Acute Physiology And Chronic Health Evaluation II Score Research Articles

Analysis of risk factors on prognosis of Acinetobacter baumannii bloodstream infection

To explore the risk factors on prognosis of Acinetobacter baumannii bloodstream infection. Clinical data from 78 patients with Acinetobacter baumannii bloodstream infection hospitalized in First Affiliated Hospital of Nanjing Medical University from January 2010 to November 2012 were analyzed retrospectively. According to the 28-day prognosis after admission, the patients were divided into non-survivors (n=40) and survivors (n=38). Data on demographic and clinical characteristics, wards, underlying diseases, treatments, invasive medical procedures, bacterial resistance to antibiotics, and acute physiology and chronic health evaluation II (APACHEII) score in the beginning were collected. The index as an independent risk factor of mortality was demonstrated by multivariate logistic regression analysis. The predictor value was concluded by comparing area under the receiver operating characteristic curve (ROC curve) of each index. Risk factors of mortality of Acinetobacter baumannii bloodstream infection goes as following, including intensive care unit admission[ICU, odds ratio (OR)=12.9,95% confidence interval (95%CI) 2.4-63.5, P=0.001], trachea intubation or tracheostomy (OR=6.2, 95%CI 1.5-30.4, P=0.023), invasive mechanical ventilation (OR=5.1, 95%CI 1.4-22.6, P=0.042), invasive medical procedure besides central venous catheter (including thoracentesis, bone marrow puncture, lumbar puncture, catheterization, bronchoalveolar lavage with bronchofibroscope, arteriovenous fistula plastic operation, OR=8.4, 95%CI 1.7-37.8, P=0.011), APACHEII score ≥19 in the beginning (OR=35.4, 95%CI 3.8-318.6, P=0.001). With respect to APACHE II score≥ 19 as mortality cut-off point, an area under the receiver operating curve of 0.938 was statistically significant (P<0.05), with sensitivity 76.2% and specificity 94.1%. The relationship between prognosis and antibiotic resistance did not have statistically significance. Invasive medical procedures and treatments were associated with increased mortality of patients with Acinetobacter baumannii bloodstream infection. A strong predictor of adverse outcome in such conditions was APACHEII score ≥19.

A study on causes of re-admission to surgical intensive care unit and risk factors analysis of their prognosis

To evaluate the causes of readmission of patients to surgical intensive care unit (SICU), and the risk factors involved in their prognosis. Among 7381 SICU patients admitted between January 2009 and February 2012, clinical data of 178 patients readmitted to the SICU were analyzed retrospectively and assessed by univariate and multiple step wise regression analysis. The SICU readmission rate was 2.41% (178/7381). Among 178 patients readmitted to SICU, 39.89% (71/178) of them were over 70 years old in age, and 46.07% (82/178) of readmission to SICU occurred within 48 hours after their first SICU discharge. The death rate of readmitted patients was 37.08% (66/178). At discharge from SICU and at readmission, the acute physiology and chronic health evaluation II (APACHEII) score in death group (n=66) was higher than that in survivor group (n=112, 9.15±4.13 vs. 7.74±3.62, 18.47±5.67 vs. 12.99±6.32, P<0.05 and P<0.01). At readmission, Glasgow coma score (GCS) was lower than that in survive group (10.88±4.37 vs. 12.37±2.68, P<0.01). Respiratory and operation related complications were the most common causes of SICU readmission. The incidence of sepsis, septic shock and multiple organ dysfunction syndrome(MODS) in death group was obviously higher than that in survivor group (22.7% vs. 7.1%, 19.7% vs. 7.1%, 10.6% to 0 respectively, all P<0.05). The APACHEII score and complicating MODS at time of SICU readmission were found to be the independent risk factors of death as shown by multiple step wise regression analysis (t=5.0163, P=0.0000; t=2.3641, P=0.0192). The study indicated that the criteria for discharge of patients from SICU should be strictly controlled in line with patients' condition. It is very important to actively monitor the APACHEII score and GCS score, to control both respiratory and operation related complications in order to reduce the re-admission rate of the patients to SICU.

Role of acute kidney injury staging by KDIGO criteria in choosing the opportune time of continuous blood purification

