Clinical–epidemiological characteristics and survival time of deceased COVID-19 patients treated at hospitals belonging to Red Sabogal–Callao in 202

e24042 Background: Owing to its incurable nature and cumulative toxicities from multiple treatment lines, managing symptoms and complications of multiple myeloma (MM) will inevitably utilize healthcare resources. Early palliative care (PC) integration has been shown to curb the use of resources, especially towards the end of life. It remains unknown whether the same effect is seen in patients with MM. In our previous study of patients with newly diagnosed symptomatic MM (case group), we observed that functional well-being, pain experience and overall quality of life improved with PC involvement within eight weeks of diagnosis. In this study, we compared this cohort to patients who received standard care (control group) to determine the effect of early PC on healthcare utilization. Methods: Using propensity score-matching, control patients were identified by age, gender and Eastern Cooperative Oncology Group (ECOG) score with a 1:2 ratio. Outcome measures included number of emergency room (ER) visits, number of unplanned hospital and intensive care unit (ICU) admissions and number of hospital and ICU days. Data were collected within a year from time of diagnosis. Wilcoxon rank sum test was used to compare outcomes between case and control patients. Results: The case group’s (n=20) median (IQR) age was 65 (60-69.5); 63.5 (57.5-70) for control patients (n=40). In both groups, 75% were female and 55% had an ECOG score of 1. Case group had a median (IQR) of 0 (0-0.5) ER visits, 1.5 (0-11.5) unplanned hospital days and 0 (0-0.5) ICU days, while control group had 0 (0-1), 0 (0-10) and 0 (0-0), respectively. There were no significant differences in ER visits, unplanned hospital admissions, ICU admissions, hospital days and ICU days between groups. Conclusions: Early PC integration did not appear to differ from standard care on healthcare utilization in this small cohort of patients with MM. Future studies should focus on patients further along the trajectory, namely those with relapsed or progressive symptomatic MM. Summary of healthcare resource utilization by case-control status. Healthcare Resource Group N Min 25 th Percentile Median 75 th Percentile Max P-value Number of ER 1 Visits Control 40 0 0 0 1 6 0.69 Case 20 0 0 0 0.5 3 Number of Hospital Admissions Control 40 0 0 2 4 9 0.82 Case 20 0 1 2 2.5 11 Total Number of Hospital Days Control 40 0 0 13 21 53 0.79 Case 20 0 1 9 15.5 32 Number of Unplanned Hospital Admissions Control 40 0 0 0 1 5 0.42 Case 20 0 0 1 2 5 Total Number of Unplanned Hospital Days Control 40 0 0 0 10 38 0.58 Case 20 0 0 1.5 11.5 31 Number of ICU 2 Admissions Control 40 0 0 0 0 2 0.15 Case 20 0 0 0 0.5 1 Total Number of ICU Days Control 40 0 0 0 0 6 0.17 Case 20 0 0 0 0.5 7 1 ER – emergency room; 2 ICU – intensive care unit.

This study examined records of 2566 consecutive COVID-19 patients at five Massachusetts hospitals and sought to predict level-of-care requirements based on clinical and laboratory data. Several classification methods were applied and compared against standard pneumonia severity scores. The need for hospitalization, ICU care, and mechanical ventilation were predicted with a validation accuracy of 88%, 87%, and 86%, respectively. Pneumonia severity scores achieve respective accuracies of 73% and 74% for ICU care and ventilation. When predictions are limited to patients with more complex disease, the accuracy of the ICU and ventilation prediction models achieved accuracy of 83% and 82%, respectively. Vital signs, age, BMI, dyspnea, and comorbidities were the most important predictors of hospitalization. Opacities on chest imaging, age, admission vital signs and symptoms, male gender, admission laboratory results, and diabetes were the most important risk factors for ICU admission and mechanical ventilation. The factors identified collectively form a signature of the novel COVID-19 disease.

