Crude 30-day Mortality Research Articles

Clinical and Microbiological Characteristics of Perianal Infections in Adult Patients with Acute Leukemia

BackgroundPerianal infection is a common problem for patients with acute leukemia. However, neutropenia and bleeding tendency are relatively contraindicated to surgical intervention. The epidemiology, microbiology, clinical manifestations and outcomes of perianal infection in leukemic patients are also rarely discussed.MethodThe medical records of 1102 adult patients with acute leukemia at a tertiary medical center in Taiwan between 2001 and 2010 were retrospectively reviewed and analyzed.ResultThe prevalence of perianal infection was 6.7% (74 of 1102) in adult patients with acute leukemia. Twenty-three (31%) of the 74 patients had recurrent episodes of perianal infections. Patients with acute myeloid leukemia had higher recurrent rates than acute lymphoblastic leukemia patients (p = 0.028). More than half (n = 61, 53%) of the perianal infections were caused by gram-negative bacilli, followed by gram-positive cocci (n = 36, 31%), anaerobes (n = 18, 15%) and Candida (n = 1, 1%) from pus culture. Eighteen patients experienced bacteremia (n = 24) or candidemia (n = 1). Overall 41 (68%) of 60 patients had polymicrobial infection. Escherichia coli (25%) was the most common micro-organism isolated, followed by Enterococcus species (22%), Klebsiella pneumoniae (13%), and Bacteroides species (11%). Twenty-five (34%) of 74 patients received surgical intervention. Acute leukemia patients with surgically managed anal fistulas tended to have fewer recurrences (p = 0.067). Four (5%) patients died within 30 days after diagnosis of perianal infection. Univariate analysis of 30-day survival revealed the elderly (≧ 65 years) (p = 0.015) and patients with shock (p<0.001) had worse outcome. Multivariate analysis showed septic shock to be the independent predictive factor of 30-day crude mortality of perianal infections (p = 0.016).ConclusionPerianal infections were common and had high recurrence rate in adult patients with acute leukemia. Empirical broad-spectrum antibiotics with anaerobic coverage should be considered. Shock independently predicted 30-day crude mortality. Surgical intervention for perianal infection remains challenging in patients with acute leukemia.

Relationship between hospital volume and risk-adjusted mortality rate following percutaneous coronary intervention in Korea, 2003 to 2004

There have been a large number of studies that have investigated the relationship between outcomes and provider volume for a wide variety of medical conditions and surgical conditions. The objective of this study was to explore the relation between hospital volume and risk-adjusted mortality following percutaneous coronary intervention between 2003 and 2004 in Korea. This is a retrospective analysis of database in National Health Insurance Review & Assessment Service and Korean National Statistical Office. The study data set confined to the ICD-10 diagnosis and procedure codes that were recorded in the National Health Insurance Review Agency. Risk modeling was performed through logistic regression and validated with cross-validation. The statistical performance of the developed model was evaluated using c-statistics, R², and Hosmer-Lemeshow statistic. Crude and risk-adjusted 30-day mortality was evaluated among patients who underwent Percutaneous Coronary Intervention (PCI) between 2003 and 2004 at low (less 200 cases/year), medium (200~399 cases/year), and high (400 cases or more/year) PCI volume hospitals. The final risk-adjustment model consisted of ten risk factors for 30-day mortality. These factors were found to have statistically significant effects on patient mortality. The c-statistic and Hosmer-Lemeshow χ² goodness-of-fit test and the model's performance were good [R²=0.147, c-statistic 0.823, 4.1037 (p=0.8476)]. A total number of 60 low-volume hospitals (9.071 patients) and 27 medium-volume hospitals (15.623 patients) and 15 high-volume hospitals (19.669 patients) were included. Crude 30-day mortality rate was 1.4%, 1.1%, and 1.0% (p=0.0106) in each volume hospitals. But risk-adjusted mortality rate was not significantly different among three groups (1.3%, 1.0%, and 1.1% in each volume hospitals). Although we found a significant different crude 30-day mortality rates according to hospital PCI volume, but did not find a relationship between hospital volume and 30-day risk-adjusted mortality rates following PCI in Korea.