To investigate the role of acute kidney injury staging in multiple organ dysfunction syndrome (MODS) patients with acute kidney injury (AKI) for deciding the opportune time of continuous blood purification (CBP). A retrospective study was conducted. One hundred and twenty-six MODS patients with AKI in general intensive care unit (ICU) and emergency intensive care unit (EICU) requiring continuous venous-venous hemofiltration treatment were enrolled. According to the criteria of "Kidney Disease: Improving Global Outcomes Organization (KDIGO standard)" and acute physiology and chronic health evaluation II (APACHEII) score, the patients were stratified into KDIGO 1, 2, 3 groups and APACHEII score of <15, 15-25, >25 groups. ICU survival rate and renal function outcome, CBP treatment total ultrafiltration, average ICU day and the average medical costs of survivals were compared among groups. Compared with APACHEII ≤ 25, KDIGO 1, 2 hospitalized patients had significantly higher survival rate [94.1% (32/34) vs. 76.8% (43/56), P<0.05]. Renal function improvement rate in survivors of KDIGO 1, 2 patients was significantly higher than that in APACHEII ≤ 25 [90.6% (29/32) vs. 62.8 (27/43), P<0.01], and number of patients requiring CBP treatment, mean ICU day, and medical expenses were significantly reduced (CBP treatment of total ultrafiltration: 199.0±44.7 L vs. 239.0 ± 73.3 L, the mean length of stay in ICU: 12.9±3.4 days vs. 15.1±4.8 days, medical expenses: 2.6±0.4 million vs. 3.0±1.0 million, all P<0.05). There was no significant difference in above indexes between survivors in KDIGO 3 and APACHEII>25, and the indexes in KDIGO 3 and APACHEII >25 were worse than those in KDIGD 1, 2 and APACHEII>25. In patients of MODS accompanied by AKI, compared using as APACHEIIscore≤25 as opportune time to start CBP, to commence the treatment in the period of KDIGO standard 1, 2 cannot only improve patient survival with recovery of renal function, but also can reduce the ICU stay and medical expenses.

The value of bispectral index in the unconscious patients with acute brain injury due to different pathogenic factors

To observe the differences in bispectral index (BIS) in unconscious patients with acute brain injury due to different pathogenic factors, and approach its clinical significance. A retrospective study was conducted. One hundred and twenty-two unconscious patients with acute brain injured admitted to the intensive care unit (ICU) from March 2009 to August 2012 were involved. According to the pathogenic factors, all patients were divided into direct injury group (n=66) and indirect injury group (n=56). Based on BIS value, all patients were divided into the BIS<60 group (n=80) and the BIS≥60 group (n=42). The BIS was continuously measured for 12 hours during the first 3 days, or 24 hours after stoppage of sedative after admission to ICU. The mean value of BIS (BISmean) was evaluated. The acute physiology and chronic health evaluationII (APACHEII) score, probability of survival (PS) and Glasgow coma score (GCS) were recorded. On the same day, the serum protein S100 and neuron-specific enolase (NSE) were determined. The mortality and the rate of the poor neurological outcome were analyzed. (1) There were no significant differences in the age, sex, APACHEII score, PS and days of stay in ICU between the direct and indirect injury groups. (2) BISmean and GCS in direct injury group were significantly lower than those of the indirect injury group [BISmean: 39.0 (2.5, 58.0) vs. 59.0 (42.0, 71.0), GCS score: 3 (3, 5) vs. 4 (3, 6), both P<0.01], while serum S100 levels was significantly higher [2.30 (0.75, 6.66) mg/L vs. 0.84 (0.40, 3.62) mg/L, P<0.01]. There was no significant difference in the NSE level between the direct and indirect injury groups. (3) The mortality rate and poor neurological outcome rate in BIS<60 group were significantly higher than the BIS≥60 group (mortality rate: 67.50% vs. 40.48%, poor neurological outcome rate: 86.25% vs. 66.67%, P<0.01 and P<0.05). In the BIS<60 group, there were no significant differences in the mortality and poor neurological outcome rate between direct and indirect injury group. There are differences in pathogenic factors, the injury mechanism, and the degree of the brain injury between the direct and indirect injury groups. BIS monitoring could help judge the degree of different kinds of brain injury. BIS<60 indicates poor prognosis and neurological outcome in spite of the inducing factor of brain injury.

The use of Charlson weighted index of comorbidities scoring system to evaluate the impact of original diseases for prognosis in intensive care unit patients

To investigate the efficiency of original diseases by the Charlson weighted index of comorbidities (WIC) in predicting 28-day mortality in patients with critical illnesses in intensive care unit (ICU). A single-center retrospective analysis of clinical data of 406 patients admitted between January 2009 and October 2011 to Shanghai Changzheng Hospital was conducted. The patients were divided into non-survivor group (n=104) and survivor group (n=302) according to 28-day outcome. The data were recorded, and the WIC and the acute physiology and chronic health evaluation II (APACHEII) score were calculated. Logistic regression analysis was used to determine the independent predictors for 28-day mortality. Compared with survivors, the average age, WIC and APACHEII scores, severe sepsis, pneumonia, and multiple injuries were higher in non-survivors. The univariate analysis showed that age, the WIC score, APACHEII score, pneumonia, multiple injuries and severe sepsis were related with patients' 28-day prognosis. The multivariate logistic regression revealed that 28-day prognosis depended significantly on WIC score [odds ratio (OR)=1.538, 95% confidence interval (95%CI) 1.265 - 1.869, P=0.000], APACHEII score (OR=1.193, 95%CI 1.137 - 1.252, P=0.000), pneumonia (OR=0.546, 95%CI 0.304 - 0.982, P=0.043), and severe sepsis (OR=0.178, 95%CI 0.098 - 0.323, P=0.000). The area under the receiver operating characteristics curve (ROC curve) in predicting mortality was 0.657 (0.592 - 0.722) for the WIC score, 0.790 (0.739 - 0.841) for APACHEII score and 0.821 (0.772 - 0.869) for their combination. The WIC scoring system can be a good evaluation method for 28-day prognosis in ICU patients.