Decision letter: Early prediction of level-of-care requirements in patients with COVID-19

Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care units (ICUs), but little is known about its prevalence in the emergency department (ED). The objective was to describe the prevalence of ALI among mechanically ventilated adult nontrauma patients in the ED. The hypothesis was that the prevalence of ALI in adult ED patients would be low. This was a retrospective cohort study of admitted nontrauma patients presenting to an academic ED. Two trained investigators abstracted data from patient records using a standardized form. The use of mechanical ventilation in the ED was identified in two phases. First, all ED patients were screened for the current procedural terminology (CPT) code for endotracheal intubation (CPT 31500) from January 1, 2003, to December 31, 2006. Second, each patient record was reviewed to verify the use of mechanical ventilation. ALI was defined in accordance with a modified version of the American-European Consensus Conference criteria as: 1) hypoxemia defined as PaO(2) /FiO(2) ratio ≤300 mm Hg on all arterial blood gases (ABGs) in the ED and the first 24 hours of admission, 2) the presence of bilateral infiltrates on chest radiograph, and 3) the absence of left atrial hypertension. Data are presented in absolute numbers and percentages. Interobserver agreement was evaluated using the kappa statistic. Of the 552 patients who received mechanical ventilation in the ED and were subsequently admitted, a total of 134 (24.3%, 95% confidence interval [CI] = 20.8% to 28.0%) met hypoxemia criteria. Of these, 34 had evidence of left atrial hypertension, 52 did not have chest radiograph findings consistent with ALI, and two did not have a chest radiograph performed; the remaining 46 met ALI criteria. An additional two patients who died in the ED had clinical evidence of ALI. Thus, 48 of 552, or 8.7% (95% CI = 6.6% to 11.3%), met criteria for ALI. The kappa value for determination of ALI was 0.84 (95% CI = 0.54 to 1.0). The prevalence of ALI was nearly 9% in adult nontrauma patients receiving mechanical ventilation in the ED. Further study is required to determine which types of patients present to the ED with ALI, the extent to which lung protective ventilation is used, and the need for ED ventilator management algorithms.

Resuming liver transplantation amid the COVID-19 pandemic

Objective To investigate the risk factors and nursing strategy of ventilator-associated pneumonia (VAP) in intensive care unit (ICU),and provide reference for preventing and controlling VAP.Methods Totals of 168 cases with mechanical ventilation (MV) duration over 48 hours in ICU from Jan 2011 to Dec 2011 were studied.The clinical epidemiological characteristics and treatment process were recorded.The risk factors of VAP were analyzed by Logistic regression.Results Totally 60 VAP cases among 168 patients were collected,the incidence of VAP was 35.7％.The univariate analysis showed that enteral nutrition,mechanical ventilation type,tracheotomy,infections at other sites,the number of antibiotics,ventilator time and total hospital days and ICU days were important risk factors of VAP.Logistic regression analysis showed that mechanical ventilation type (OR =10.945,P ＜0.05),the number of antibiotics (OR =1.653,P ＜0.01) and ICU hospital days (OR =1.111,P ＜ 0.01) were independently associated with VAP.Conclusions Because of many risks factors,the patients in ICU are the high risk group of VAP.Specific measures should be taken to prevent the incidence of VAP,such as:reducing the duration of mechanical ventilation,ICU length of stay and invasive treatment Etc. Key words: Intensive care unit; Ventilator-associated pneumonia; Risk factors; Logistic regression analysis

Pain-associated Respiratory Failure in Chest Trauma

Survival from critical illness has improved in recent years, leading to increased attention to the sequelae of such illness. Neuromuscular weakness in the intensive care unit (ICU) is common, persistent, and has significant public health implications. The differential diagnosis of weakness in the ICU is extensive and includes critical illness neuromyopathy. Prolonged immobility and bedrest lead to catabolism and muscle atrophy, and are associated with critical illness neuromyopathy and ICU-acquired weakness. Early mobilization therapy has been advocated as a mechanism to prevent ICU-acquired weakness. Early mobilization is safe and feasible in most ICU patients, and improves outcomes. Implementation of early mobilization therapy requires changes in ICU culture, including decreased sedation and bedrest. Various technologies exist to increase compliance with early mobilization programs. Drugs targeting muscle pathways to decrease atrophy and muscle-wasting are in development. Additional research on early mobilization in the ICU is needed.

