血清D-二聚体、尿素氮与肌酐比值联合C反应蛋白与白蛋白比值对重症肺炎患者院内死亡的评估价值

摘要 目的：探讨血清D-二聚体（D-D）、尿素氮与肌酐比值（UCR）联合C反应蛋白与白蛋白比值（CAR）对重症肺炎（SP）患者院内死亡的评估价值。方法：选取2019年6月～2022年6月我院收治的101例SP患者,根据是否发生院内死亡分为死亡组和存活组。检测血清D-D和计算UCR、CAR。分析SP患者院内死亡的影响因素,受试者工作特征（ROC）曲线分析血清D-D、UCR、CAR对SP患者院内死亡的评估价值。结果：101例SP患者院内死亡率40.59％（41/101）。死亡组血清D-D、UCR、CAR高于存活组（P均＜0.05）。多因素Logistic回归分析显示,年龄增加、肺外并发症≥2个和D-D、UCR、CAR升高为SP患者院内死亡的独立危险因素（P均＜0.05）。ROC曲线分析显示,血清D-D、UCR、CAR单独与联合评估SP患者院内死亡的曲线下面积分别为0.781、0.798、0.793、0.929,血清D-D、UCR联合CAR评估SP患者院内死亡的AUC大于各指标单独评估。结论：血清D-D、UCR、CAR升高为SP患者院内死亡的独立危险因素,D-D、UCR联合CAR对SP患者院内死亡的评估价值较高。     

Risk Factors for Fatality among Confirmed Adult Dengue Inpatients in Singapore: A Matched Case-Control Study

Objectives

To identify demographic, clinical and laboratory risk factors for death due to dengue fever in adult patients in Singapore.

Methods

Multi-center retrospective study of hospitalized adult patients with confirmed dengue fever in Singapore between 1 January 2004 and 31 December 2008. Non-fatal controls were selected by matching age and year of infection with fatal cases. World Health Organization 1997, 2009 criteria were applied to define dengue hemorrhagic fever (DHF), warning signs and severe dengue. Statistical significance was assessed by conditional logistic regression modeling.

Results

Significantly more fatal cases than matched controls had pre-existing co-morbid conditions, and presented with abdominal pain/tenderness. Median pulse rates were significantly higher while myalgia was significantly less frequent in cases. . Fatal cases also had higher leucocyte counts, platelet counts, serum sodium, potassium, urea, creatine and bilirubin levels on admission compared to controls. There was no statistical significant difference between the prevalence of DHF and hematocrit level among cases and controls. Multivariate analysis showed myalgia and leucocyte count at presentation were independent predictors of fatality (adjusted odds ratios 0.09 and 2.94 respectively). None of the controls was admitted to intensive care unit (ICU) or given blood transfusion, while 71.4% and 28.6% of fatal cases received ICU admission and blood transfusion.

Conclusions

Absence of myalgia and leucocytosis on admission were independently associated with fatality in our matched case-control study. Fatalities were also commonly associated with co-morbidities and clinicians should be alarmed if dengue patients fulfilled severe dengue case definition on admission.     

Lower Low-Density Lipoprotein Cholesterol Levels Are Associated with Severe Dengue Outcome

Dengue virus (DENV) is a flavivirus of worldwide importance, with approximately 4 billion people across 128 countries at risk of infection, and up to 390 million infections and 96 million clinically apparent cases estimated annually. Previous in vitro studies have shown that lipids and lipoproteins play a role in modifying virus infectivity. However, the relationship between development of severe dengue and total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C), respectively, is unclear. We analyzed data from 789 laboratory-confirmed dengue cases and 447 other febrile illnesses (OFI) in a prospective pediatric hospital-based study in Managua, Nicaragua between August 2005 and January 2013, using three different classifications of dengue severity: World Health Organization (WHO) 1997, WHO 2009, and standardized intervention categories. Total serum cholesterol and LDL-C levels decreased over the course of illness and were generally lower with increasing dengue severity, regardless of classification scheme. Greater decreases in LDL-C than HDL-C were observed among dengue-positive patients compared to patients with OFI and among severe dengue compared to mild dengue cases. Furthermore, daily cholesterol levels declined with daily albumin blood levels. To examine the effect of cholesterol at presentation on subsequent risk of development of severe dengue, relative risks and 95% confidence intervals were calculated using multivariable modified Poisson models. We found that lower total serum cholesterol and LDL-C levels at presentation were associated with subsequent risk of developing dengue hemorrhagic fever/dengue shock syndrome using the WHO 1997 dengue severity classification, and thus that the reduction in LDL-C is likely driving the decreases observed in total serum cholesterol levels among dengue-positive patients. Our results suggest that cholesterol blood levels are important correlates of dengue pathophysiology and should be explored as part of a prognostic biomarker panel for severe dengue.     