The predictive value of plasma N-terminal pro-B-type natriuretic peptide levels in the evaluation of prognosis and the severity of patients with septic shock induced myocardial suppression

To investigate the predictive value of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in the evaluation of prognosis and the severity of patients with septic shock induced myocardial suppression. A prospective study was conducted, with enrollment of 102 patients with septic shock in intensive care unit (ICU) of Beijing Shijitan Hospital from August 2009 to August 2011. Plasma NT-pro-BNP levels were measured on the 1st, 3rd and 5th day after admission, and the acute physiology and chronic health evaluationII (APACHEII) score, sequential organ failure assessment (SOFA) score were monitored at admission to ICU. With the 28-day mortality after admission to ICU as the standard, the patients with septic shock were divided into the survivor group and non-survivor group. Dynamic changes in plasma NT-proBNP levels and score of APACHEII and SOFA were compared between two groups. The patients were divided into non-cardiac dysfunction group [cardiac index (CI)>50.0 ml×s(-1)×m(-2)] and cardiac dysfunction group (CI<50.0 ml×s(-1)×m(-2)) according to levels of CI after admission 24 hours. The level of plasma NT-proBNP was compared between two groups. The predictive value of plasma NT-proBNP on 28-day mortality was evaluated by multivariate logistic regression analysis. (1)APACHEII score, SOFA score and plasma NT-proBNP levels in non-survivor group (n=45) were higher than those of survivor group (n=57, 1-day APACHEII score: 23.8±0.6 vs. 14.3±0.3, 1-day SOFA score: 12.4±3.0 vs. 7.7±2.8; NT-proBNP 1 day: 4.13±1.05 μg/L vs. 1.65±0.26 μg/L, 3 days: 5.32±0.93 μg/L vs. 1.87±0.29 μg/L, 5 days: 6.90±1.33 μg/L vs. 1.23±0.19 μg/L, P<0.05 or P<0.01). (2)Plasma NT-proBNP levels in cardiac dysfunction group (n=47) were higher than those of non-cardiac dysfunction group (n=55), and elevated obviously in non-survivors than those in survivors. (3)In multivariate logistic regression analysis, NT-proBNP level and APACHEII score were independent predictors of 28-day mortality (P<0.05 or P<0.01). Plasma NT-proBNP levels show obvious significance in evaluation of prognosis and the severity of patients with septic shock induced myocardial depression. Plasma NT-proBNP level and APACHEII score are independent prognostic markers of mortality and sepsis-induced myocardial depression in septic shock.

Treatment of lactic acidosis with early continuous blood purification

To observe the therapeutic effect of early continuous blood purification (CBP) on lactic acidosis patients. Using prospective randomized study method, 41 patients with lactic acidosis in intensive care unit (ICU) from January 2010 to April 2012 were randomly divided into CBP group (n=21) and control group (n=20). Among them, blood gas analysis, lactic acid, blood biochemistry were prospectively monitored at the time before treatment, 12, 24 and 72 hours after treatment. They were also evaluated with acute physiology and chronic health evaluation II (APACHEII) score, and length of stay in ICU and mortality in 28 days were recorded. Lactic acid level and APACHEII score were gradually decreased after treatment in both groups. Compared with control group, lactic acid at 12, 24 and 72 hours in CBP group was obviously lowered (12 hours: 8.23±3.94 mmol/L vs. 12.47±4.62 mmol/L, 24 hours: 4.46±1.57 mmol/L vs. 10.54±3.48 mmol/L, 72 hours: 2.69±1.03 mmol/L vs. 5.74±1.56 mmol/L, all P<0.01), while the APACHEII score at 12, 24 and 72 hours in CBP group was also significantly lowered (12 hours: 18.23±5.85 vs. 21.64±5.38, 24 hours: 16.49±4.62 vs. 20.61±5.71, 72 hours: 11.54±3.67 vs. 16.02±4.34, all P<0.05). Compared with control group, length of stay in ICU was also significantly shorter in CBP group (6.58±3.45 days vs. 11.65±4.94 days, P<0.05), and 28-day mortality was significantly lower in CBP group (23.8% vs. 45.0%, P<0.05). Early correction of lactic acidosis with CBP could reduce the mortality of lactic acidosis.

Clinical significance of melatonin concentrations in predicting the severity of acute pancreatitis