Age of red blood cells and outcome in acute kidney injury

IntroductionTransfusion of red blood cells (RBCs) and, in particular, older RBCs has been associated with increased short-term mortality in critically ill patients. We evaluated the association between age of transfused RBCs and acute kidney injury (AKI), hospital, and 90-day mortality in critically ill patients.MethodsWe conducted a prospective, observational, predefined sub-study within the FINNish Acute Kidney Injury (FINNAKI) study. This study included all elective ICU admissions with expected ICU stay of more than 24 hours and all emergency admissions from September to November 2011. To study the age of RBCs, we classified transfused patients into quartiles according to the age of oldest transfused RBC unit in the ICU. AKI was defined according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria.ResultsOut of 1798 patients, 652 received at least one RBC unit. The median [interquartile range] age of the oldest RBC unit transfused was 12 [11-13] days in the freshest quartile and 21 [17-27] days in the quartiles 2 to 4. On logistic regression, RBC age was not associated with the development of KDIGO stage 3 AKI. Patients in the quartile of freshest RBCs had lower crude hospital and 90-day mortality rates compared to those in the quartiles of older blood. After adjustments, older RBC age was associated with significantly increased risk for hospital mortality. Age, Simplified Acute Physiology Score II (SAPS II)-score without age points, maximum Sequental Organ Failure Assessment (SOFA) score and the total number of transfused RBC units were independently associated with 90-day mortality.ConclusionsThe age of transfused RBC units was independently associated with hospital mortality but not with 90-day mortality or KDIGO stage 3 AKI. The number of transfused RBC units was an independent risk factor for 90-day mortality.

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Introduction: The purpose of this study is to evaluate the potential for using transthoracic echocardiography (TTE) as an alternative modality to assist in placement of venovenous double lumen bicaval catheters via the internal jugular (IJ) approach. Hypothesis: Currently TTE or fluoroscopy are used to assist in placement of VV ECMO cannulae. The hypothesis of this study is there is no increased complication rate using bedside TTE performed by trained critical care specialists for this procedure. Methods: This is a retrospective cohort of adult patients admitted with refractory respiratory failure at two tertiary hospitals of the Montefiore Medical Center, Bronx, New York. The inclusion criterion was patients placed on VV ECMO using TTE to assist in placement of the cannula. Venous cannulation was achieved with the aid of ultrasound guidance of the right IJ vein. The Avalon Elite® Dual Lumen Bicaval catheter was placed by a cardiothoracic surgeon. The guidewire was identified at the IVC/right atrial junction via transthoracic echococardiographic views obtained by an intensivist. The proper ECMO cannula position was confirmed at the level of the tricuspid valve via a transthoracic echocardiographic view with the aid of color Doppler flow. A chest radiograph was obtained to rule out pneumothorax post cannula insertion. Results: Between June 1, 2009 and August 20, 2012, there were 5 cases of VV ECMO via the right IJ approach performed at the bedside assisted by TTE performed by trained intensivists. The median (IQR) age was 27 (23, 44) years, 57% were men and 57% were African American. The median (IQR) body mass index was 25 (23, 32). Two patients had ARDS, two had status asthmaticus and one had pulmonary edema. The mean+/-SD PF ratio was 48+/-8 in the ARDS group and 67 in the patient with pulmonary edema. The pCO2 was 113 and 148 in the group with status asthmaticus. The median (IQR) hospital length of stay was 12(9,54) days. All patients survived with no complications related to catheter placement or while on ECMO. The crude 90-day mortality was zero (n=4, one patient has not reached 90-days). Conclusions: TTE performed by an intensivist presents a viable option to aid in VV ECMO cannulation.

Carbapenem-Sparing Antibiotic Regimens for Infections Caused by Klebsiella pneumoniae Carbapenemase-Producing K. pneumoniae in Intensive Care Unit

A carbapenem-sparing regimen of tigecycline plus gentamicin or colistin was effective for treating 24 of 26 (92%) Klebsiella pneumoniae carbapenemase-producing K. pneumoniae infectious episodes in 22 polytrauma intensive care unit patients without comorbidities. The 30-day crude mortality rate was 14%. Regimens were considered appropriate in 12% of episodes according to the Vitek 2 System and in 100% based on E-test.

Comparison of polymyxin B with other antimicrobials in the treatment of ventilator-associated pneumonia and tracheobronchitis caused by Pseudomonas aeruginosa or Acinetobacter baumannii

This study was designed to compare the efficacy of polymyxin B with other antimicrobials in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT) by Pseudomonas aeruginosa or Acinetobacter baumannii. A prospective cohort study was performed. Patients >18 years of age with the diagnosis of VAP or VAT who received appropriate therapy for >48 h were analyzed. The primary outcome was 30-day mortality. Clinical covariates were assessed and compared between the groups. A total of 67 episodes were analyzed: 45 (67 %) treated with polymyxin B and 22 (33 %) with comparators. The crude 30-day mortality was 53 % (24 of 45) in the polymyxin B group and 27 % (6 of 22) in the comparator group (P = 0.08). Multivariable analysis using Cox regression models indicated that polymyxin B treatment was independently associated with increased mortality. Polymyxin B treatment in the currently recommended dosage may be inferior to other drugs in the treatment of VAP and VAT caused by organisms tested as susceptible in vitro to this agent.