A possible role for B cells in COVID-19? Lesson from patients with agammaglobulinemia

Head and Neck Cancer: A High-Risk Population for COVID-19

We conducted this study to investigate how physicians in a pediatric intensive care unit (ICU) currently make decisions to withdraw and withhold life support. Consultation with the patient's primary caregiver often precedes decisions about withdrawal and limitation of life support in chronically ill patients. In these scenarios, the patient's primary caregiver was the pediatric oncologist. To evaluate the influence of subspecialty training, we compared the attitudes of the pediatric intensivists and the oncologists using scenarios describing critically ill oncology patients. Cross-sectional survey. Each physician was randomly assigned 4 of 8 potential case scenarios. A total of 29 American pediatric ICUs. Pediatric intensive care and oncology attendings and fellows. Systematic manipulation of patient characteristics in two hypothetical case scenarios describing 6-year-old female oncology patients presenting to the ICU after the institution of mechanical ventilator support for acute respiratory failure. Cases 1 through 4 described a patient who, before admission, had a 99% projected 1-year probability of survival from her underlying cancer and suffered from severe neurologic disabilities. Cases 5 through 8 described a patient who was neurologically normal before admission and had a <1% chance of surviving longer than 1 year because of her underlying cancer. Each physician was randomly assigned 2 cases from cases 1 through 4 and 2 cases from cases 5 through 8. Within each of these case scenarios, parental preferences (withdraw or advance support or look for guidance from the caregivers) and probability of survival (5% vs 40%) were manipulated. Before distribution, the survey instrument was pilot-tested and underwent a rigorous assessment for clinical sensibility. Physicians ratings of the importance of 10 factors considered in the decision to withdraw life support, and their decisions about the appropriate level of care to provide. Respondents were offered five management options representing five levels of care: 1) discontinue inotropes and mechanical ventilation but continue comfort measures; 2) discontinue inotropes and other maintenance therapy but continue mechanical ventilation and comfort measures; 3) continue with current management but add no new therapeutic intervention; 4) continue with current management, add additional inotropes, change antibiotics and the like as needed, but do not start dialysis; and 5) continue with full aggressive management and plan for dialysis if necessary. Respondents also were asked whether they would obtain an ethics consultation. A total of 270 physicians responded to our survey (165 of 198 potentially eligible pediatric intensivists and 105 of 178 pediatric oncologists for response rates of 83% and 59%, respectively). The respondents considered the probability of ICU survival and the wishes of the parents regarding the aggressiveness of care most important in the decision to limit life-support interventions. No clinically important differences were found when the responses of oncologists were compared with those of intensivists. In six of eight possible scenarios, the same level of intensity of care was chosen by less than half of all respondents. In three scenarios, >/=10% of respondents chose full aggressive management as the most appropriate level of care, whereas another >/=10% chose comfort measures only when viewing the same scenario. The most significant respondent factors affecting choices were professional status (attending vs fellow) and the self-rated importance of functional neurologic status. The majority of respondents (83%) believed that the intensive care and the oncology staff were usually in agreement at their institution about the level of intervention to recommend to the parents. (ABSTRACT TRUNCATED)