To assess the value of plasma melatonin in predicting acute pancreatitis when combined with the acute physiology and chronic health evaluation II (APACHEII) and bedside index for severity in acute pancreatitis (BISAP) scoring systems. APACHEII and BISAP scores were calculated for 55 patients with acute physiology (AP) in the first 24 h of admission to the hospital. Additionally, morning (6:00 AM) serum melatonin concentrations were measured on the first day after admission. According to the diagnosis and treatment guidelines for acute pancreatitis in China, 42 patients suffered mild AP (MAP). The other 13 patients developed severe AP (SAP). A total of 45 healthy volunteers were used in this study as controls. The ability of melatonin and the APACHEII and BISAP scoring systems to predict SAP was evaluated using a receiver operating characteristic (ROC) curve. The optimal melatonin cutoff concentration for SAP patients, based on the ROC curve, was used to classify the patients into either a high concentration group (34 cases) or a low concentration group (21 cases). Differences in the incidence of high scores, according to the APACHEII and BISAP scoring systems, were compared between the two groups. The MAP patients had increased melatonin levels compared to the SAP (38.34 ng/L vs 26.77 ng/L) (P = 0.021) and control patients (38.34 ng/L vs 30.73 ng/L) (P = 0.003). There was no significant difference inmelatoninconcentrations between the SAP group and the control group. The accuracy of determining SAP based on the melatonin level, the APACHEII score and the BISAP score was 0.758, 0.872, and 0.906, respectively, according to the ROC curve. A melatonin concentration ≤ 28.74 ng/L was associated with an increased risk of developing SAP. The incidence of high scores (≥ 3) using the BISAP system was significantly higher in patients with low melatonin concentration (≤ 28.74 ng/L) compared to patients with high melatonin concentration (> 28.74 ng/L) (42.9% vs 14.7%, P = 0.02). The incidence of high APACHEII scores (≥ 10) between the two groups was not significantly different. The melatonin concentration is closely related to the severity of AP and the BISAP score. Therefore, we can evaluate the severity of disease by measuring the levels of serum melatonin.

Modification of Acute Physiology and Chronic Health Evaluation II score through recalibration of risk prediction model in critical care patients of a respiratory disease referral center

Background:Several models have been developed to measure the severity of illness in intensive care unit (ICU) patients, It is suggested that the models should be customized depending on the characteristics of different population of patients. This study is aimed to assess and modify the performance of Acute Physiology and Chronic Health Evaluation II (APACHE-II) model in a respiratory diseases referral center.Materials and Methods:A total of 730 patients, admitted to an intensive care unit during one year, were divided into two sets (71% training and 29% test). Our modified APACHE-II model was developed and calibrated on training set. Then, the integrity of the customized model was checked and compared to the original APACHE-II, on the test set. Logistic regression was used to develop ROC analysis, F-measure and kappa coefficient and were employed to calibrate the model.Results:Both Original and Our modified APACHE-II scores performed acceptable discriminative power (AUC = 0.908: 95%CI 0.861-0.854; and AUC = 0.856: 95%CI 0.789-0.923, respectively); the difference was not significant (P = 0.132). Our modified APACHE-II showed improved accuracy (87.9% vs. 84.1%) and sensitivity (56.4% vs. 16.3%) compared to the original model. F-measure and Kappa also gave the impression of improvement for our modified APACHE-II system.Conclusion:The results demonstrated that a modified APACHE-II system in a local ICU of respiratory disease could have similar discrimination and comparable calibration to the original model.

Clinical study of kidney injury molecule-1 in the treatment of sepsis patients

To investigate the relationship between kidney injury molecule-1 (KIM-1) in urine and acute physiology and chronic health evaluation II (APACHEII) score, and the prognosis in the patients suffered from sepsis. In the perspective study, 56 patients in intensive care unit (ICU) from March 2010 to September 2011 suffered from sepsis were enrolled and treated according to the early goal-directed therapy (EGDT). The patients were divided into two groups according to the perform in EGDT or not within 6 hours (groupI, group II). Monitoring included APACHEII score, KIM-1, blood urea nitrogen (BUN) and creatinine (Cr) at before resuscitation (T0), 6 hours after resuscitation (T6 h), and 1 day (T1 d), 2 days (T2 d), 3 days (T3 d), 4 days (T4 d) and 5 days (T5 d) after ICU admission. According to the 28-day prognosis, all the patients were divided into survival group or death group. The value of APACHEII score, urine KIM-1, BUN and Cr in groupI(n=30), decreased after fluid resuscitation and decreased to the lowest at T5 d. The value of APACHEII score, urine KIM-1, BUN and Cr in groupII(n=26), increased after failure of fluid resuscitation and increased to the highest at T5 d. The value of APACHEII score at T2 d and urine KIM-1 at T1 d in groupII were significantly higher than those in groupI (APACHEII score: 26.35±6.18 vs. 13.25±4.72, urine KIM-1: 4.721±1.432 μg/L vs. 0.909±0.325 μg/L, both P<0.05). The mortality in groupI was significantly lower than that in group II [10.0% (3/30) vs. 73.1% (19/26), P<0.05]. The value of APACHEII score, urine KIM-1, BUN and Cr in survival group (n=34) decreased with the clinical condition improved and decreased to the lowest at T5 d, while the value of APACHEII score, urine KIM-1, BUN and Cr in death group (n=22) increased and increased to the highest at T5 d. The value of APACHEII score at T1 d, and urine KIM-1 at T6 d in death group were significantly higher than those in survival group (APACHEII score:26.39±8.95 vs. 14.27±5.11, urine KIM-1:3.134±1.117 μg/L vs. 1.447±0.472 μg/L, both P<0.05). KIM-1 in urine could be a good index for evaluation of sepsis, and it is helpful to understand the disease development by continuous surveillance. It is very important for the appraisal of prognosis, development and prognosis in sepsis, combined with APACHEII score.

