/oligoclonal m-bands in the serum. We suggest that as a rare complication of XLA some pre-B-cells may escape the blockade to B-cell maturation and produce mono/oligoclonal IgG, possibly due to chronic infectious stimulation.

Agammaglobulinemia↗
PubMed1987

Fetal blood group determination in first-trimester pregnancy for the management of severe immunization.

The presence or absence of Rho (D) and Kell antigens on fetal red blood cells was determined in the first trimester of pregnancy on erythrocytes obtained by chorionic villi sampling with the use of mixed agglutination and solid phase microimmunofluorescence techniques. Pregnancies in one Kell-sensitized woman and seven severely RH-sensitized women with a poor obstetric history and a partner heterozygous for the offending antigen were examined. A conclusive diagnosis could be made in seven of the eight cases studied.

Blood Grouping and Crossmatching↗
PubMed1987

Sensitive methods for determining subclasses of IgG anti-A and anti-B in sera of blood-group-O women with a blood-group-A or -B child.

The determination of the subclasses of IgG antibodies against blood groups A and B is important in order to improve our understanding and predict haemolytic disease of the newborn due to IgG anti-A or -B. We describe two techniques that circumvent the problem of the agglutination of A and B red cells by the corresponding IgG antibodies in saline: an antiglobulin consumption test and a modified solid-phase micro-immunofluorescence test. The results of the two techniques are compared with the results obtained in the indirect antiglobulin test beyond the saline agglutination titre in a microplate technique. The solid-phase micro-immunofluorescence test was the most sensitive for the determination of the subclasses of IgG anti-A and -B. Usually sera contained IgG2 anti-A, B in a higher titre than antibodies of other subclasses.

ABO Blood-Group System↗
PubMed1986

ABO and Rhesus phenotyping of fetal erythrocytes in the first trimester of pregnancy.

Determination of fetal red blood cell antigens in early pregnancy can be important in cases with a history of severe haemolytic disease of the newborn. From chorionic villus biopsies (CVB) between the 8th and 12th week of gestation a small number of fetal red blood cells was obtained, inevitably highly contaminated with maternal blood cells. Two techniques were used to demonstrate the minor (fetal) cell population with a blood group antigen differing from the major (maternal) cell population: a solid-phase microfluorescence technique (introduced in this paper) which was compared with the mixed agglutination technique. In series of artificial mixtures of erythrocytes it was shown that with the microfluorescence technique the ABO and Rhesus phenotypes of minor cell populations could be determined at a ratio of 1 in 4000 erythrocytes of the major population, making this technique 4 times as sensitive as the mixed agglutination technique. We further investigated the reliability of the microfluorescence technique to demonstrate antagonistic fetal blood groups in the first trimester of pregnancy. Of 18 women undergoing CVB prior to therapeutic abortion, blood group antagonism (ABO and Rhesus systems) was demonstrate in all 11 cases in which it was present. Therefore, it seems that CVB can be reliably used for the prenatal diagnosis of (recurrent) blood group antagonism.

ABO Blood-Group System↗