Cefepime Therapy for Monomicrobial Bacteremia Caused by Cefepime-Susceptible Extended-Spectrum Beta-Lactamase–Producing Enterobacteriaceae: MIC Matters

Extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae isolates are important clinical pathogens. In addition, the efficacy of cefepime for such infections is controversial. We performed a retrospective study of monomicrobial bacteremia caused by ESBL producers at 2 medical centers between May 2002 and August 2007. The patients definitively treated with in vitro active cefepime (cases) were compared with those treated with a carbapenem (controls) in a propensity score-matched analysis to assess therapeutic effectiveness. The 30-day crude mortality is the primary endpoint. A total of 178 patients were eligible for the study. Patients who received cefepime (n = 17) as definitive therapy were more likely to have a clinical failure (odds ratio [OR] 6.2; 95% confidence interval [CI], 1.7-22.5; P = .002), microbiological failure (OR 5.5; 95% CI, 1.3-25.6; P = .04), and 30-day mortality (OR 7.1; 95% CI, 2.5-20.3; P < .001) than those who received carbapenem therapy (n = 161). Multivariate regression revealed that a critical illness with a Pitt bacteremia score ≥ 4 points (OR 5.4; 95% CI, 1.4-20.9; P = .016), a rapidly fatal underlying disease (OR 4.4; 95% CI, 1.5-12.6; P = .006), and definitive cefepime therapy (OR 9.9; 95% CI, 2.8-31.9; P < .001) were independently associated with 30-day crude mortality. There were 17 case-control pairs in the propensity scores matched analysis. The survival analysis consistently found that individuals who received cefepime therapy had a lower survival rate (log-rank test, P = .016). Based on the current Clinical and Laboratory Standards Institute susceptible breakpoint of cefepime (minimum inhibitory concentration ≤ 8 μg/mL), cefepime definitive therapy is inferior to carbapenem therapy in treating patients with so-called cefepime-susceptible ESBL-producer bacteremia.

Stable incidence and continued improvement in short term mortality of Staphylococcus aureus bacteraemia between 1995 and 2008

BackgroundThe objective of this study was to assess temporal changes in incidence and short term mortality of Staphylococcus aureus bacteraemia (SAB) from 1995 through 2008.MethodsThe study was conducted as a nation-wide observational cohort study with matched population controls. The setting was hospitalized patients in Denmark 1995-2008. Uni- and multivariate analyses were used to analyze the hazard of death within 30 days from SAB.ResultsA total of 16 330 cases of SAB were identified: 57% were hospital-associated (HA), 31% were community-acquired (CA) and 13% were of undetermined acquisition. The overall adjusted incidence rate remained stable at 23 per 100 000 population but the proportion of SAB cases older than 75 years increased significantly. Comorbidity in the cohort as measured by Charlson comorbidity index (CCI) score and alcohol-related diagnoses increased over the study period. In contrast, among the population controls the CCI remained stable and alcohol-related diagnoses increased slightly. For HA SAB crude 30-day mortality decreased from 27.8% to 21.8% (22% reduction) whereas the change for CA SAB was small (26.5% to 25.8%). By multivariate Cox regression, age, female sex, time period, CCI score and alcohol-related diagnoses were associated with increased mortality regardless of mode of acquisition.ConclusionsThroughout a 14-year period the overall incidence of SAB remained stable while the overall short term prognosis continued to improve despite increased age and accumulation of comorbidity in the cohort. However, age and comorbidity were strong prognostic indicators for short term mortality.

Comparison of epidemiology and treatment outcome of patients with candidemia at a teaching hospital in Northern Taiwan, in 2002 and 2010