Revisiting Unplanned Endotracheal Extubation and Disease Severity in Intensive Care Units

Most reports regarding unplanned extubation (UE) are case-control studies with matching age and disease severity. To avoid diminishing differences in matched factors, this study with only matching duration of mechanical ventilation aimed to re-examine the risk factors and the factors governing outcomes of UE in intensive care units (ICUs). This case-control study was conducted on 1,775 subjects intubated for mechanical ventilation. Thirty-seven (2.1%) subjects with UE were identified, and 156 non-UE subjects were randomly selected as the control group. Demographic data, acute Physiological and Chronic Health Evaluation II (APACHE II) scores, and outcomes of UE were compared between the two groups. Logistic regression analysis was used to identify the risk factors of UE. Milder disease, younger age, and higher Glasgow Coma Scale (GCS) scores with more frequently being physically restrained (all p<0.05) were related to UE. Logistic regression revealed that APACHE II score (odds ratio (OR) 0.91, p<0.01), respiratory infection (OR 0.24, p<0.01), physical restraint (OR 5.36, p<0.001), and certain specific diseases (OR 3.79–5.62, p<0.05) were related to UE. The UE patients had a lower ICU mortality rate (p<0.01) and a trend of lower in-hospital mortality rate (p = 0.08). Cox regression analysis revealed that in-hospital mortality was associated with APACHE II score, age, shock, and oxygen used, all of which were co-linear, but not UE. The results showed that milder disease with higher GCS scores thereby requiring a higher use of physical restraints were related to UE. Disease severity but not UE was associated with in-hospital mortality.     

Endothelial adhesion molecules and multiple organ failure in patients with severe sepsis

ObjectiveTo determine if serum levels of endothelial adhesion molecules were associated with the development of multiple organ failure (MOF) and in-hospital mortality in adult patients with severe sepsis.DesignThis study was a secondary data analysis of a prospective cohort study.SettingPatients were admitted to two tertiary intensive care units in San Antonio, TX, between 2007 and 2012.PatientsPatients with severe sepsis at the time of intensive care unit (ICU) admission were enrolled. Inclusion criteria were consistent with previously published criteria for severe sepsis or septic shock in adults. Exclusion criteria included immunosuppressive medications or conditions.InterventionsNone.MeasurementsBaseline serum levels of the following endothelial cell adhesion molecules were measured within the first 72 h of ICU admission: Intracellular Adhesion Molecule 1 (ICAM-1), Vascular Cell Adhesion Molecule-1 (VCAM-1), and Vascular Endothelial Growth Factor (VEGF). The primary and secondary outcomes were development of MOF (⩾2 organ dysfunction) and in-hospital mortality, respectively.Main resultsForty-eight patients were enrolled in this study, of which 29 (60%) developed MOF. Patients that developed MOF had higher levels of VCAM-1 (p = 0.01) and ICAM-1 (p = 0.01), but not VEGF (p = 0.70) compared with patients without MOF (single organ failure only). The area under the curve (AUC) to predict MOF according to VCAM-1, ICAM-1 and VEGF was 0.71, 0.73, and 0.54, respectively. Only increased VCAM-1 levels were associated with in-hospital mortality (p = 0.03). These associations were maintained even after adjusting for APACHE and SOFA scores using logistic regression.ConclusionsHigh levels of serum ICAM-1 was associated with the development of MOF. High levels of VCAM-1 was associated with both MOF and in-hospital mortality.     