The relationship between the level of N-terminal pro-B-type natriuretic peptide and prognosis in patients with sepsis

To detect the relationship between the level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and prognosis in patients with sepsis. A prospective controlled study was conducted. Sixty cases, including 39 sepsis and 21 severe sepsis, were enrolled from May 2010 to October 2011 in intensive care unit (ICU) of Second Hospital of Tianjin Medical University. The serum level of NT-proBNP was determined and acute physiology and chronic health evaluation II (APACHEII) score was calculated on the 1st and 3rd day. The receiver operator characteristic curve (ROC curve) was draw. According to the 28-day prognosis, all patients were divided into the survival group (n=42) or the death group (n=18). At the same time 30 healthy people were enrolled as control group. The level of NT-proBNP in the sepsis patients on the 1st and 3rd day were significantly higher than those of healthy controls (65.77±34.78 ng/L, 74.23±42.12 ng/L vs. 48.36±35.53 ng/L, P<0.05 and P<0.01). The level on 1st day of the severe sepsis group was higher than sepsis group (71.69±32.86 ng/L vs. 50.11±36. 98 ng/L, P<0.05), but there was no statistically significance on the 3rd day. The level of NT-proBNP in death group was increased gradually and significantly higher than that of survival group on the 3rd days (99.20±44.34 ng/L vs. 66.79±39.28 ng/L, P<0.05), but no difference was found on the 1st day. The APACHEII score of severe sepsis group were much higher than those of sepsis group on the 1st and 3rd day (1st day:23.92±7.57 vs. 14.87±6.50, 3rd day:19.28±8.80 vs. 10.43±7.27, both P<0.01). The APACHEII score of death group were also much higher than those of survival group on the 1st and 3rd day (1st day:26.71±6.72 vs. 18.83±7.84, 3rd day:31.11±5.06 vs. 13.80±7.27, both P<0.01). The cut point for the evaluation of sepsis prognosis were NT-proBNP≥63.5 ng/L and APACHEII score≥20, which sensitivity were 65.4% and 88.5%, and specificity were 62.5% and 69.4% respectively. Serum NT-proBNP levels elevation imply the poor prognosis in patients with sepsis.

Methicillin-resistant Staphylococcus aureus bacteremia in hemodialysis and nondialysis patients

Increased mortality has been reported in patients treated with vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with high minimum inhibitory concentration (MIC) values within the susceptibility range. However, this finding has not been verified in hemodialysis patients, who have much higher invasive MRSA infection rates than nondialysis patients. We aimed at comparing vancomycin MICs between hemodialysis and nondialysis patients, and identifying predictors of high vancomycin MICs and infection-related mortality in hemodialysis patients with MRSA bacteremia. Patients with MRSA bacteremia from January 2008 through December 2009 were enrolled. Vancomycin MIC was determined for each first isolate using the Etest method. Clinical characteristics and vancomycin MICs were compared between hemodialysis and nondialysis patients. Factors associated with high vancomycin MIC (2 μg/mL) and infection-related mortality in hemodialysis patients were analyzed. A total of 162 MRSA bacteremia episodes were identified. Forty-four (27.0%) isolates were obtained from hemodialysis patients and 118 (73.0%) from nondialysis patients. Diabetes (63.3% vs. 39.8%, p = 0.007) and prior vancomycin exposure in 30 days (31.8% vs. 12.7%, p = 0.005) were more prevalent in hemodialysis group than in nondialysis group. A higher prevalence of vancomycin MIC of 2 μg/mL was observed in hemodialysis group in comparison with nondialysis group (11.4% vs. 1.7%, p = 0.016). In following analyses of hemodialysis group, patients with initial presentation of septic shock had a higher risk of vancomycin MIC of 2 μg/mL than nonseptic shock patients (100.0% vs. 38.5% p = 0.014). Infection-related mortality was associated with age, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score >15, presence of septic shock, receipt of mechanical ventilation, and failure to remove source of bacteremia in univariate analysis. Hemodialysis patients with MRSA bacteremia are more likely to have a high vancomycin MIC (2 μg/mL) compared with nondialysis patients. Infection-related mortality is associated with the patient's clinical manifestations, including age, APACHE-II score >15, presence of septic shock, receipt of mechanical ventilation, and failure to remove source of bacteremia. Treatment selection should be tailored according to the patient's clinical condition.

The influence of sex hormones on human leukocyte antigen-DR, soluble myeloid cell receptor-1 and prognosis in patients with severe intra-abdominal infection