The incidence of candidemia varied between hospitals and different study periods. Few, if any, studies provide the reasons. This hospital-based population study aimed to describe and compare the patient population hospitalized in 2002 and 2010 and determine the disease-specific incidences of candidemia and evaluate the impact of time to initiate antifungal therapy on 30-day mortality. All patients hospitalized at a 2300-bed teaching hospital in Taiwan in 2002 and 2010 were analyzed for the distribution of age, sex, and type of underlying diseases (maximum of six diagnoses). All patients with blood isolates that were collected in 2002 and 2010 and yielded Candida species were included for analysis of the demographic and clinical characteristics, distribution of Candida species, length of hospital stay before candidemia, stay in the intensive care units at onset of candidemia, time of initiating systemic antifungal agent, antifungal regimen, and 30-day crude mortality. In 2010, the hospitalized patients were older (p<0.001), had a higher Charlson Comorbidity Index (p<0.001), and more underlying disease/status, including chronic pulmonary diseases, moderate-to-severe renal diseases, leukemia, lymphoma, and gastrointestinal malignancies (p<0.001) than those seen in 2002. Multivariate analysis identified the following host factors were associated with the occurrence of candidemia in 2010: neonate (adjust odds ratio [OR], 3.67), 45-64 year (OR, 2.18) and the elderly (OR 2.64), compared with young adult (20-44 year); patients with moderate-to-severe renal diseases (OR, 8.08), leukemia (OR, 4.58) and lymphoma (OR 3.98) and gastrointestinal malignancies (OR 2.80). The incidence density of candidemia was 0.34 and 0.41 per 1000 patient-days in 2002 and 2010, respectively (p=0.04). The majority of characteristics of patients with candidemia and disease-specific incidences of candidemia did not differ between 2002 and 2010. Despite more patients in 2010 receiving antifungal therapy on the same day or 1 day after onset (27.5% vs. 41.2%, respectively, p=0.002), the 30-day mortality remained high (45.9% in 2002 and 44.4% in 2010). Moreover, time to initiate antifungal therapy had no impact on 30-day mortality. This hospital-based population study demonstrated that the incidence density of candidemia was high and increased in 2010 compared with 2002, which was at least in part due to the increase in the proportion of patients at a higher risk of candidemia. Although antifungal therapy was initiated earlier in 2010, the 30-day mortality remained high.

Associated clinical characteristics of patients with candidemia among different Candida species

The rising incidence of non-albicans Candida (NAC) infection has been associated with a potentially adverse outcome for patients with candidemia. However, categorizing various species causing candidemia into a single NAC group might lead to inappropriate conclusions due to heterogeneity in species. Thus we examined the associated factors among patients with candidemia caused by different species. This retrospective study was conducted at a tertiary medical center in Taiwan from 2006 to 2009. Mortality rate, demographic and clinical characteristics, albumin levels, and severity scores of acute illness of patients at the onset of candidemia were analyzed. A total of 447 episodes among 418 patients were included for analysis. The overall 30-day crude mortality was 48.2%, with no significant difference between C. albicans and NAC candidemia, but apparently C. parapsilosis candidemia was associated with a lower mortality rate. Time to positivity for yeast was significantly different between species. Compared with infection involving C. albicans, more frequent use of total parenteral nutrition, lower Sequential Organ Failure Assessment score and higher albumin levels were observed for C. parapsilosis candidemia. Identifying associated factors for each species may be a more effective approach than single NAC grouping. Time to positivity may be a hint for treatment guidance in candidemia. More frequent use of total parenteral nutrition and less virulent nature were noted for C. parapsilosis candidemia.

Association of Changes in Clinical Characteristics and Management With Improvement in Survival Among Patients With ST-Elevation Myocardial Infarction

The contemporary decline in mortality reported in patients with ST-segment elevation myocardial infarction (STEMI) has been attributed mainly to improved use of reperfusion therapy. To determine potential factors-beyond reperfusion therapy-associated with improved survival in patients with STEMI over a 15-year period. Four 1-month French nationwide registries, conducted 5 years apart (between 1995, 2000, 2005, 2010), including a total of 6707 STEMI patients admitted to intensive care or coronary care units. Changes over time in crude 30-day mortality, and mortality standardized to the 2010 population characteristics. Mean (SD) age decreased from 66.2 (14.0) to 63.3 (14.5) years, with a concomitant decline in history of cardiovascular events and comorbidities. The proportion of younger patients increased, particularly in women younger than 60 years (from 11.8% to 25.5%), in whom prevalence of current smoking (37.3% to 73.1%) and obesity (17.6% to 27.1%) increased. Time from symptom onset to hospital admission decreased, with a shorter time from onset to first call, and broader use of mobile intensive care units. Reperfusion therapy increased from 49.4% to 74.7%, driven by primary percutaneous coronary intervention (11.9% to 60.8%). Early use of recommended medications increased, particularly low-molecular-weight heparins and statins. Crude 30-day mortality decreased from 13.7% (95% CI, 12.0-15.4) to 4.4% (95% CI, 3.5-5.4), whereas standardized mortality decreased from 11.3% (95% CI, 9.5-13.2) to 4.4% (95% CI, 3.5-5.4). Multivariable analysis showed a consistent reduction in mortality from 1995 to 2010 after controlling for clinical characteristics in addition to the initial population risk score and use of reperfusion therapy, with odds mortality ratios of 0.39 (95%, 0.29-0.53, P <.001) in 2010 compared with 1995. In France, the overall rate of cardiovascular mortality among patients with STEMI decreased from 1995 to 2010, accompanied by an increase in the proportion of women younger than 60 years with STEMI, changes in other population characteristics, and greater use of reperfusion therapy and recommended medications.

