Acuity Of Illness Research Articles

Therapeutic Plasma Exchange for the Treatment of Thrombotic Microangiopathy without Severe ADAMTS13 Deficiency: A Propensity Score-Matched Study

▪Introduction: Thrombotic microangiopathies (TMA) are a group of uncommon disorders characterized clinically by the presence of thrombocytopenia and microangiopathic hemolytic anemia (MAHA). Therapeutic plasma exchange (TPE) is a proven treatment for cases of autoimmune thrombotic thrombocytopenic purpura (TTP) characterized by an ADAMTS13 activity level of ≤10%, but the efficacy of TPE in TMA with an ADAMTS13 activity level of >10% remains controversial.Methods: We conducted a retrospective cohort study of 186 adult patients included in the Harvard TMA Research Collaborative registry who presented with MAHA and thrombocytopenia concerning for TTP but an ADAMTS13 activity level of >10%. A propensity score (PS) logistic regression model was constructed based on 11 clinically relevant confounding variables: age; sex; ethnicity; Charlson Comorbidity Index (CCI); history of prior solid organ or bone marrow transplant; the presence of neurologic symptoms; the presence of sepsis, shock, or multiorgan failure (MOF); platelet count; creatinine; LDH; and INR. Matching was performed using a 1:1 nearest neighbor method without replacement within a set caliper distance. Standardized differences were used to assess the quality of matching and ensure balance of baseline characteristics. The primary outcome was 90-day survival. Secondary outcomes included in-hospital mortality, percent of patients experiencing platelet count recovery, time to platelet count recovery, and hospital length of stay (LOS).Results: Prior to matching, patients treated with TPE (N=71) had a lower acuity of illness compared to untreated patients (N=115) as reflected by a lower mean CCI (2.3 vs. 3.4, P = 0.003), lower mean INR (1.1 vs. 1.3, P = 0.02), and lower incidence of sepsis, shock or MOF (23% vs. 36%, P = 0.06). Consistent with this confounding, TPE in the pre-matched cohort appeared to be associated with reduced mortality at 90 days (HR 0.51, P = 0.01). The PS match was performed to address these imbalances and resulted in 59 TPE-treated patients paired to 59 untreated controls. After matching, baseline characteristics of the treated and untreated groups were well balanced, with a standardized difference of ≤11% in all PS variables (see Figure).In contrast to the unmatched cohort, Cox regression analysis stratified by matched pairs showed no significant difference in the primary outcome of 90-day survival between the treated and untreated groups (HR 0.88, 95% CI 0.44-1.8, P = 0.72) (see Table). We performed subgroup analyses by age, diagnostic category, and ADAMTS13 activity level and again did not observe any benefit to TPE. With regard to secondary outcomes, in-hospital mortality (OR 0.77, P = 0.53), percent of patients with platelet count recovery (OR 1.6, P = 0.21), median time to platelet count recovery (6 vs. 6 days, P = 0.99), and median hospital LOS (14 vs. 18 days, P = 0.93) did not differ significantly between the two groups.Conclusions: In the absence of a randomized controlled trial, PS matching represents a rigorous statistical approach to study the effect of treatment while adjusting for differences in baseline characteristics across groups of patients. Here we have used PS matching to assess the efficacy of TPE in the management of TMA associated with an ADAMTS13 activity level of >10%. Our data indicate that there is no benefit from TPE for this diverse group of TMA patients without severe ADAMTS13 deficiency. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Portal Venous Gas in a Patient with End-Stage Renal Disease

An 86-year-old man with end-stage renal disease presented with acute epigastric pain during a hemodialysis session. Computed tomography on admission demonstrated extensive gaseous distension of the portal venous system and signs of ileus without bowel necrosis. His constipation and portal venous gas (PVG) completely resolved with conservative management. While PVG can often signal impending decompensation in critically ill patients, it can also be observed in relatively benign processes and does not necessarily correlate with the acuity of illness. Its occurrence in patients undergoing hemodialysis may begin with a low-flow state, which can lead to ischemic injury.

Medical outcomes for adults hospitalized with severe anorexia nervosa: An analysis by age group.