To evaluate the influence of serum estradiol, prolactin and testosterone levels on human leukocyte antigen-DR (HLA-DR), soluble myeloid cell receptor-1 (sTREM-1) and prognosis in patients with severe abdominal infection, in order to evaluate the clinical value of the above-mentioned sex hormones. From July 10, 2009 to February 9, 2010, 73 cases with severe intra-abdominal infections hospitalized in surgical intensive care unit (ICU) of Tianjin Nankai Hospital were enrolled. Within 72 hours after enrollment, serum estradiol, prolactin and testosterone levels were detected by radioimmunoassay. Based on their levels, all the cases were divided into increased estradiol group (n=38) and non-increased estradiol group (n=35), increased prolactin group (n=28) and non-increased prolactin group (n=45), decreased testosterone group (n=33) and non-decreased testosterone group (n=40) respectively. In addition, HLA-DR (flow cytometry), as well as of sTREM-1 (enzyme linked immunosorbent assay), acute physiology and chronic health evaluation II (APACHEII) score, hospital days, the ICU length, hospital costs and 28 day mortality were recorded. Compared with non-increased estradiol group, HLA-DR in increased estradiol group decreased significantly [(61.22±22.39)% vs. (75.09±14.85)%], while sTREM-1 (ng/L) increased obviously (291.59±148.13 vs. 216.48±124.82), APACHEII score lowered dramatically (11.47±6.88 vs. 15.36±8.79), hospital costs (ten thousands) raised significantly (10.98±8.15 vs 6.25±3.51), ICU length (days) was much shorter (8.56±4.05 vs. 12.17±7.99), and 28 days mortality was significantly lowered (10.00% vs. 32.75%,P<0.05 or P<0.01). Compared with non-increased prolactin group, increased prolactin group had much lower HLA-DR levels [(61.19±21.50)% vs. (72.02±18.49)%], higher sTREM-1 levels (307.92±173.93 vs. 223.01±106.93), at the same time, their cost of hospitalization (7.75±3.52 vs. 11.36±8.24) and ICU stay length (9.14±3.15 vs. 13.24±2.16) were significantly lower (all P<0.05). Compared with non-decreased testosterone group, HLA-DR in decreased testosterone group increased significantly [(74.69±14.72)% vs. (62.24±22.54)%], while sTREM-1 decreased obviously (208.77±77.80 vs. 294.20±169.36), APACHEII score lowered dramatically (10.57±6.97 vs. 15.39±9.46), hospital costs decreased significantly (7.67±3.81 vs. 11.19±8.05), and 28 days mortality lowered significantly (0 vs. 30.14%, P<0.05 or P<0.01). In the early stage of severe intra-abdominal infection, estrogen, prolactin and testosterone levels had powerful influences on immune, inflammation, and prognosis, which may indicated a widespread clinical application.

Effect of interleukin-10 level and human leukocyte antigen-DR expression as prognostic predictors in critically ill patients undergoing continuous renal replacement therapy

To inquire into interleukin-10 (IL--10) level and monocyte expression of human leukocyte antigen--DR (HLA--DR) are predictors of infection and prognosis in critically ill patients undergoing continuous renal replacement therapy (CRRT). A total of 43 critically ill patients undergoing continuous veno-venous hemofiltration (CVVH) were recruited from the intensive care unit (ICU). Anti--coagulated blood was obtained at 1 day before and 4 days after undergoing CVVH, and plasma IL--10 level (enzyme linked immunosorbent assay) and HLA--DR expression (flow cytometry) were determined. Thirty healthy subjects were enrolled as controls. In addition, the correlation between IL--10 and acute physiology and chronic health evaluation II (APACHEII) score was assessed. (1)Altogether, 7 patients died among a total of 43 critically ill patients, the mortality was 16.3%. Eighteen patients had negative cultures during the study (group I), and 19 patients had positive cultures (group II), and in 6 patients positive bacterial culture appeared 72 hours after the beginning of the treatment (group III). (2) The IL--10 level (ng/L) was higher in patients than in healthy subjects [23.46 (46.71) vs. 0.32 (0.45), P < 0.01]. Compared with group I, the levels of IL--10 in group II and III were higher significantly [40.20 (46.44), 41.78 (49.63) vs. 7.33 (21.05), both P < 0.05]. Continuous observation revealed that IL--10 rapidly lowered in group I after treatment [4.50 (7.44) vs. 7.33 (21.05), P < 0.05], while there was no apparent change in patients of other two groups. It was found that IL--10 was significant positive correlation with the APACHEII score (r = 0.71, P < 0.01).(3) HLA--DR was lower in patients than in healthy individuals [21.65% (25.62%) vs. 90.39% (9.80%), P < 0.01]. After CVVH, HLA--DR expression was obviously increased in group I [64.95% (35.03%) vs. 32.45% (45.03%), P < 0.01]. However, there were no significant changes in the other two groups. The patients who died had persistent and extremely low HLA--DR expression. (1)A significant discriminative power of IL--10 levels in predicting disease severity was found among the patients receiving CRRT, and persistently high IL--10 level predicts poor prognosis. (2) Persistently low monocyte HLA--DR expression may indicate concomitant or impending infection in patients receiving CRRT.

Procalcitonin and BISAP score versus c-reactive protein and APACHE II score in early assessment of severity and outcome of acute pancreatitis

Early assessment of severity and continuous monitoring of patients are the key factors for adequate treatment of acute pancreatitis (AP). The aim of this study was to determine the value of procalcitonin (PCT) and Bedside Index for Severity in Acute Pancreatitis (BISAP) scoring system as prognostic markers in early stages of AP with comparison to other established indicators such as C-reactive protein (CRP) and Acute Physiology and Chronic Health Evaluation (APACHE) II score. This prospective study included 51 patients (29 with severe AP). In the first 24 h of admission in all patients the APACHE II score and BISAP score, CRP and PCT serum concentrations were determined. The values of PCT serum concentrations and BISAP score were compared with values of CRP serum concentrations and APACHE II score, in relation to the severity and outcome of the disease. Values of PCT, CRP, BISAP score and APACHE II score, measured at 24 h of admission, were significantly elevated in patients with severe form of the disease. In predicting severity of AP at 24 h of admission, sensitivity and specificity of the BISAP score were 74% and 59%, respectively, APACHE II score 89% and 69%, respectively, CRP 75% and 86%, respectively, and PCT 86% and 63%, respectively. It was found that PCT is highly significant predictor of the disease outcome (p < 0,001). In early assessment of AP severity, PCT has better predictive value than CRP, and similar to the APACHE II score. APACHE II score is a stronger predictor of the disease severity than BISAP score. PCT is a good predictor of AP outcome.