Despite variation in volume, Veterans Affairs hospitals show consistent outcomes among patients with non-postoperative mechanical ventilation*

To assess the relationship between volume of nonoperative mechanically ventilated patients receiving care in a specific Veterans Health Administration hospital and their mortality. Retrospective cohort study. One-hundred nineteen Veterans Health Administration medical centers. We identified 5,131 hospitalizations involving mechanically ventilated patients in an intensive care unit during 2009, who did not receive surgery. None. We extracted demographic and clinical data from the VA Inpatient Evaluation Center. For each hospital, we defined volume as the total number of nonsurgical admissions receiving mechanical ventilation in an intensive care unit during 2009. We examined the hospital contribution to 30-day mortality using multilevel logistic regression models with a random intercept for each hospital. We quantified the extent of interhospital variation in 30-day mortality using the intraclass correlation coefficient and median odds ratio. We used generalized estimating equations to examine the relationship between volume and 30-day mortality and risk-adjusted all models using a patient-level prognostic score derived from clinical data representing the risk of death conditional on treatment at a high-volume hospital. Mean age for the sample was 65 (SD 11) yrs, 97% were men, and 60% were white. The median VA hospital cared for 40 (interquartile range 19-62) mechanically ventilated patients in 2009. Crude 30-day mortality for these patients was 36.9%. After reliability and risk adjustment to the median patient, adjusted hospital-level mortality varied from 33.5% to 40.6%. The intraclass correlation coefficient for the hospital-level variation was 0.6% (95% confidence interval 0.1, 3.4%), with a median odds ratio of 1.15 (95% confidence interval 1.06, 1.38). The relationship between hospital volume of mechanically ventilated and 30-day mortality was not statistically significant: each 50-patient increase in volume was associated with a nonsignificant 2% decrease in the odds of death within 30 days (odds ratio 0.98, 95% confidence interval 0.87-1.10). Veterans Health Administration hospitals caring for lower volumes of mechanically ventilated patients do not have worse mortality. Mechanisms underlying this finding are unclear, but, if elucidated, may offer other integrated health systems ways to overcome the disadvantages of small-volume centers in achieving good outcomes.

Multicentric investigation of survival after Spanish emergency department discharge for acute heart failure

Ideally, discharges from the emergency department (ED) should be as safe as discharges after hospitalization. We have ascertained this hypothesis in patients with acute heart failure (AHF) directly discharged from EDs, analyzing their short-term outcome. A prospective, cohort, multicentric, noninterventional study of consecutive patients with AHF who visited in 20 Spanish EDs was conducted. Patients were grouped according to whether discharge had been from the ED (maximum 24-h ED stay) or after hospitalization. We collected baseline and current AHF episode data. Short-term outcome (30-day mortality and revisit rates) of both groups was compared by univariate crude analysis and stratified by predicted risk of 30-day mortality as well as by logistic regression adjustment for the differences found between ED and hospital groups. A total of 1669 patients were analysed: 546 (32.7%) discharged from ED and 1123 (67.3%) after hospitalisation; 75 (4.5%) died and 420 (25.2%) revisited the ED. Crude 30-day mortality rates of ED and hospital discharges were 2.9 and 5.3%, respectively (odds ratio for ED discharge: 0.56; 95% confidence interval: 0.33-0.96), whereas 30-day revisit rates were 23.8 and 26.4% (odds ratio: 0.96; 95% confidence interval: 0.77-1.19). Stratified analysis according to predicted risk of mortality and multivariate analysis adjusted for the discrepancy in baseline and current AHF episode characteristics in ED and hospital discharges confirmed the lack of short-term outcome differences between the two groups. Direct ED discharge of patients with AHF after treatment and a short observation period is as safe as discharge after a longer time of inpatient hospitalization in general wards.