Relatively little has been written about the outcomes of medical stabilization, analyzed specifically across the age spectrum, in adults with severe anorexia nervosa (AN). We retrospectively evaluated clinical parameters relevant to acuity of illness and outcomes of early refeeding in 142 adults with severe AN, admitted for definitive inpatient medical stabilization from October 1, 2008 to December 31, 2012. Patients were categorized into three age groups: 17 to 29, 30 to 40, and 41+ years. The study included 142 patients with median age of 28 years old (range 17-65 years). Fifty-four percent (n = 78) were under 30 years old, 23% (n = 32) between 30 and 40 years old, and 23% (n = 32) were over 40 years old. Average admission BMI did not differ among age groups, ranging from 12.7 to 13.2 kg/m(2). Of the admission parameters, only low serum albumin levels (more prevalent in older patients), high international normalized ratio (INR) levels (more prevalent in younger patients), and neutropenia (more prevalent in the <30 age group) varied with age. During hospitalization, rates of bradycardia, hypoglycemia, liver dysfunction, very low %IBW, refeeding hypophosphatemia, refeeding edema, length of stay, and discharge BMI did not differ with age. Age group was associated with rate of weekly weight gain only in patients with AN-binge purge subtype. Results demonstrate medical abnormalities and response to medical stabilization in severely ill AN patients during hospitalization were mostly similar across the age span. This information should allay fears that the effect of age will make medical stabilization more difficult.

High Rate of Hospital Admissions Among Patients with Cirrhosis Seeking Care in US Emergency Departments.

Emergency Departments (ED) can serve as a gateway to specialty care for patients with cirrhosis with limited care access. We described the rates and characteristics of patients with cirrhosis who access United States (US) EDs, and identified factors associated with subsequent hospitalization. Using data from the National Hospital Ambulatory Medical Care Survey, cirrhosis-related ED from 2000 to 2009 were identified and compared to all other ED visits. From 2000 to 2009, there were an estimated 1,029,693 cirrhosis and 877 million non-cirrhosis visits. Compared to the general ED population, those with cirrhosis were more frequently male (58 vs. 44 %, p = 0.02), Hispanic (18.6 vs. 10.6 %, p < 0.05), seeking care in urban areas (91.6 vs. 73.4 %, p < 0.05) and had Medicaid/no insurance (43 vs. 35 %, p < 0.01). Patients with cirrhosis were more frequently triaged immediately or emergently (72.3 vs. 54.2 %, p < 0.01). The majority were admitted or transferred to another hospital (66.8 vs. 17.4 %, p < 0.01). Among patients with cirrhosis, patients with age ≥ 65 years were more likely to be admitted (adjusted OR 2.49, 95 % CI 1.08-5.73), and Medicaid/uninsured (adjusted OR 0.34; 95 % CI 0.17-0.67) were less likely to be admitted, after adjusting for patient demographics, hospital characteristics, and triage score. Patient with cirrhosis account for approximately 100,000 US ED visits annually. The higher admission rates among patients with cirrhosis indicate a high acuity of illness. Older age among those admitted may reflect poorer functional status. Finally, high visit but low admission rates among those with Medicaid/no insurance suggest a gap in specialty care.

Effectiveness of implantable cardioverter-defibrillators in survivors of inhospital cardiac arrest

Although implantable cardioverter-defibrillators (ICDs) reduce mortality in patients with out-of-hospital cardiac arrest, their effectiveness in survivors of "inhospital" cardiac arrest-a population with different arrest etiologies and higher illness acuity than out-of-hospital cardiac arrest-is unknown. We therefore sought to conduct a comparative effectiveness study of ICD therapy in survivors of inhospital cardiac arrest. We linked data from a national inpatient cardiac arrest registry with Medicare files and identified 1,200 adults from 267 hospitals between 2000 and 2008 who were discharged after surviving an inhospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia and who otherwise met traditional inclusion and exclusion criteria for secondary prevention ICD trials. The association between ICD treatment and long-term mortality was evaluated using an optimal match (≤4 controls for each ICD patient) propensity-score analysis. Of 1,200 survivors, 343 (28.6%) received an ICD during the index hospitalization. Overall, 3-year mortality was 44.2%, with higher unadjusted mortality in the non-ICD versus the ICD group (46.9% vs 37.3%; log-rank; P < .001). After successfully matching 343 patients treated with ICDs with 823 untreated patients by propensity score, ICD treatment was associated with a 24% lower mortality rate (adjusted hazard ratio [HR] 0.76; 95% CI 0.60-0.97; P = .025). This lower mortality was mediated by lower rates of out-of-hospital deaths among ICD-treated patients (22.1% vs 30.8%; adjusted HR 0.71 [0.52-0.96]; P = .019), whereas deaths occurring during a readmission were similar (15.2% vs 16.1%; adjusted HR 0.89 [95% CI 0.60-1.32]; P = .56). Implantable cardioverter-defibrillator therapy in survivors of inhospital cardiac arrest due to a pulseless ventricular rhythm is used uncommonly but associated with lower long-term mortality. Given that fewer than 3 in 10 eligible survivors are treated with ICDs after surviving an inhospital cardiac arrest, our findings highlight a potentially modifiable process of care, which could improve long-term survival in this high-risk population.

