Intensive Care Unit Status Research Articles

Treatment of candidemia and invasive candidiasis in the intensive care unit: post hoc analysis of a randomized, controlled trial comparing micafungin and liposomal amphotericin B

IntroductionInvasive candidiasis and candidemia are life-threatening nosocomial infections in intensive care patients.MethodsA post hoc analysis of a phase 3 trial assessing micafungin (100 mg/day for subjects > 40 kg; 2 mg/kg/day for subjects ≤ 40 kg) versus liposomal amphotericin B (3 mg/kg/day). Subgroups were defined according to the type of ward on the first day of treatment: intensive care unit (ICU) or non-ICU. Multivariate regression was performed to identify factors associated with treatment success at end of therapy and all-cause mortality at days 8 and 30.ResultsIn non-ICU subjects, treatment success was significantly higher for micafungin versus liposomal amphotericin B (85% (n = 108/127) versus 72.1% (n = 98/136); P = 0.0113). However, for ICU subjects, treatment success rates for micafungin versus liposomal amphotericin B were similar (62.5% (n = 75/120) versus 66.4% (n = 73/110); P = 0.5828). Overall, treatment success was significantly lower in ICU subjects compared with non-ICU subjects (64.3% (n = 148/230) versus 78.3% (n = 206/263); P = 0.0006). Multivariate regression analysis revealed a lower likelihood of treatment success for: ICU versus non-ICU subjects; persistent neutropenia; and high versus low Acute Physiology and Chronic Health Evaluation (APACHE) II scores. However, when interactions between potential explanatory factors were included in the analysis model, ICU status no longer emerged as a significant associated variable but the association between APACHE II score and treatment outcome remained. Further analyses indicated that the likelihood of mortality at day 8 and day 30 was lower for subjects with lower APACHE II scores. Renal function was significantly better in micafungin versus liposomal amphotericin B subjects: a difference (liposomal amphotericin B - micafungin in mean peak change in estimated glomerular filtration rate (ml/minute/1.73 m2) of -18.2 (P < 0.0001) and -17.7 (P = 0.0124) in non-ICU and ICU subjects, respectively.ConclusionsOverall, ICU subjects had lower treatment success rates than non-ICU subjects for both liposomal amphotericin B and micafungin. Multivariate regression after controlling for potential confounding factors suggested the APACHE II score remained a potential explanatory factor associated with treatment success, mortality at day 8, and mortality at day 30.Trial registrationPost hoc analysis - clinicaltrials.gov trial NCT00106288.

Predicting ICU survival: A meta-level approach

BackgroundThe performance of separate Intensive Care Unit (ICU) status scoring systems vis-à-vis prediction of outcome is not satisfactory. Computer-based predictive modeling techniques may yield good results but their performance has seldom been extensively compared to that of other mature or emerging predictive models. The objective of the present study was twofold: to propose a prototype meta-level predicting approach concerning Intensive Care Unit (ICU) survival and to evaluate the effectiveness of typical mining models in this context.MethodsData on 158 men and 46 women, were used retrospectively (75% of the patients survived). We used Glasgow Coma Scale (GCS), Acute Physiology And Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Injury Severity Score (ISS) values to structure a decision tree (DTM), a neural network (NNM) and a logistic regression (LRM) model and we evaluated the assessment indicators implementing Receiver Operating Characteristics (ROC) plot analysis.ResultsOur findings indicate that regarding the assessment of indicators' capacity there are specific discrete limits that should be taken into account. The Az score ± SE was 0.8773± 0.0376 for the DTM, 0.8061± 0.0427 for the NNM and 0.8204± 0.0376 for the LRM, suggesting that the proposed DTM achieved a near optimal Az score.ConclusionThe predicting processes of ICU survival may go "one step forward", by using classic composite assessment indicators as variables.