When to Suspect Tick-Borne Illness

This study compared treatment outcomes of adult patients with bacteraemia due to extended-spectrum β-lactamase-producing Escherichia coli or Klebsiella pneumoniae (ESBL-EK) receiving flomoxef versus those receiving a carbapenem as definitive therapy. In propensity score matching (PSM) analysis, case patients receiving flomoxef shown to be active in vitro against ESBL-EK were matched with controls who received a carbapenem. The primary endpoint was 30-day crude mortality. The flomoxef group had statistically significantly higher sepsis-related mortality (27.3% vs. 10.5%) and 30-day mortality (28.8% vs. 12.8%) than the carbapenem group. Of the bacteraemic episodes caused by isolates with a MICflomoxef of ≤1 mg/L, sepsis-related mortality rates were similar between the two treatment groups (8.7% vs. 6.4%; P = 0.73). The sepsis-related mortality rate of the flomoxef group increased to 29.6% and 50.0% of episodes caused by isolates with a MICflomoxef of 2–4 mg/L and 8 mg/L, respectively, which was significantly higher than the carbapenem group (12.3%). In the PSM analysis of 86 case–control pairs infected with strains with a MICflomoxef of 2–8 mg/L, case patients had a significantly higher 30-day mortality rate (38.4% vs. 18.6%). Multivariate regression analysis revealed that flomoxef therapy for isolates with a MICflomoxef of 2–8 mg/L, concurrent pneumonia or urosepsis, and a Pitt bacteraemia score ≥4 were independently associated with 30-day mortality. Definitive flomoxef therapy appears to be inferior to carbapenems in treating ESBL-EK bacteraemia, particularly for isolates with a MICflomoxef of 2–8 mg/L, even though the currently suggested MIC breakpoint of flomoxef is ≤8 mg/L.

Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma

IntroductionThe mortality benefit of whole-body computed tomography (CT) in early trauma management remains controversial and poorly understood. The objective of this study was to assess the impact of whole-body CT compared with selective CT on mortality and management of patients with severe blunt trauma.MethodsThe FIRST (French Intensive care Recorded in Severe Trauma) study is a multicenter cohort study on consecutive patients with severe blunt trauma requiring admission to intensive care units from university hospital trauma centers within the first 72 hours. Initial data were combined to construct a propensity score to receive whole-body CT and selective CT used in multivariable logistic regression models, and to calculate the probability of survival according to the Trauma and Injury Severity Score (TRISS) for 1,950 patients. The main endpoint was 30-day mortality.ResultsIn total, 1,696 patients out of 1,950 (87%) were given whole-body CT. The crude 30-day mortality rates were 16% among whole-body CT patients and 22% among selective CT patients (p = 0.02). A significant reduction in the mortality risk was observed among whole-body CT patients whatever the adjustment method (OR = 0.58, 95% CI: 0.34-0.99 after adjustment for baseline characteristics and post-CT treatment). Compared to the TRISS predicted survival, survival significantly improved for whole-body CT patients but not for selective CT patients. The pattern of early surgical and medical procedures significantly differed between the two groups.ConclusionsDiagnostic whole-body CT was associated with a significant reduction in 30-day mortality among patients with severe blunt trauma. Its use may be a global indicator of better management.

Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study

IntroductionPositive fluid balance has been associated with an increased risk for mortality in critically ill patients with acute kidney injury with or without renal replacement therapy (RRT). Data on fluid accumulation prior to RRT initiation and mortality are limited. We aimed to study the association between fluid accumulation at RRT initiation and 90-day mortality.MethodsWe conducted a prospective, multicenter, observational cohort study in 17 Finnish intensive care units (ICUs) during a five-month period. We collected data on patient characteristics, RRT timing, and parameters at RRT initiation. We studied the association of parameters at RRT initiation, including fluid overload (defined as cumulative fluid accumulation > 10% of baseline weight) with 90-day mortality.ResultsWe included 296 RRT-treated critically ill patients. Of 283 patients with complete data on fluid balance, 76 (26.9%) patients had fluid overload. The median (interquartile range) time from ICU admission to RRT initiation was 14 (3.3 to 41.5) hours. The 90-day mortality rate of the whole cohort was 116 of 296 (39.2%; 95% confidence interval 38.6 to 39.8%). The crude 90-day mortality of patients with or without fluid overload was 45 of 76 (59.2%) vs. 65 of 207 (31.4%), P < 0.001. In logistic regression, fluid overload was associated with an increased risk for 90-day mortality (odds ratio 2.6) after adjusting for disease severity, time of RRT initiation, initial RRT modality, and sepsis. Of the 168 survivors with data on RRT use at 90 days, 34 (18.9%, 95% CI 13.2 to 24.6%) were still dependent on RRT.ConclusionsPatients with fluid overload at RRT initiation had twice as high crude 90-day mortality compared to those without. Fluid overload was associated with increased risk for 90-day mortality even after adjustments.