Hope for successful implementation of psychosocial/psychiatric rehabilitation in the forensic mental health setting.

To explore staff perceptions of the successes and barriers to implementation of the psychosocial/psychiatric rehabilitation (PSR) model in the forensic mental health setting and identify staff supports needed for greater implementation. A qualitative descriptive design was used and staff focus group data was analyzed using the constant comparative method. All aspects of PSR are being implemented in the forensic setting. Barriers limiting comprehensive implementation include hospital processes and functions, legal components, client clinical presentation, staff attributes and interactions, and lack of resources. To foster greater implementation, employees require support to improve interprofessional interactions and acquire additional resources and education. Strengthening existing successes and addressing barriers identified will foster greater PSR implementation in the forensic setting. Adjusting the physical environment, streamlining documentation, shifting focus from security to rehabilitation goals, and adapting PSR principles to various levels of illness acuity and stages of treatment would enhance PSR implementation. A management focus on improving staff morale, self-care, peer support, team cohesion, and communication would limit burnout and increase successful implementation of PSR. Additional educational opportunities and ongoing training are suggested to support a unified understanding and sustained approach to PSR implementation in the forensic setting.

Effectiveness of exome and genome sequencing guided by acuity of illness for diagnosis of neurodevelopmental disorders.

Neurodevelopmental disorders (NDDs) affect more than 3% of children and are attributable to single-gene mutations at more than 1000 loci. Traditional methods yield molecular diagnoses in less than one-half of children with NDD. Whole-genome sequencing (WGS) and whole-exome sequencing (WES) can enable diagnosis of NDD, but their clinical and cost-effectiveness are unknown. One hundred families with 119 children affected by NDD received diagnostic WGS and/or WES of parent-child trios, wherein the sequencing approach was guided by acuity of illness. Forty-five percent received molecular diagnoses. An accelerated sequencing modality, rapid WGS, yielded diagnoses in 73% of families with acutely ill children (11 of 15). Forty percent of families with children with nonacute NDD, followed in ambulatory care clinics (34 of 85), received diagnoses: 33 by WES and 1 by staged WES then WGS. The cost of prior negative tests in the nonacute patients was $19,100 per family, suggesting sequencing to be cost-effective at up to $7640 per family. A change in clinical care or impression of the pathophysiology was reported in 49% of newly diagnosed families. If WES or WGS had been performed at symptom onset, genomic diagnoses may have been made 77 months earlier than occurred in this study. It is suggested that initial diagnostic evaluation of children with NDD should include trio WGS or WES, with extension of accelerated sequencing modalities to high-acuity patients.

Change Trajectories: Children's Patterns of Improvement in Acute-Stay Inpatient Care.

This study estimated classes of children's acute-stay psychiatric acuity trajectories in terms of shape (i.e., linear, quadratic, cubic) and rate of change (slope). A total of 788 children served on three child units (ages 4-12) were studied. The Children's Acuity of Psychiatric Illness (CAPI) was completed each weekday by trained frontline staff on the milieu. Latent class growth analysis was applied to the data, and seven acuity trajectory classes provided the most parsimonious fit. Four classes evidenced a significant quadratic term, one class a significant linear term, and two classes did not evidence a significant change in acuity. The classes varied in survival time to rehospitalization, in pre-treatment community service use and rates of seclusion, restraint, and emergency medications during the episode. Overall, the results suggest that acute-stay patients may have distinct and identifiable psychiatric acuity change patterns during their episodes and that some may experience non-linear (i.e., quadratic) acuity trajectories.