An Economic Evaluation of Venous Thromboembolism Prophylaxis Strategies in Critically Ill Trauma Patients at Risk of Bleeding

Background

Critically ill trauma patients with severe injuries are at high risk for venous thromboembolism (VTE) and bleeding simultaneously. Currently, the optimal VTE prophylaxis strategy is unknown for trauma patients with a contraindication to pharmacological prophylaxis because of a risk of bleeding.

Methods and Findings

Using decision analysis, we estimated the cost effectiveness of three VTE prophylaxis strategies—pneumatic compression devices (PCDs) and expectant management alone, serial Doppler ultrasound (SDU) screening, and prophylactic insertion of a vena cava filter (VCF)—in trauma patients admitted to an intensive care unit (ICU) with severe injuries who were believed to have a contraindication to pharmacological prophylaxis for up to two weeks because of a risk of major bleeding. Data on the probability of deep vein thrombosis (DVT) and pulmonary embolism (PE), and on the effectiveness of the prophylactic strategies, were taken from observational and randomized controlled studies. The probabilities of in-hospital death, ICU and hospital discharge rates, and resource use were taken from a population-based cohort of trauma patients with severe injuries (injury severity scores >12) admitted to the ICU of a regional trauma centre. The incidence of DVT at 12 weeks was similar for the PCD (14.9%) and SDU (15.0%) strategies, but higher for the VCF (25.7%) strategy. Conversely, the incidence of PE at 12 weeks was highest in the PCD strategy (2.9%), followed by the SDU (1.5%) and VCF (0.3%) strategies. Expected mortality and quality-adjusted life years were nearly identical for all three management strategies. Expected health care costs at 12 weeks were Can$55,831 for the PCD strategy, Can$55,334 for the SDU screening strategy, and Can$57,377 for the VCF strategy, with similar trends noted over a lifetime analysis.

Conclusions

The attributable mortality due to PE in trauma patients with severe injuries is low relative to other causes of mortality. Prophylactic placement of VCF in patients at high risk of VTE who cannot receive pharmacological prophylaxis is expensive and associated with an increased risk of DVT. Compared to the other strategies, SDU screening was associated with better clinical outcomes and lower costs. Please see later in the article for Editors'' Summary     

探讨NTIS在ICU重症患者的预后影响

目的：观察NTIS在ICU重症患者中的发病情况,及对病情的预后。方法：2010年1月到2010年3月,收集上海交通大学附属第六人民医院重症监护病房ICU收治的患者共161例。根据甲状腺功能情况分组。记录其年龄、性别、血糖、血白蛋白、肝肾功能、电解质、白细胞、血气、心率、血压等,统计有创呼吸机的使用率、使用天数、APACHEII评分、ICU住院天数和住院期间的死亡率,分析相关的影响因素。结果：161例入住ICU的重症患者中74例伴有NTIS（45.96%）,血清游离三碘甲状腺原氨酸（FT3）水平是ICU住院时间的独立影响因素,低T3与住院期间死亡率明显相关,是主要死亡危险因子;NTIS患者较正常甲状腺患者死亡风险增加2.93倍（95%CI,1.052～8.182）。结论：低T3在重症疾病患者中发病常见,与住院期间死亡率明显相关,对于预测患者病情的严重程度和预后有重要的价值。     

Risk of severe outcomes among patients admitted to hospital with pandemic (H1N1) influenza

Background

We describe the disease characteristics and outcomes, including risk factors for admission to intensive care unit (ICU) and death, of all patients in Canada admitted to hospital with pandemic (H1N1) influenza during the first five months of the pandemic.

Methods

We obtained data for all patients admitted to hospital with laboratory-confirmed pandemic (H1N1) influenza reported to the Public Health Agency of Canada from Apr. 26 to Sept. 26, 2009. We compared inpatients who had nonsevere disease with those who had severe disease, as indicated by admission to ICU or death.

Results

A total of 1479 patients were admitted to hospital with confirmed pandemic (H1N1) influenza during the study period. Of these, 1171 (79.2%) did not have a severe outcome, 236 (16.0%) were admitted to ICU and survived, and 72 (4.9%) died. The median age was 23 years for all of the patients, 18 years for those with a nonsevere outcome, 34 years for those admitted to ICU who survived and 51 years for those who died. The risk of a severe outcome was elevated among those who had an underlying medical condition and those 20 years of age and older. A delay of one day in the median time between the onset of symptoms and admission to hospital increased the risk of death by 5.5%. The risk of a severe outcome remained relatively constant over the five-month period.