Improvements in Transcatheter Aortic Valve Implantation Outcomes in Lower Surgical Risk Patients: A Glimpse Into the Future

The purpose of this study was to investigate the evolution of patient selection criteria for transcatheter aortic valve implantation (TAVI) and its impact on clinical outcomes. Anecdotal evidence suggests that patient selection for TAVI is shifting toward lower surgical risk patients. The extent of this shift and its impact on clinical outcomes, however, are currently unknown. We conducted a single-center study that subcategorized TAVI patients into quartiles (Q1 to Q4) defined by enrollment date. These subgroups were subsequently examined for differences in baseline characteristics and 30-day and 6-month mortality rate. The relationship between quartiles and mortality rate was examined using unadjusted and adjusted (for baseline characteristics) Cox proportional hazard models. Each quartile included 105 patients (n = 420). Compared with Q4 patients, Q1 patients had higher logistic EuroSCORES (25.4 ± 16.1% vs. 17.8 ± 12.0%, p < 0.001), higher Society of Thoracic Surgeons scores (7.1 ± 5.5% vs. 4.8 ± 2.6%, p > 0.001), and higher median N-terminal pro-B-type natriuretic peptide levels (3,495 vs. 1,730 ng/dl, p < 0.046). From Q1 to Q4, the crude 30-day and 6-month mortality rate decreased significantly from 11.4% to 3.8% (unadjusted hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.11 to 1.01; p = 0.053) and from 23.5% to 12.4% (unadjusted HR: 0.49; 95 CI: 0.25 to 0.95; p = 0.07), respectively. After adjustment for baseline characteristics, there were no significant differences between Q1 and Q4 in 30-day mortality rate (adjusted HR ratio: 0.29; 95% CI: 0.08 to 1.08; p = 0.07) and 6-month mortality rate (HR: 0.67; 95% CI: 0.25 to 1.77; p = 0.42). The results of this study demonstrate an important paradigm shift toward the selection of lower surgical risk patients for TAVI. Significantly better clinical outcomes can be expected in lower than in higher surgical risk patients undergoing TAVI.

Universal antifungal therapy is not needed in persistent febrile neutropenia: a tailored diagnostic and therapeutic approach

Giving antifungal therapy exclusively to selected patients with persistent febrile neutropenia may avoid over-treatment without increasing mortality. The aim of this study was to validate an innovative diagnostic and therapeutic approach based on assessing patients' risk profile and clinical criteria in order to select those patients requiring antifungal therapy. The efficacy of this approach was compared to that of universal empirical antifungal therapy. This was a prospective study which included all consecutive adult hematology patients with neutropenia and fever refractory to 5 days of empirical antibacterial therapy admitted to a teaching hospital in Spain over a 2-year period. A diagnostic and therapeutic approach based on clinical criteria and risk profile was applied in order to select patients for antifungal therapy. The sensitivity, specificity and negative predictive value of this approach and also the overall success rate, according to the same criteria of efficacy described in classical clinical trials, were analyzed. Eighty-five episodes were included, 35 of them (41.2%) in patients at high risk of invasive fungal infections. Antifungal therapy was not indicated in 33 episodes (38.8%). The overall incidence of proven and probable invasive fungal infections was 14.1%, all of which occurred in patients who had received empirical antifungal therapy. The 30-day crude mortality rate was 15.3% and the invasive fungal infection-related mortality rate was 2.8% (2/72). The overall success rate following the diagnostic and therapeutic approach was 36.5% compared with 33.9% and 33.7% obtained in the trial by Walsh et al. The sensitivity, specificity and negative predictive value of the study approach were 100%, 52.4% and 100%, respectively. Based on the high negative predictive value of this diagnostic and therapeutic approach in persistent febrile neutropenia patients with hematologic malignancies or patients who have received a hematopoietic stem cell transplant, the approach is useful for identifying patients who are not likely to develop invasive fungal infection and do not, therefore, require antifungal therapy. The effectiveness of the strategy is similar to that of universal empirical antifungal therapy reported in controlled trials.