Prediction of Failure in Vancomycin-Treated Methicillin-Resistant Staphylococcus aureus Bloodstream Infection: a Clinically Useful Risk Stratification Tool

Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of bloodstream infection (BSI) and is often associated with invasive infections and high rates of mortality. Vancomycin has remained the mainstay of therapy for serious Gram-positive infections, particularly MRSA BSI; however, therapeutic failures with vancomycin have been increasingly reported. We conducted a comprehensive evaluation of the factors (patient, strain, infection, and treatment) involved in the etiology and management of MRSA BSI to create a risk stratification tool for clinicians. This study included consecutive patients with MRSA BSI treated with vancomycin over 2 years in an inner-city hospital in Detroit, MI. Classification and regression tree analysis (CART) was used to develop a risk prediction model that characterized vancomycin-treated patients at high risk of clinical failure. Of all factors, the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, with a cutoff point of 14, was found to be the strongest predictor of failure and was used to split the population into two groups. Forty-seven percent of the population had an APACHE-II score < 14, a value that was associated with low rates of clinical failure (11%) and mortality (4%). Fifty-four percent of the population had an APACHE-II score ≥ 14, which was associated with high rates of clinical failure (35%) and mortality (23%). The risk stratification model identified the interplay of three other predictors of failure, including the vancomycin MIC as determined by Vitek 2 analysis, the risk level of the source of BSI, and the USA300 strain type. This model can be a useful tool for clinicians to predict the likelihood of success or failure in vancomycin-treated patients with MRSA bloodstream infection.

Evaluation of continuous monitoring of bispectral index in prognosis in patients with acute brain injury

To discuss the effect of continuous monitoring of bispectral index (BIS) on the prognosis of patients with acute brain injury. A retrospective study was carried out, 61 patients with acute brain injury admitted to the intensive care unit (ICU) from March 2009 to July 2010 were divided into survival group (n=25) and death group (n=36). The BIS was continuously monitored for 12 hours within the first 3 days or 24 hours after stoppage of sedative after admission to ICU. The mean value of BIS (BISmean), the maximal value of BIS (BISmax), and the minimal value of BIS (BISmin) were evaluated. At the same time, the acute physiology and chronic health evaluationII (APACHEII) score, probability of survival (PS) and Glasgow coma score (GCS) were evaluated. The values of serum S100 protein and neuron-specific enolase (NSE) were determined. The relationship between BISmean and GCS, S100 protein and NSE were respectively analyzed. (1)There was no significant difference in the sex, age, or duration of mechanical ventilation between two groups. APACHEII score in death group was significantly higher than the survival group (27.36±5.99 vs. 23.28±6.69), PS was significantly lower than the survival group (0.31±0.17 vs. 0.49±0.19), and length of stay in ICU (days) was significantly lower than that of the survival group (6.33±4.48 vs. 27.88±54.46), P<0.05 or P<0.01. (2) BISmean, BISmax, BISmin, GCS in death group were significantly lower than those in the survival group (BISmean: 35.45±28.31 vs. 55.91±17.53, BISmax: 51.92±34.24 vs. 74.84±16.58, BISmin: 22.39±24.83 vs. 39.68±15.72, GCS score: 3.64±1.19 vs. 5.60±2.22), P<0.05 or P<0.01, while serum S100 protein and NSE levels were significantly higher than the survival group [S100 protein (μg/L): 7.54±10.49 vs. 1.18±1.57, NSE (μg/L): 120.74±109.01 vs. 49.83±54.94], both P<0.01. (3) By bivariate analysis, BISmean was positively correlated with GCS (r=0.379, P=0.003), whereas it was found to be negatively correlated with S100 protein and NSE levels (r₁=-0.418, P₁=0.001; r₂=-0.290, P₂=0.023). BIS monitoring can be applied as an early objective indicator to evaluate the prognosis of the acute brain injured patients with the characteristics of being noninvasive, intuitive, easy-to-manipulate, and non-stop monitoring.