Interpretation

The population-based incidence of admission to hospital with laboratory-confirmed pandemic (H1N1) influenza was low in the first five months of the pandemic in Canada. The risk of a severe outcome was associated with the presence of one or more underlying medical conditions, age of 20 years or more and a delay in hospital admission.The first cases of pandemic (H1N1) influenza in Canada were reported on Apr. 26, 2009. Retrospective case-finding determined that the onset of symptoms in the first Canadian case, involving a traveller returning from Mexico, occurred on Apr. 12, 2009. The first patient admitted to hospital began to experience symptoms on Apr. 18.During the first few weeks of the outbreak, in-depth follow-up and reporting of cases was conducted in keeping with the World Health Organization’s pandemic plans for each country to comprehensively assess its first 100 cases.¹ By mid-May, many Canadian jurisdictions moved away from this approach because it became increasingly taxing on both public health human resources and laboratory capacity. It was decided that reporting of individual cases would continue nationally only for patients who were admitted to hospital or who died. We provide a detailed review of the disease characteristics and outcomes, including risk factors for admission to intensive care unit (ICU) and death, of patients admitted to hospital in Canada during the first five months of the pandemic.     

Risk Models and Scoring Systems for Predicting the Prognosis in Critically Ill Cirrhotic Patients with Acute Kidney Injury: A Prospective Validation Study

Background

Cirrhotic patients with acute kidney injury (AKI) admitted to intensive care units (ICUs) show extremely high mortality rates. We have proposed the MBRS scoring system, which can be used for assessing patients on the day of admission to the ICU; this new system involves determination of mean arterial pressure (MAP) and bilirubin level and assessment of respiratory failure and sepsis. We had used this scoring system to analyze the prognosis of ICU cirrhotic patients with AKI in 2008, and the current study was an external validation of this scoring system.

Methods

A total of 190 cirrhotic patients with AKI were admitted to the ICU between March 2008 and February 2011. We prospectively analyzed and recorded the data for 31 demographic parameters and some clinical characteristic variables on day 1 of admission to the ICU; these variables were considered as predictors of mortality.

Results

The overall in-hospital mortality rate was 73.2% (139/190), and the 6-month mortality rate was 83.2% (158/190). Hepatitis B viral infection (43%) was observed to be the cause of liver disease in most of the patients. Multiple logistic regression analysis indicated that the MBRS and Acute Physiology and Chronic Health Evaluation III (ACPACHE III) scores determined on the first day of admission to the ICU were independent predictors of in-hospital mortality in patients. In the analysis of the area under the receiver operating characteristic (AUROC) curves, the MBRS scores showed good discrimination (AUROC: 0.863±0.032, p<0.001) in predicting in-hospital mortality.

Conclusion

On the basis of the results of this external validation, we conclude that the MBRS scoring system is a reproducible, simple, easy-to-apply evaluation tool that can increase the prediction accuracy of short-term prognosis in critically ill cirrhotic patients with AKI.     

影响急性重症胰腺炎患者死亡的危险因素分析

目的:分析影响急性重症胰腺炎患者死亡的危险因素,为临床防治提供依据。方法:回顾性分析我院2014年11月至2018年10月收治的101例急性重症胰腺炎患者临床资料,根据其治疗结局将其分为生存组(好转出院)82例和死亡组(住院期间死亡)19例,分析影响急性重症胰腺炎患者死亡的危险因素。结果:单因素分析显示:死亡组Ranson评分、急性生理与慢性健康评分(APACHE-II)、CT严重指数(CTSI)、病因、血钙(Ca)、血清白蛋白(ALB)、血糖、血肌酐(Cr)、血尿素氮(BUN)、谷草转氨酶(AST)、上消化道出血发生率、胸腔积液发生率、脓毒血症发生率、休克发生率、多器官功能衰竭发生率与生存组比较差异均有统计学意义(P0.05)。多因素logistic回归分析显示:APACHE-II评分、血糖、Cr、BUN、脓毒血症、休克、多器官功能衰竭是急性重症胰腺炎患者死亡独立危险因素(P0.05),Ca、ALB是其保护因素(P0.05)。结论:影响急性重症胰腺炎患者死亡危险因素包括APACHE-II评分、FPG、Cr、BUN、AST、脓毒血症、休克、多器官功能衰竭,保护因素包括Ca、ALB。     