Predictors of mental health-related acute service utilisation and treatment costs in the 12 months following an acute psychiatric admission.

A key step in informing mental health resource allocation is to identify the predictors of service utilisation and costs. This project aims to identify the predictors of mental health-related acute service utilisation and treatment costs in the year following an acute public psychiatric hospital admission. A dataset containing administrative and routinely measured outcome data for 1 year before and after an acute psychiatric admission for 1757 public mental health patients was analysed. Multivariate regression models were developed to identify patient- and treatment-related predictors of four measures of service utilisation or cost: (a) duration of index admission; and, in the year after discharge from the index admission (b) acute psychiatric inpatient bed-days; (c) emergency department (ED) presentations; and (d) total acute mental health service costs. Split-sample cross-validation was used. A diagnosis of psychosis, problems with living conditions and prior acute psychiatric inpatient bed-days predicted a longer duration of index admission, while prior ED presentations and self-harm predicted a shorter duration. A greater number of acute psychiatric inpatient bed-days in the year post-discharge were predicted by psychosis diagnosis, problems with living conditions and prior acute psychiatric inpatient admissions. The number of future ED presentations was predicted by past ED presentations. For total acute care costs, diagnosis of psychosis was the strongest predictor. Illness acuity and prior acute psychiatric inpatient admission also predicted higher costs, while self-harm predicted lower costs. The development of effective models for predicting acute mental health treatment costs using existing administrative data is an essential step towards a workable activity-based funding model for mental health. Future studies would benefit from the inclusion of a wider range of variables, including ethnicity, clinical complexity, cognition, mental health legal status, electroconvulsive therapy, problems with activities of daily living and community contacts.

Care in the home for seriously ill children with complex needs: A narrative literature review.

This article reviews contemporary literature on home care of the seriously ill child with complex care needs and the sick child/parent dyad. The literature search revealed three major themes, namely the increasing acuity of child illness, the evolving role of the parent as care provider, and the health professional as care provider. While there is much known about the complexity of care of children and the role of family in that care, little is known about what families require in terms of support and sustenance during the long years of care provision.

(255) - Heart Transplantation Outcomes in Patients with Continuous Flow Left Ventricular Assist Device Related Complications

(255) - Heart Transplantation Outcomes in Patients with Continuous Flow Left Ventricular Assist Device Related Complications

(254) - De Novo DQ Donor-Specific Antibodies Are Associated With Chronic Lung Allograft Dysfunction

s S99 Device related complications (DRC) raise acuity of illness allowing patients to be listed as status 1A. We sought to study HTx outcomes of status 1A patients supported with CF LVADs with (DRC+) or without (DRC-) device related complications. Methods: UNOS data (2006 to 2012), on adult HTx patients listed as status 1A with CF LVADs at HTx was analyzed. Outcomes were compared between DRC+ and DRCgroups. Data on DRC+ group was further analyzed under five UNOS categories (B1 = Thromboembolism, B2 = Device related infections, B3 = Mechanical failure, B4 = Ventricular arrhythmia, B5 = other). Results: During the study period 6799 patients received HTx under 1A listing, of which 2113 (31%) were supported with CF LVADs (Fig). Substantially more patients are supported with CF LVADs under 1A listing, 11.4% in 2006 to 41.5% in 2012. Alarming number of CF LVAD patients are added to 1A listing for DRC, 20% in 2006 to 55% in 2012, p = 0.0001. Majority of DRC are in B2 category54% followed by B117.4%. Demographics and perioperative variables between DRC+ and DRCwere comparable except DRC+ had longer wait times (330 ± 323 days vs 168 ± 298 days), more blood group O (57% v 40%) and higher BMI (29 ± 5.5 vs 27± 5). Post HTx survival for DRC+ was significantly inferior compared to DRCgroup both at 1 yr (85.6% vs 89.4%, p = 0.01) and 3 yrs (78% vs 82.7%, p = 0.01). Among DRC+ subgroups, 1 and 3 yr survival was inferior only for B2 category (85% and 77%, p = 0.01). Conclusion: Increasing number of patients receiving HTx under 1A listing are supported with CF LVADs. DRC are steadily increasing, majority of them from B2 category. Longer wait times, blood group O and higher BMI are associated with DRC. Post HTx survival in the DRC+ group is inferior, primarily for B2 category. Benefits of CF LVADs for patients awaiting HTx need to be weighed against the development of DRC and inferior post HTx survival.