Admission Visfatin Levels Predict Pancreatic and Peripancreatic Necrosis in Acute Pancreatitis and Correlate With Clinical Severity

Adipocytes of peripancreatic and intrapancreatic adipose tissue secret adipocytokines such as leptin, adiponectin, and resistin. For resistin, a role as an early predictor of peripancreatic necrosis and clinical severity in acute pancreatitis has been reported. It was the aim of this study to investigate whether the adipocytokine visfatin is able to serve as an early marker predicting peripancreatic necrosis and clinical severity. A total of 50 patients (20 females and 30 males) with acute pancreatitis were included in this noninterventional, prospective, and monocentric cohort study on diagnostic accuracy. Clinical severity was classified by the Ranson score and APACHE-II (Acute Physiology and Chronic Health Evaluation II) score. Pancreatic and peripancreatic necrosis were quantified by the computed tomography-based Balthazar score, the Schroeder score, and the pancreatic necrosis score. Visfatin was measured at admission and daily for 10 days by enzyme-linked immunosorbent assay (ELISA). Visfatin values were significantly and positively correlated with clinical severity (APACHE-II score and Ranson score) and with clinical end points such as death and need for interventions. Admission visfatin levels were significantly elevated in patients with higher pancreatic and extrapancreatic necrosis scores. It was shown by receiver operator characteristics that admission visfatin concentration provides a positive predictive value of 93.3% in predicting the extent of peripancreatic necrosis (area under the curve (AUC): 0.89, P<0.001, sensitivity: 93.3%, specificity: 81.8%, likelihood ratio: 5.1, post-test probability: 93%) by using a cutoff value of 1.8 ng/ml. Admission visfatin concentration serves as an early predictive marker of peripancreatic necrosis and clinical severity in acute pancreatitis. Visfatin may have potential for clinical use as a new and diagnostic serum marker.

Usefulness of N-terminal pro-brain natriuretic peptide and C-reactive protein to predict ICU mortality in unselected medical ICU patients: a prospective, observational study

IntroductionThe performance of N-terminal pro-brain natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) to predict clinical outcomes in ICU patients is unimpressive. We aimed to assess the prognostic value of NT-proBNP, CRP or the combination of both in unselected medical ICU patients.MethodsA total of 576 consecutive patients were screened for eligibility and followed up during the ICU stay. We collected each patient's baseline characteristics including the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, NT-proBNP and CRP levels. The primary outcome was ICU mortality. Potential predictors were analyzed for possible association with outcomes. We also evaluated the ability of NT-proBNP and CRP additive to APACHE-II score to predict ICU mortality by calculation of C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) indices.ResultsMultiple regression revealed that CRP, NT-proBNP, APACHE-II score and fasting plasma glucose independently predicted ICU mortality (all P < 0.01). The C-index with respect to prediction of ICU mortality of APACHE II score (0.82 ± 0.02; P < 0.01) was greater than that of NT-proBNP (0.71 ± 0.03; P < 0.01) or CRP (0.65 ± 0.03; P < 0.01) (all P < 0.01). As compared with APACHE-II score (0.82 ± 0.02; P < 0.01), combination of CRP (0.83 ± 0.02; P < 0.01) or NT-proBNP (0.83 ± 0.02; P < 0.01) or both (0.84 ± 0.02; P < 0.01) with APACHE-II score did not significantly increase C-index for predicting ICU mortality (all P > 0.05). However, addition of NT-proBNP to APACHE-II score gave IDI of 6.6% (P = 0.003) and NRI of 16.6% (P = 0.007), addition of CRP to APACHE-II score provided IDI of 5.6% (P = 0.026) and NRI of 12.1% (P = 0.023), and addition of both markers to APACHE-II score yielded IDI of 7.5% (P = 0.002) and NRI of 17.9% (P = 0.002). In the cardiac subgroup (N = 213), NT-proBNP but not CRP independently predicted ICU mortality and addition of NT-proBNP to APACHE-II score obviously increased predictive ability (IDI = 10.2%, P = 0.018; NRI = 18.5%, P = 0.028). In the non-cardiac group (N = 363), CRP rather than NT-proBNP was an independent predictor of ICU mortality.ConclusionsIn unselected medical ICU patients, NT-proBNP and CRP can serve as independent predictors of ICU mortality and addition of NT-proBNP or CRP or both to APACHE-II score significantly improves the ability to predict ICU mortality. NT-proBNP appears to be useful for predicting ICU outcomes in cardiac patients.

Red cell distribution width as a novel predictor of mortality in ICU patients

Background. The red cell distribution width (RDW) in ICU patients has never been investigated. Methods. A total of 602 consecutive patients were prospectively enrolled. We collected each patient's base-line characteristics including the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, RDW, and C-reactive protein (CRP). The primary outcome for this analysis was ICU mortality, and secondary outcome was the total length of stay in hospital (TLSH). Potential predictors were analyzed for possible association with outcomes. Results. There was a significantly graded increase in APACHE-II score (tertile I = 10.7 ± 6.5 versus tertile II = 13.3 ± 6.2 versus tertile III = 15.8 ± 7.2; all P < 0.001) and ICU mortality rate (tertile I = 11.2% versus tertile II = 18.8% versus tertile III = 33.8%; all P < 0.001) across increasing of RDW tertile. As compared with APACHE-II score, combination of RDW and APACHE-II score increased the area under the curve (AUC) for predicting ICU mortality from 0.832 ± 0.020 to 0.885 ± 0.017 (P < 0.05). Multivariate analysis demonstrated that RDW, APACHE-II score, and CRP were independent predictors of ICU mortality (P < 0.05). RDW was also independently associated with TLSH in patients alive (P < 0.05). Conclusion. We found a graded independent relation between higher RDW and adverse outcomes in ICU patients. RDW has the potentially clinical utility to predict outcome in ICU patients.