The role of neuromuscular blocking drugs in early severe acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is defined as severe hypoxemic respiratory failure resulting from diffuse lung injury and secondary to direct and indirect insults. Despite advances, mortality remains as high as 40-60%. Neuromuscular blocking agents (NMBAs) are used to facilitate mechanical ventilation in patients with ARDS and have been shown to improve arterial partial pressure of oxygen. However, the association between NMBAs and mortality is unclear. Furthermore, morbidity concerns exist, particularly regarding a putative role in intensive care unit (ICU)-acquired weakness. The purpose of this study was to compare survival in adult patients with early ARDS who were randomized to receive either a 48-hr infusion of the NMBA, cisatracurium, or a placebo. This study was a multicentre double-blinded randomized controlled trial involving 20 ICUs in France from March 2006 to March 2008. Eligible patients were > 18 yr with an intubated trachea and ventilated lungs for acute hypoxemic respiratory failure. Their PaO(2)/F(i)O(2) ratio was < 150 at a tidal volume of 6-8 mL·kg(-1) ideal body weight and a positive end-expiratory pressure (PEEP) ≥ 5 cm H(2)O for < 48 hr. Additional inclusion criteria were radiographic evidence of bilateral pulmonary infiltrates and the absence of left atrial hypertension. Exclusion criteria included patients already receiving NMBA at enrolment; those who had increased intracranial pressure, severe chronic respiratory disease, or severe chronic liver disease; those who had received a bone marrow transplant or had chemotherapy-induced neutropenia; those who had a pneumothorax; and those who were expected to require mechanical ventilation for < 48 hr or were enrolled in another trial within 30 days. Three hundred twenty-six patients were screened, and 340 of these underwent randomization in blocks of four and received either a 48-hr infusion of cisatracurium (15 mg bolus followed by 37.5 mg·hr(-1)) or a volume equivalent placebo. One hundred and seventy-eight patients received a cisatracurium infusion, and one patient withdrew leaving 177 patients included in the analysis. One hundred and sixty-two patients received the placebo infusion. Prior to either infusion, patients were sedated to a Ramsay sedation score of 6. Patients' lungs were ventilated by a volume assist-controlled mode according to the ARDS Clinical Network Mechanical Ventilation Protocol (http://www.ardsnet.org/) with the goal SpO(2) of 88-95% (or PaO(2) 55-80 mmHg) and goal plateau pressure ≤ 35 cm H(2)O. Open-label boluses of cisatracurium 20 mg (maximum of two per 24-hr period) were allowed if plateau pressures remained > 32 cm H(2)O despite increased sedation and despite decreased PEEP and decreased tidal volumes. Monitoring of paralysis via peripheral nerve stimulation was not permitted. The primary outcome was death before hospital discharge and within 90 days of study enrolment. It was determined a priori that this would be adjusted for imbalance in key risk factors at baseline, as derived from Cox regression. Secondary outcomes included 28-day mortality, number of ventilator-free days, number of days outside of ICU, number of days without organ system failure, rate of barotrauma, and rate of ICU-acquired paresis (as defined by a Medical Research Council [MRC] score < 48) on day 28 and at ICU discharge. With regard to the primary outcome, crude 90-day mortality was 31.6% in the cisatracurium group vs 40.7% in the placebo group. This outcome did not reach statistical significance (P = 0.08). However, post hoc analysis found a reduction in 90-day mortality in the cisatracurium group compared with placebo (95% confidence interval 0.48 to 0.98; P = 0.04). Results suggest that the reduction in 90-day mortality in the cisatracurium group was confined to those patients with a PaO(2)/F(i)O(2) ratio < 120. Additionally, 28-day mortality was significantly lower in the cisatracurium group (absolute difference -9.6%; P = 0.05). The cisatracurium group also had significantly more ventilator-free days, more days outside of the ICU, and more days free of organ-failure. Similarly, pneumothorax developed more often and earlier in the placebo group than in the cisatracurium group. The rate of ICU-acquired weakness at day 28 or at ICU discharge did not differ significantly between the two groups. Treatment in early severe ARDS with the NMBA, cisatracurium, for 48 hr was associated with lower adjusted 90-day mortality. It was also associated with decreased morbidity, which included increased ventilator-free days, increased ICU-free days, and increased organ failure-free days. These benefits occurred without increasing the incidence of ICU-acquired weakness.

Invasive Non-AspergillusMold Infections in Transplant Recipients, United States, 2001–2006

Recent reports describe increasing incidence of non-Aspergillus mold infections in hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients. To investigate the epidemiology of infections with Mucorales, Fusarium spp., and Scedosporium spp. molds, we analyzed data from the Transplant-Associated Infection Surveillance Network, 23 transplant centers that conducted prospective surveillance for invasive fungal infections during 2001–2006. We identified 169 infections (105 Mucorales, 37 Fusarium spp., and 27 Scedosporium spp.) in 169 patients; 124 (73.4%) were in HCT recipients, and 45 (26.6%) were in SOT recipients. The crude 90-day mortality rate was 56.6%. The 12-month mucormycosis cumulative incidence was 0.29% for HCT and 0.07% for SOT. Mucormycosis incidence among HCT recipients varied widely, from 0.08% to 0.69%, with higher incidence in cohorts receiving transplants during 2003 and 2004. Non-Aspergillus mold infections continue to be associated with high mortality rates. The incidence of mucormycosis in HCT recipients increased substantially during the surveillance period.