Education About Palliative Care in the Intensive Care Unit: Rediscovering Opportunity

Underlying palliative care is a philosophy that aligns patients' health care with what they deem most important. For patients in the final stages of life, this often includes the desire to avoid burdensome and high-intensity care. In the intensive care unit (ICU), where we see the highest acuity of illness, often there are many competing priorities. The principles of palliative care are vital in refocusing our attention on what matters most to the patient and his or her family. Because of the value of these principles, there is increasing interest in finding ways to improve education in palliative care and to integrate palliative care education into the ICU. To achieve this goal, 3 models for incorporating palliative care in the ICU have been proposed: the integrative model (education in primary palliative care skills for ICU clinicians); the consultative model (access to palliative care specialists); and the mixed model that uses both of these approaches simultaneously.1,2 It is increasingly clear that a mixed model, in which the education and deployment of palliative care specialists is combined with the education of all clinicians in basic principles of palliative care, is the optimal approach to address the diverse range of palliative care needs in the ICU.2

The Royal Free Hospital Score: A Calibrated Prognostic Model for Patients With Cirrhosis Admitted to Intensive Care Unit. Comparison With Current Models and CLIF-SOFA Score

OBJECTIVES:Prognosis for patients with cirrhosis admitted to intensive care unit (ICU) is poor. ICU prognostic models are more accurate than liver-specific models. We identified predictors of mortality, developed a novel prognostic score (Royal Free Hospital (RFH) score), and tested it against established prognostic models and the yet unvalidated Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) model.METHODS:Predictors of mortality were defined by logistic regression in a cohort of 635 consecutive patients with cirrhosis admitted to ICU (1989–2012). The RFH score was derived using a 75% training and 25% validation set. Predictive accuracy and calibration were evaluated using area under the receiver operating characteristic (AUROC) and goodness-of-fit χ2 for the RFH score, as well as for SOFA, Model for End-Stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE II), and Child-Pugh. CLIF-SOFA was applied to a recent subset (2005–2012) of patients.RESULTS:In-hospital mortality was 52.3%. Mortality improved over time but with a corresponding reduction in acuity of illness on admission. Predictors of mortality in training set, which constituted the RFH score, were the following: bilirubin, international normalized ratio, lactate, alveolar arterial partial pressure oxygen gradient, urea, while variceal bleeding as indication for admission conferred lesser risk. Classification accuracy was 73.4% in training and 76.7% in validation sample and did not change significantly across different eras of admission. The AUROC for the derived model was 0.83 and the goodness-of-fit χ2 was 3.74 (P=0.88). AUROC for SOFA was 0.81, MELD was 0.79, APACHE II was 0.78, and Child-Pugh was 0.67. In 2005–2012 cohort, AUROC was: SOFA: 0.74, CLIF-SOFA: 0.75, and RFH: 0.78. Goodness-of-fit χ2 was: SOFA: 6.21 (P=0.63), CLIF-SOFA: 9.18 (P=0.33), and RFH: 2.91 (P=0.94).CONCLUSIONS:RFH score demonstrated good discriminative ability and calibration. Internal validation supports its generalizability. CLIF-SOFA did not perform better than RFH and the original SOFA. External validation of our model should be undertaken to confirm its clinical utility.