A Scoring System Predicting the Risk for Intensive Care Unit Admission for Complications After Major Lung Resection: A Multicenter Analysis

We aimed to develop and validate a scoring system to predict intensive care unit (ICU) admission for complications after major lung resection for purposes of optimizing planning of resources for patient care. Patients undergoing major lung resections performed between 2000 and 2006 at three thoracic surgery units were analyzed for unplanned admission to the ICU for complications. Variables were initially screened by univariate analysis. Selected variables were used in a stepwise logistic regression analysis that was validated by bootstrap analysis. The scoring system was developed by proportional weighting of the significant and reliable predictors estimates and validated on patients operated on in a different center. In the derivation set of 1297 patients, 82 (6.3%) had ICU admission for complications, and 30 died (associated mortality rate, 36.5%). Predictive variables and their scores were pneumonectomy, 2 points; and 1 point each for age older than 65, predicted postoperative forced expiratory volume in 1 second below 65%, predicted postoperative carbon monoxide lung diffusion capacity below 50%, and cardiac comorbidity. Patients were grouped into three risk classes by their scores, which were significantly associated with incremental risk of ICU admission in the validation set of 349 patients. This scoring system predicts incremental risk of ICU admission for complications after major lung resection. This system may help in assessing the need for additional postoperative resources and in modifying indicators used to determine the appropriateness of initial transfer of postoperative patients from ICU or stepdown status and in developing criteria for future cost-effectiveness trials.

Understanding the role of ethnic status in Intensive Care Unit (ICU) deaths among advanced cancer patients

6506 Background: Studies suggest Blacks receive less aggressive, curative care for cancer but more aggressive care at end of life (EOL). This study investigated possible socio-cultural mediators (e.g. patient preference) of the relationship between ethnic status and aggressive care at EOL, defined as risk of death in the ICU, among advanced cancer patients. Methods: Location of death was established for 292 self-reported, Black (N=61) or White (N=231), Stage IV cancer patients interviewed at baseline as part of the prospective, multi-institutional Coping with Cancer study. We tested for mediators of the relationship between ICU death and ethnicity, controlling for possible confounding factors (e.g. socioeconomic status). Results: Blacks were more likely to die in the ICU than Whites (odds ratio, OR=4.40; 95% confidence interval, CI 1.81–10.72). Age, but no other sociodemographic factor (e.g. education), proved a confounder, reducing the ethnicity odds ratio to 3.65 (CI 1.47–9.08). Full mediators included religiousness/spirituality (OR=2.38, CI 0.69–8.31) and patient preference for a care plan emphasizing life extension despite pain or discomfort (OR=2.30, CI 0.78–6.77), with the latter being the only significant variable in the final model (OR 1.48, CI 0.31–7.15). Other factors investigated, but not found to be significant, included health, mental health status, social support, doctor-patient relationship and communication, terminal illness acknowledgement, and advance care planning (e.g. do-not-resuscitate orders). Conclusions: The increased risk of ICU death among Black advanced cancer patients compared to Whites was mediated by a disproportionate preference for care that focused on life extension among Blacks. Future studies should investigate whether this is an informed preference and therefore a true ethnic difference in values. Other prevailing hypotheses (e.g. trust) were not supported by this study. No significant financial relationships to disclose.

Risk factors for the development of fulminant Clostridium difficile colitis

The development of fulminant Clostridium difficile colitis (FCDC) requires prompt operative intervention and is associated with a high mortality rate. The aim of this study was to use a case-control design to define the clinical and laboratory parameters that predict which patients with Clostridium difficile infection are most likely to progress to FCDC. Cases from 1994 to 2006 with documented in-hospital progression of Clostridium difficile infection to FCDC were matched retrospectively at the start of medical therapy by age, sex, and intensive care unit (ICU) status to controls with Clostridium difficile infection who did not develop FCDC. Chi-Square and multivariable logistic regression were used to identify risk factors for progression to FCDC. A total of 35 patients with FCDC were matched to 70 controls with Clostridium difficile infection who did not develop FCDC. The patients with FCDC underwent colectomy after an average of 4.6 days of medical therapy and had a mortality rate of 40%. On multivariate analysis, independent risk factors for the development of FCDC were a WBC > 16,000 cells/mm(3) (P < .01) at initiation of therapy, operative therapy within the last 30 days (P = .03), a history of inflammatory bowel disease (P = .04), and a history of intravenous immunoglobulin treatment (P < .01). Leukocytosis, recent prior operative therapy, and a history of inflammatory bowel disease and intravenous immunoglobulin treatment were negative prognostic indicators for patients with Clostridium difficile infection. The presence of these factors merits close observation for progression to FCDC and acceleration of the planning process for operative intervention.