Transfusion Patterns in All Patients Admitted to the Intensive Care Unit and in Those Who Die in Hospital: A Descriptive Analysis

While it is known that the use of health care resources increases at the end of life in patients admitted to the Intensive Care Unit (ICU), the allocation of blood products at the end of life has not been described. The objective of this study was to describe overall transfusion patterns in the ICU, and specifically in patients who die in hospital. We conducted a retrospective cohort study of adult patients admitted to the ICU of a university-affiliated hospital, who were discharged or died between November 1, 2006 and June 30, 2012. During the study period, 10,642 patients were admitted at least once to the ICU. Of these patients, 4079 (38.3%) received red blood cells (RBCs), plasma or platelets in the ICU. The ICU mortality rate was 28.1% and in-hospital mortality rate was 32.3%. Among 39,591 blood product units transfused over the course of the study in the ICU (18,144 RBC units, 16,920 plasma units and 4527 platelet units), 46.2% were administered to patients who later died within the same hospitalization (41.2% of RBCs, 50.4% of plasma and 50.8% of platelets). Of all blood product units (RBCs, plasma and platelets) administered in the ICU over the study period, 11% were given within the last 24 hours before death. A large proportion of blood products used in the ICU are administered to patients who ultimately succumb to their illness in hospital, and many of these blood units are given in close proximity to death.     

Situación funcional como factor independiente asociado con el mal pronóstico de pacientes ancianos ingresados en Cuidados Intensivos

Objective

To assess the association of previous functional status in elderly patients admitted to the ICU, estimated by the Barthel and Short Form-Late Life Function and Disability instrument scales, and the relationship with prognosis and functional capacity at hospital discharge.

AECOPD并重度呼吸衰竭患者有创机械通气的治疗时机探讨及其预后的影响因素分析

摘要 目的：探讨慢性阻塞性肺疾病急性加重（AECOPD）合并重度呼吸衰竭患者有创机械通气的治疗时机,并分析其预后的影响因素。方法：选取2020年3月~2021年12月期间于首都医科大学附属北京世纪坛医院治疗的161例AECOPD合并重度呼吸衰竭患者,按照气管插管时间分为早期组（n=89）和延期组（n=72）,对比两组治疗后临床指标、血气分析指标及28 d内病死率（预后）。根据预后的不同将患者分为死亡组（n=29）和存活组（n=132）,收集患者的一般资料和实验室资料,采用Logistic回归分析预后的影响因素。结果：早期组的总机械通气时间、有创通气时间、重症监护室（ICU）住院时间均短于延期组（P<0.05）。两组治疗后动脉血二氧化碳分压（PaCO₂）较治疗前下降,氧合指数（OI）、动脉血氧分压（PaO₂）较治疗前升高,且早期组变化程度大于延期组（P<0.05）。延期组28 d内病死率为15/72（20.83%）。早期组28 d内病死率为14/89（15.73%）,两组患者的28 d病死率对比无差异（P>0.05）。单因素分析结果显示,AECOPD合并重度呼吸衰竭患者的预后影响因素与并发呼吸机相关肺炎、并发多脏器功能不全综合征、年龄、PaCO₂、血红蛋白（Hb）、血尿素氮（BUN）、白细胞计数（WBC）、pH值、中性粒细胞计数/淋巴细胞计数比值（NLR）、血小板计数/淋巴细胞计数（PLR）、C反应蛋白（CRP）、D-二聚体（D-D）、B型尿钠肽有关（P<0.05）。AECOPD合并重度呼吸衰竭患者预后不良的危险因素主要有并发呼吸机相关肺炎、并发多脏器功能不全综合征、PaCO₂偏高、年龄偏大、Hb偏低、pH值偏低、D-D偏高（P<0.05）。结论：AECOPD合并重度呼吸衰竭患者早期使用有创机械通气,可有效改善血气分析,缩短有创通气时间、总机械通气时间、ICU住院时间。并发呼吸机相关肺炎、并发多脏器功能不全综合征、PaCO₂偏高、年龄偏大、Hb偏低、pH值偏低、D-D偏高均是导致AECOPD合并重度呼吸衰竭患者预后不良的危险因素。     

Performance of Three Prognostic Models in Patients with Cancer in Need of Intensive Care in a Medical Center in China

Objective

The aim of this study was to evaluate the performance of Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score 3 (SAPS 3), and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) in patients with cancer admitted to intensive care unit (ICU) in a single medical center in China.