SALIVARY CARBONIC ANHYDRASE VI, ZINC SULFATE TASTE ACUITY AND FREQUENCY OF ILLNESS: A PILOT STUDY

Salivary Carbonic Anhydrase VI (CA6) is a zinc-dependent metalloenzyme which may be important for normal taste function. Though many taste assessment methods exist, the assessment of zinc sulfate taste acuity is a method that has been suggested to have diverse relationships to human health. A double-blinded pilot study was conducted among 21 individuals to analyze the relationships between salivary CA6 concentrations, zinc sulfate taste acuity and self-reported frequency of illness. ELISA was performed to quantify CA6 concentrations, the Bryce-Smith and Simpson "Zinc Taste Test" (BS-ZTT) protocol and a Taste Intensity Visual Analog Scale (TI-VAS) were utilized to assess zinc sulfate taste acuity and a health history questionnaire was used to determine the frequency of illness. A statistically significant correlation existed between CA6 concentration and zinc sulfate taste acuity determined via the BS-ZTT (rs = 0.62; p = 0.03). A moderate statistically significant negative correlation was found between self-reported frequency of illness and BS-ZTT scores (rs = -0.64, p = 0.034). Likewise, a strong statistically significant negative correlation was found between self-reported frequency of illness and TI-VAS scores (rs = -0.81, p = 0.003). The results of this pilot study suggest that zinc sulfate taste acuity may be reflective of salivary CA6 concentration in addition to being a retrospective indicator of illness frequency.

Intravenous Metoprolol Versus Diltiazem for Rate Control in Noncardiac, Nonthoracic Postoperative Atrial Fibrillation

Little guidance exists on effective management of postoperative atrial fibrillation (POAF) following noncardiac, nonthoracic (NCNT) surgery. The purpose of this study was to identify whether a difference exists between intravenous (IV) metoprolol and diltiazem when used to achieve hemodynamically stable rate control in POAF following NCNT surgery. This retrospective cohort study examined critically ill adult surgical patients experiencing POAF with rapid ventricular response. Inclusion in the metoprolol or diltiazem treatment group was determined by the initial rate control agent chosen by the prescriber. The primary end point was hemodynamically stable rate control, defined by heart rate (HR) <110 beats/min and blood pressure >90 mm Hg, maintained for 6 hours. Patients on metoprolol (n = 66) and diltiazem (n = 55) were similar in age, comorbidities, surgical procedure distribution, acuity of illness, and home rate and rhythm control medications continued during hospitalization; 76% of diltiazem-treated patients achieved hemodynamically stable rate control, compared with only 53% of those receiving metoprolol (P = .005). Safety end points were similar between groups, including the portion requiring a new vasopressor or fluid bolus for hemodynamic support. In NCNT surgery, patients with POAF, IV diltiazem more effectively controlled HR and hemodynamics compared with metoprolol. Results warrant further research into optimal medical management of POAF in this population using these 2 agents.

Liver Transplantation in Children Using Organ Donation After Circulatory Death

While orthotopic liver transplantation (OLT) is a durable life-saving treatment for patients with irreversible liver disease, the waiting list mortality rate for children younger than 6 years is 4 times higher than for children aged 11 to 17 years and adults owing to scarce availability of size-appropriate grafts for transplantation. To compare long-term outcomes for children (aged ≤18 years) undergoing OLT using grafts from donation after circulatory death (DCD) and donation after brain death (DBD). Retrospective study using case-control matched groups at a university transplant center. All patients aged 18 years and younger who underwent OLT using DCD organs between February 1, 1990, and November 30, 2010, at the University of California, Los Angeles, were matched in a 1 to 3 ratio with patients who received primary OLT from DBD donors within a 12-month period. Other matching criteria included recipient age, weight, cause of liver disease, and acuity of illness. Outcomes after OLT were compared for DCD (n = 7) and DBD (n = 21) donors. The median follow-up was 4.5 years. The primary outcome measure was graft failure-free survival; the secondary end point was the development of ischemic cholangiopathy. Comparing DCD and DBD groups, recipient median age (28.4 vs 20.1 months, respectively; P = .80), weight (12.0 vs 11.6 kg, respectively; P = .87), Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease score (19 vs 11, respectively; P = .48), and donor age (24.0 vs 13.1 months, respectively; P = .72) were similar. For the DCD donors, the median donor warm ischemia duration was 24 minutes. Liver test results were similar for both groups at 1 week and 3, 6, and 12 months following OLT. Ten-year patient and graft survival rates for both DCD and DBD were 100%. Neither ischemic cholangiopathy nor vascular complications occurred in the DCD group. Biliary anastomotic strictures occurred in 1 DCD patient and 3 DBD patients. Our study showed excellent long-term outcomes with liver transplantation in children using DCD organs. Use of liver grafts procured after circulatory death is an effective approach to expand the donor pool and remains an untapped resource for children with end-stage liver disease.