Current status of neonatal intensive care units in Korea

Neonatal intensive care in Korea has improved remarkably since the 1990s, but there is still a shortage of facilities and equipment in NICUs. Only 71.1% of the beds needed for neonatal intensive care are available. Mechanical ventilators are not appropriately distributed to the NICUs that are equipped to handle neonatal intensive care. The number of doctors is far too small, making the number of patients per doctor very high. Nurses, too, need to take care of 7.7 patients per nurse, making it very difficult to provide adequate intensive care. All this is caused by insufficient investment by the hospitals, which, in turn, is caused by inadequate reimbursement from health insurance. Therefore, a government-sponsored effort is necessary to bring the level of neonatal intensive care up to par.

Intensivist Bedside Ultrasound (INBU) for Volume Assessment in the Intensive Care Unit: A Pilot Study

Estimation of volume status in the high-acuity surgical population can be challenging. The use of intensivist bedside ultrasound (INBU) to rapidly assess volume status in the surgical intensive care unit (SICU) was hypothesized to be feasible and as accurate as invasive measures. Clinician sonographers (CSs) were trained to perform basic cardiac ultrasound and sonographic assessment of the inferior vena cava (IVC). A convenience sample of general surgery and trauma patients was enrolled in the SICU. The CS interpreted IVC and cardiac parameters and then categorized the subject as hypovolemic or not hypovolemic. Intensivists caring for the patients were blinded to the INBU findings and made a real-time expert clinical judgment (ECJ) of the patient's volume status (hypovolemic vs. not hypovolemic) using all available traditional data. A total of nine CSs performed 70 studies; three of the CSs performed the majority of the studies (86%). Adequate ultrasound (US) views for cardiac and IVC assessment were obtained in 96% and 89% of studies, respectively. The ECJ was considered to be the standard to which comparisons were made. The concordance rate between ECJ and central venous pressure was 62%. ECJ concordance with sonographic measures were similar (cardiac US = 75%, IVC US = 67%, and IVC collapse index = 65%). All pairwise comparisons against the ECJ/CVP agreement were not significantly different. INBU is feasible in the SICU and is equivalent to central venous pressure in assessing volume status. Noninvasive methods to assess volume status may decrease the need for invasive procedures.

Invasive candidiasis treated in the intensive care unit: Observations from a randomized clinical trial