Materials and Methods

This is a retrospective observational cohort study including nine hundred and eighty one consecutive patients over a 2-year period.

Results

The hospital mortality rate was 4.5%. When all 981 patients were evaluated, the area under the receiver operating characteristic curve (AUROC, 95% Confidential Intervals) of the three models in predicting hospital mortality were 0.948 (0.914–0.982), 0.863 (0.804–0.923), and 0.873 (0.813–0.934) for SAPS 3, APACHE II and APACHE IV respectively. The p values of Hosmer-Lemeshow statistics for the models were 0.759, 0.900 and 0.878 for SAPS 3, APACHE II and APACHE IV respectively. However, SAPS 3 and APACHE IV underestimated the in-hospital mortality with standardized mortality ratio (SMR) of 1.5 and 1.17 respectively, while APACHE II overestimated the in-hospital mortality with SMR of 0.72. Further analysis showed that discrimination power was better with SAPS 3 than with APACHE II and APACHE IV whether for emergency surgical and medical patients (AUROC of 0.912 vs 0.866 and 0.857) or for scheduled surgical patients (AUROC of 0.945 vs 0.834 and 0.851). Calibration was good for all models (all p > 0.05) whether for scheduled surgical patients or emergency surgical and medical patients. However, in terms of SMR, SAPS 3 was both accurate in predicting the in-hospital mortality for emergency surgical and medical patients and for scheduled surgical patients, while APACHE IV and APACHE II were not.

Conclusion

In this cohort, we found that APACHE II, APACHE IV and SAPS 3 models had good discrimination and calibration ability in predicting in-hospital mortality of critically ill patients with cancer in need of intensive care. Of these three severity scores, SAPS 3 was superior to APACHE II and APACHE IV, whether in terms of discrimination and calibration power, or standardized mortality ratios.     

Severe imported falciparum malaria: a cohort study in 400 critically ill adults

Background

Large studies on severe imported malaria in non-endemic industrialized countries are lacking. We sought to describe the clinical spectrum of severe imported malaria in French adults and to identify risk factors for mortality at admission to the intensive care unit.

Methodology and Principal Findings

Retrospective review of severe Plasmodium falciparum malaria episodes according to the 2000 World Health Organization definition and requiring admission to the intensive care unit. Data were collected from medical charts using standardised case-report forms, in 45 French intensive care units in 2000–2006. Risk factors for in-hospital mortality were identified by univariate and multivariate analyses.Data from 400 adults admitted to the intensive care unit were analysed, representing the largest series of severe imported malaria to date. Median age was 45 years; 60% of patients were white, 96% acquired the disease in sub-Saharan Africa, and 65% had not taken antimalarial chemoprophylaxis. Curative quinine treatment was used in 97% of patients. Intensive care unit mortality was 10.5% (42 deaths). By multivariate analysis, three variables at intensive care unit admission were independently associated with hospital death: older age (per 10-year increment, odds ratio [OR], 1.72; 95% confidence interval [95%CI], 1.28–2.32; P = 0.0004), Glasgow Coma Scale score (per 1-point decrease, OR, 1.32; 95%CI, 1.20–1.45; P<0.0001), and higher parasitemia (per 5% increment, OR, 1.41; 95%CI, 1.22–1.62; P<0.0001).

Conclusions and Significance

In a large population of adults treated in a non-endemic industrialized country, severe malaria still carried a high mortality rate. Our data, including predictors of death, can probably be generalized to other non-endemic countries where high-quality healthcare is available.     

The Incidence,Clinical Outcomes,and Risk Factors of Thrombocytopenia in Intra-Abdominal Infection Patients: A Retrospective Cohort Study

Background

Studies on the incidence and risk factors of thrombocytopenia among intra-abdominal infection patients remain absent, hindering efficacy assessments regarding thrombocytopenia prevention strategies.