Modern Protective Ventilation Strategies: Impact upon the Right Heart

‘Protective ventilation’ for acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) is a major advance in intensive care medicine. However, components of protective ventilation expose the right heart to challenges. Acute cor pulmonale (ACP), patent foramen ovale (PFO) and right ventricular failure (RVF) are recognised complications that could potentially reduce the benefit of protective ventilation. We sought to determine the rates of ACP, PFO and RVF in critically ill adults undergoing protective ventilation with ARDS/ALI and to identify their impact on mortality and critical illness acuity. A comprehensive search of electronic databases including Medline (OVID, EmBase) and CINAHL (EBSCO) was undertaken, including Cochrane Library and international registries, between January 1991 and December 2011. A systematic review identified a total of 248 articles; 27 were reviewed in full and 22 studies were included. All 22 included studies were observational or quasi-experimental with no randomised, controlled trials available. ACP was present in 16–100%, PFO 1.3–22.0% and RVF 9.6–26.0%. Neither ACP nor PFO was associated with an adverse effect on mortality and ACP seemed reversible in survivors; however both ACP and PFO were associated with prolonged need for ICU support. RVF was variously associated with no increase in mortality to an odds ratio 5.1 for death in multivariate analysis. There was marked heterogeneity in the studies included, explaining the range of observed values. Recommendations for future research and practice were produced. Modern protective ventilation during ARDS has been shown to exert inconsistent effects on the right heart which may be of clinical significance. Further research is needed to determine these effects better.

Low prealbumin is a significant predictor of medical complications in severe anorexia nervosa

Prealbumin levels have been proven to correlate with hospital length of stay, wound healing, infection rates, and mortality in adults hospitalized for medical or surgical purposes, or those who have chronic illnesses. Little is known about the utility of prealbumin evaluation in adults with severe anorexia nervosa (AN). We retrospectively evaluated prealbumin levels, along with numerous other clinical parameters relevant to illness acuity and early refeeding outcomes, in 132 adults with AN admitted for definitive inpatient medical stabilization from October 1, 2008 to December 31, 2012. Per clinical protocol, prealbumin was checked on admission and approximately weekly thereafter until discharge. Patients had a median age of 28 years old, a mean admission body mass index (BMI) of 12.9 kg/m(2) (S.D. 6.1), and 89% of patients were women. A total of 47% of patients had a low prealbumin at the time of admission. By discharge, 77% of patients had normalized their prealbumin levels. Patients with low admission prealbumin levels had a threefold increased risk of refeeding hypophosphatemia and a twofold increase in hypoglycemia compared with patients who had a normal admission prealbumin, independent of admission BMI. A low serum prealbumin level appeared concurrent with other markers of serious medical compromise, and was associated with two potentially life threatening complications of early refeeding: hypophosphatemia and hypoglycemia. The cause of low prealbumin remains elusive. Prealbumin should be checked in patients with severe AN prior to initiating weight restoration, as low levels may be an important harbinger of early refeeding complications.

Critical Care Medicine in the United States

Intensivists are increasingly needed to care for the critically ill and manage ICUs as ICU beds, utilization, acuity of illness, complexity of care and costs continue to rise. However, there is a nationwide shortage of intensivists that has occurred despite years of well publicized warnings of an impending workforce crisis from specialty societies and the federal government. The magnitude of the intensivist shortfall, however, is difficult to determine because there are many perspectives of optimal ICU administration, patient coverage and intensivist availability and a lack of national data on intensivist practices. Nevertheless, the intensivist shortfall is quite real as evidenced by the alternative solutions that hospitals are deploying to provide care for their critically ill patients. In the midst of these manpower struggles, the critical care environment is dynamically changing and becoming more stressful. Severe hospital bed availability and fiscal constraints are forcing ICUs to alter their approaches to triage, throughput and unit staffing. National and local organizations are mandating that hospitals comply with resource intensive and arguably unproven initiatives to monitor and improve patient safety and quality, and informatics systems. Lastly, there is an ongoing sense of professional dissatisfaction among intensivists and a lack of public awareness that critical care medicine is even a distinct specialty. This article offers proposals to increase the adult intensivist workforce through expansion and enhancements of internal medicine based critical care training programs, incentives for recent graduates to enter the critical care medicine field, suggestions for improvements in the critical care profession and workplace to encourage senior intensivists to remain in the field, proactive marketing of critical care, and expanded engagement by the critical care societies in the challenges facing intensivists.