Objectives The objectives of this study were to contrast risk factors, microbiology, and outcomes in patients with invasive candidiasis treated in an intensive care unit (ICU) with those in patients with invasive candidiasis treated outside an ICU and to describe therapeutic results with caspofungin in ICU patients. Materials and Methods We retrospectively identified patients with documented invasive candidiasis who received their first dose of the study drug in the ICU as part of a double-blind randomized trial. Participants were not stratified at entry by their ICU status. Patients received caspofungin (50 mg/d after a 70-mg loading dose) or conventional amphotericin B (0.6-1.0 mg/kg per day) for 10 to 14 days. A favorable response required resolution of signs and symptoms as well as eradication of Candida pathogens. Results Of the 224 patients, 97 (43%) received their first dose of the study drug in the ICU. Most patients had well-recognized risk factors for invasive candidiasis, including broad-spectrum antibiotics, central venous catheters, and hyperalimentation. Recent surgery was more common whereas malignancy, neutropenia, and immunosuppression were less common among ICU patients than among non-ICU patients. Candidemia was demonstrated in 81% of ICU patients and in 84% of non-ICU patients. Favorable response rates in the ICU patients vs the non-ICU patients were 68% (95% confidence interval [CI] = 53%, 82%) vs 77% (95% CI = 67%, 87%) for caspofungin and 56% (95% CI = 43%, 69%) vs 67% (95% CI = 55%, 79%) for amphotericin B. After accounting for differences in APACHE (Acute Physiology and Chronic Health Evaluation) II score, neutropenia status, and geographic region, we found that patients initiating the study therapy in an ICU were still more likely to die than patients initiating study therapy outside an ICU. For ICU patients, all-cause mortality rates were 45% (95% CI = 30%, 60%) for caspofungin recipients and 40% (95% CI = 28%, 53%) for amphotericin B recipients, whereas candidiasis-attributable mortality rates were 5% (95% CI = 0%, 12%) for caspofungin recipients and 11% (95% CI = 3%, 19%) for amphotericin B recipients. Overall, drug-related adverse events were reported less often among the ICU patients than among the non-ICU patients. Conclusions In ICU patients treated with antifungal therapy, invasive candidiasis is associated with substantial mortality, but most deaths cannot be directly attributed to this infection.

The risk for bloodstream infections is associated with increased parenteral caloric intake in patients receiving parenteral nutrition

BackgroundPatients receiving total parenteral nutrition (TPN) are at high risk for bloodstream infections (BSI). The notion that intravenous calories and glucose lead to hyperglycemia, which in turn contributes to BSI risk, is widely held but is unproven. We therefore sought to determine the role that hyperglycemia and parenteral calories play in the development of BSI in hospitalized patients receiving TPN.MethodsTwo hundred consecutive patients initiated on TPN between June 2004 and August 2005 were prospectively studied. Information was collected on patient age, sex, admission diagnosis, baseline laboratory values, intensive care unit (ICU) status and indication for TPN. Patients in the ICU were managed with strict glycemic control, whereas control on the general ward was more liberal. The maximum blood glucose level over each 8-hour period was recorded, as were parenteral daily intake, enteral daily intake and total daily caloric intake. The primary outcome measure was the incidence of BSI. Additional endpoints were ICU length of stay, hospital length of stay and mortality.ResultsA total of 78 patients (39%) developed at least one BSI, which were more common in ICU patients than in other hospitalized patients (60/122 patients versus 18/78 patients; P < 0.001). Maximum daily blood glucose concentrations were similar in patients with BSI and in patients without BSI (197 mg/dl versus 196 mg/dl, respectively). Patients with BSI received more calories parenterally than patients without BSI (36 kcal/kg/day versus 31 kcal/kg/day, P = 0.003). Increased maximum parenteral calories, increased average parenteral calories, and treatment in the ICU were strong risk factors for developing BSI. There was no difference in mortality between patients with and without BSI.ConclusionIncreased parenteral caloric intake is an independent risk factor for BSI in patients receiving TPN. This association appears unrelated to hyperglycemia. Based upon our observations, we suggest that parenteral caloric intake be prescribed and adjusted judiciously with care taken to account for all intravenous caloric sources and to avoid even short periods of increased intake.

Evaluating the Use of Flowsheets in Pediatric Intensive Care to Inform Design

Flowsheets are central artifacts of information collection and exchange to support the monitoring and diagnosis of patient status in the pediatric intensive care unit. This study used field observations to examine the design and use of flowsheets. Strengths of the current paper document include portability, bundling of related data, and allowing for notes and annotations. However, the static nature of the paper document requires that users manually calculate and carry over important trends and relationships. Spatial constraints of the paper document make it necessary to squeeze data into a small space with data sometimes being difficult to read. Electronic flowsheets have the potential to overcome these limitations and introduce new features, but depending on their design, may eliminate the strengths of the original system. Studying actual practices in the work environment yielded insight into the use of the document to inform the design of an electronic flowsheet system.