Methods

We retrospectively studied 267 consecutively enrolled patients with intra-abdominal infections. Occurrence of thrombocytopenia was scanned for all patients. All-cause 28-day mortality was recorded. Variables from univariate analyses that were associated with occurrence of hospital-acquired thrombocytopenia were included in a multivariable logistic regression analysis to determine thrombocytopenia predictors.

Results

Median APACHE II score and SOFA score of the whole cohort was 12 and 3 respectively. The overall ICU mortality was 7.87% and the 28-day mortality was 8.98%. The incidence of thrombocytopenia among intra-abdominal infection patients was 21.73%. Regardless of preexisting or hospital-acquired one, thrombocytopenia is associated with an increased ICU mortality and 28-day mortality as well as length of ICU or hospital stay. A higher SOFA and ISTH score at admission were significant hospital-acquired thrombocytopenia risk factors.

Conclusions

This is the first study to identify a high incidence of thrombocytopenia in patients with intra-abdominal infections. Our findings suggest that the inflammatory milieu of intra-abdominal infections may uniquely predispose those patients to thrombocytopenia. More effective thrombocytopenia prevention strategies are necessary in intra-abdominal infection patients.     

Vitamin D Status and the Risk for Hospital-Acquired Infections in Critically Ill Adults: A Prospective Cohort Study

Introduction

To identify patient characteristics associated with low serum 25-hydroxyvitamin D (25(OH)D) concentrations in the medical intensive care unit (ICU) and examine the relationship between serum 25(OH)D and the risk for hospital-acquired infections.

Methods

This is a prospective observational cohort of adult patients admitted to the medical ICU at an urban safety net teaching hospital in Atlanta, Georgia from November 1, 2011 through October 31, 2012 with an anticipated ICU stay ≥ 1 day. Phlebotomy for serum 25(OH)D measurement was performed on all patients within 5 days of ICU admission. Patients were followed for 30 days or until death or hospital discharge, whichever came first. Hospital-acquired infections were determined using standardized criteria from review of electronic medical record.

Results

Among the 314 patients analyzed, 178 (57%) had a low vitamin D at a serum 25(OH)D concentration < 15 ng/mL. The patient characteristics associated with low vitamin D included admission during winter months (28% vs. 18%, P = 0.04), higher PaO2/FiO2 (275 vs. 226 torr, P = 0.03) and a longer time from ICU admission to study phlebotomy (1.8 vs. 1.5 days, P = 0.02). A total of 36 (11%) patients were adjudicated as having a hospital-acquired infection and in multivariable analysis adjusting for gender, alcohol use, APACHE II score, time to study phlebotomy, ICU length of stay and net fluid balance, serum 25(OH)D levels < 15 ng/mL were not associated with risk for hospital-acquired infections (HR 0.85, 95% CI 0.40-1.80, P = 0.7).

Conclusions

In this prospective, observational cohort of adults admitted to a single-center medical ICU, we did not find a significant association between low 25(OH)D and the risk for hospital-acquired infections.     

Poor Clinical Outcomes among Pneumonia Patients with Depressive Disorder

Background

Some studies suggested that psychological stress may be associated with the severity and duration of infectious diseases. In this population-based study, we investigated associations between depressive disorder (DD) and pneumonia outcomes in Taiwan with a large-scale database from the National Health Insurance.

Methods

Our study defined 112,198 patients who were hospitalized with a principal diagnosis of pneumonia. We defined their admission date for treatment of pneumonia as the index date. Subsequently, we selected 2,394 patients with DD within 3 years prior to their index date and 11,970 matched patients without DD. We carried out separate conditional logistic regressions to explore the association of clinical pneumonia treatment outcome (ICU admission, use of mechanical ventilation, acute respiratory failure and in-hospital death) with previously diagnosed DD.