Ventilator-Associated Pneumonia

PC-FACS: COVID-19

The mortality risk for critically ill patients in the intensive care unit (ICU) can be predicted through clinical assessments and laboratory test results. The accurate utilization of these parameters is essential for timely intervention and the initiation of appropriate therapeutic strategies. This study aims to retrospectively examine the relationship between patients' clinical status at ICU admission, prognostic risk scoring systems, biochemical and hematological parameters, and mortality outcomes. This descriptive, cross-sectional, retrospective cohort study was conducted in the Internal Medicine Intensive Care Unit of Kütahya Health Sciences University Evliya Çelebi Training and Research Hospital, Turkey, between July 1, 2018, and July 30, 2020, and included a total of 490 patients. The initial admission data, encompassing variables such as gender, age, chronic conditions, reasons for ICU admission, ICU length of stay, total hospital stay, requirement for mechanical ventilation (MV), Nutrition Risk Screening 2002 (NRS-2002) score, hemogram, and biochemical parameters, were recorded. The clinical and demographic characteristics, along with the initial laboratory values of patients who either died or were discharged from the ICU, were subjected to statistical analysis. Of the 490 patients, 258 were male, and 232 were female, with a median age of 72 (63-80). Of the 490 patients, 211 (43.1%) died, while 279 (46.6%) were discharged from the ICU. Logistic regression analysis showed that MV requirement, NRS-2002 score, lactate, and red cell distribution width (RDW-CV) were independent predictors of mortality (p < 0.05). MV requirement had the highest odds ratio. In both multivariate analysis and clinical practice, the independent predictors of mortality in ICU patients were identified as the need for MV, elevated NRS-2002 scores, increased lactate levels, and higher RDW-CV values. Among these, the strongest predictor of mortality was the requirement for MV. We anticipate that the results of our study will aid in the enhancement of mortality prediction models and provide important parameters to inform clinical practice.

Funding Acknowledgements Type of funding sources: None. Background The incidence of respiratory failure and the provision of invasive and non-invasive mechanical ventilation (MV) in patients admitted to cardiac intensive care units (CICU) are increasing. While institutional MV volumes are associated with reduced mortality in medical and surgical ICUs, this relationship has not been characterized in the CICU population. Purpose By describing the relationship between institutional MV volume and outcomes in the CICUs, we hope to shed light on minimum volume benchmarks for providing MV. Methods National Canadian population-based data from 2005 to 2015 was used to identify patients admitted to CICUs requiring MV. CICUs were categorized into low (≤100), intermediate (101-300), and high (&amp;gt;300) volume centers based on spline knots identified in the association between annual MV volume and mortality (Figure). Outcomes of interests included all-cause in-hospital mortality, the proportion of patients requiring prolonged MV (&amp;gt;96 hours) and CICU length of stay (LOS). Results Among the 47,173 CICU admissions that required MV, 89.5% (42,200) required invasive mechanical ventilation. The median annual CICU MV volume was 127 (range 1-490). In-hospital mortality was lower in intermediate (29.2%, adjusted odds ratio [aOR] 0.84, 95% CI 0.72-0.97, p = 0.019) and high-volume (18.2%; aOR 0.82, 95% CI 0.66-1.02, p = 0.076) centers, compared to low volume centers (35.9%). The proportion of patients requiring prolonged MV was higher in low-volume (29.2%) compared to high-volume (14.8%, OR 0.70, 95% 0.55-0.89, p = 0.003) centers. Point estimates for mortality and prolonged MV were lower in PCI-capable and academic centers (Table). Significantly (p &amp;lt;0.01) lower CICU LOS was observed only in the subgroup of PCI-capable intermediate- and high-volume hospitals. Conclusions In a national dataset, we observed that higher CICU MV hospital volumes were associated with lower in-hospital mortality, CICU LOS, and fewer episodes of prolonged MV. Pending further validation, these data suggest minimum MV volume benchmarks for CICUs caring for patients with respiratory failure. Further research is warranted to explore these associations in more detail. Unadjusted volume-outcome relationshipsOutcomesGroup 1 Annual Volume ≤100Group 2 Annual Volume 101-300Group 3 Annual Volume &amp;gt;300Totalp-valueTotal N1770224351512047173In-hospital mortality6357 (35.0%)7122 (29.2%)933 (18.2%)14412 (30.6%)p &amp;lt; 0.0001Median CICU LOS(hours)85796679p &amp;lt; 0.0001Episodes of prolonged MV5161 (29.2%)5608 (23.0%)758 (14.8%)11527 (24.4%)p &amp;lt; 0.0001Abbreviations OR (odds ratio), RD (risk difference), CI (confidence interval), PCI (percutaneous coronary intervention), LOS (length of stay)Abstract Figure. Annual CICU MV volume and mortality