Results

Patients with DD had a significantly higher probability of an intensive care unit admission (18.1% vs. 12.9%; p<0.001), need for mechanical ventilation (21.9% vs. 18.1%; p<0.001) and in-hospital death (10.4% vs. 9.0%; p = 0.025) than patients without DD. The study showed that pneumonia patients with DD were respectively 1.41- (95% CI: 1.25∼1.59, p<0.001), 1.28- (95% CI: 1.14∼1.43, p<0.001), and 1.17- times (95% CI: 1.01∼1.36, p = 0.039) greater odds of being admitted to the ICU, need for mechanical ventilation, and in-hospital death than patients without DD after adjusting for monthly income, urbanization level, geographic region and Charlson Comorbidity Index score.

Conclusions

In conclusion, we found that pneumonia patients with DD were associated with poor treatment outcomes compared to patients without DD.     

Combined Effects of Admission Serum Creatinine Concentration with Age and Gender on the Prognostic Significance of Subjects with Acute ST-Elevation Myocardial Infarction in China

Objective

to explore the impact of admission serum creatinine concentration on the in-hospital mortality and its interaction with age and gender in patients with acute ST-segment elevation myocardial infarction (STEMI) in China.

Methods

1424 acute STEMI patients were enrolled in the study. Anthropometric and laboratory measurements were collected from every patient. A Cox proportional hazards regression model was used to determine the relationships between the admission serum creatinine level (Cr level), age, sex and the in-hospital mortality. A crossover analysis and a stratified analysis were used to determine the combined impact of Cr levels with age and gender.

Results

Female (HR 1.687, 95%CI 1.051∼2.708), elevated Cr level (HR 5.922, 95%CI 3.780∼9,279) and old age (1.692, 95%CI 1.402∼2.403) were associated with a high risk of death respectively. After adjusting for other confounders, the renal dysfunction was still independently associated with a higher risk of death (HR 2.48, 95% CI 1.32∼4.63), while female gender (HR 1.19, 95%CI 0.62∼2.29) and old age (HR 1.77, 95%CI 0.92∼3.37) was not. In addition, crossover analysis revealed synergistic effects between elevated Cr level and female gender (SI = 3.01, SIM = 2.10, AP = 0.55). Stratified analysis showed that the impact of renal dysfunction on in-hospital mortality was more pronounced in patients <60 years old (odds ratios 11.10, 95% CI 3.72 to 33.14) compared with patients 60 to 74 years old (odds ratios 5.18, 95% CI 2.48∼10.83) and patients ≥75years old (odds ratios 3.99, 95% CI 1.89 to 8.42).

Conclusion

Serum Cr concentration on admission was a strong predictor for in-hospital mortality among Chinese acute STEMI patients especially in the young and the female.     

Evaluation of Pneumonia Severity and Acute Physiology Scores to Predict ICU Admission and Mortality in Patients Hospitalized for Influenza

Background

The demand for inpatient medical services increases during influenza season. A scoring system capable of identifying influenza patients at low risk death or ICU admission could help clinicians make hospital admission decisions.

Methods

Hospitalized patients with laboratory confirmed influenza were identified over 3 influenza seasons at 25 Ontario hospitals. Each patient was assigned a score for 6 pneumonia severity and 2 sepsis scores using the first data available following their registration in the emergency room. In-hospital mortality and ICU admission were the outcomes. Score performance was assessed using the area under the receiver operating characteristic curve (AUC) and the sensitivity and specificity for identifying low risk patients (risk of outcome <5%).

Results

The cohort consisted of 607 adult patients. Mean age was 76 years, 12% of patients died (71/607) and 9% required ICU care (55/607). None of the scores examined demonstrated good discriminatory ability (AUC≥0.80). The Pneumonia Severity Index (AUC 0.78, 95% CI 0.72–0.83) and the Mortality in Emergency Department Sepsis score (AUC 0.77, 95% 0.71–0.83) demonstrated fair predictive ability (AUC≥0.70) for in-hospital mortality. The best predictor of ICU admission was SMART-COP (AUC 0.73, 95% CI 0.67–0.79). All other scores were poor predictors (AUC <0.70) of either outcome. If patients classified as low risk for in-hospital mortality using the PSI were discharged, 35% of admissions would have been avoided.

Conclusions

None of the scores studied were good predictors of in-hospital mortality or ICU admission. The PSI and MEDS score were fair predictors of death and if these results are validated, their use could reduce influenza admission rates significantly.