International Perspectives

Since 1984, Tokyo Women’s Medical University has played a pioneering role in improving the treatment results of ultrapreterm infants in Japan. The results were cited in the newest edition of Avery’s Neonatology: Pathophysiology & Management of the Newborn . (1) Like many western countries, the survival rate of extremely low-birthweight (ELBW) and very low-birthweight (VLBW) infants improved in Japan in the 1990s, with the spread of new treatment methods such as surfactant therapy, new methods of mechanical ventilation such as high-frequency oscillatory ventilation (HFOV), and prenatal steroid therapy. (2) The Committee on Newborn Infants, Japan Society of Pediatrics, has performed nationwide surveys on the outcomes of ELBW and VLBW infants for reports on the current status of neonatal intensive care units and overall neonatal mortality in Japan at 5-year intervals since 1980. The mortality rate of infants weighing less than 1,000 g at birth significantly declined in the previous 2 decades from 55.3% in 1980 and 28.2% in 1990 to 17.8% in 2000 (Table⇓). In view of this, the Ministry of Health, Labor and Welfare of the Japanese government changed the definition of the threshold of viability in the Maternal Protection Law from 24 weeks of gestation to 22 weeks of gestation in January 1991. After this change, neonatologists in Japan have increasingly intervened in deliveries at 22 to 23 weeks of gestation. | Year | Number of Survivors/Number of Admissions | |:------:| ---------------------------------------- | ----------------- | | <500 g | 500 to 999 g | 1,000 to 1,499 g | | 1980 | 0/0 | 493/1,102 (45%) | 2,633/3,319 (79%) | | 1985 | 5/52 (10%) | 1,085/1,846 (59%) | 3,695/4,180 (88%) | | 1990 | 9/50 (18%) | 1,462/2,000 (73%) | 3,524/3,786 (93%) | | 1995 | 39/132 (30%) | 1,789/2,298 (78%) | 4,139/4,355 (95%) | | 2000 | 57/153 (37%) | 2,238/2,638 (85%) | 4,844/5,036 (96%) | Table. Survival Rates of Infants Weighing Less than 1,500 g at Birth in Japan Although Sumida and associates (3) and Tsuchida and colleagues (4) reported in 1999 and 2001, respectively, survival rates at 22 weeks’ gestation of approximately 30%, their results were published in Japanese, and the number of patients was small. At the Hot Topics in Neonatology conference (Washington, DC) in 2002, Nishida reported the outcomes of infants born at 22 to 23 weeks of gestation …

IntegratingEscherichia coliAntimicrobial Susceptibility Data from Multiple Surveillance Programs

Collaboration between networks presents opportunities to increase analytical power and cross-validate findings. Multivariate analyses of 2 large, international datasets (MYSTIC and SENTRY) from the Global Advisory on Antibiotic Resistance Data program explored temporal, geographic, and demographic trends in Escherichia coli resistance from 1997 to 2001. Elevated rates of nonsusceptibility were seen in Latin America, southern Europe, and the western Pacific, and lower rates were seen in North America. For most antimicrobial drugs considered, nonsusceptibility was higher in isolates from men, older patients, and intensive care unit patients. Nonsusceptibility to ciprofloxacin was higher in younger patients, rose with time, and was not associated with intensive care unit status. In univariate analyses, estimates of nonsusceptibility from MYSTIC were consistently higher than those from SENTRY, but these differences disappeared in multivariate analyses, which supports the epidemiologic relevance of findings from the 2 programs, despite differences in surveillance strategies.

Clinical Case Mix Adjustment of Cesarean Delivery Rates in U.S. Military Hospitals, 2002

To assess whether significant variations in observed cesarean rates in U.S. military hospitals may be attributed to differences in clinical case mix. Hospital discharge records for births in U.S. military hospitals in 2002 were grouped into mutually exclusive clinical strata to calculate predicted cesarean rates for subgroups defined by maternal race, health plan, hospital location, delivery volume, teaching status, and neonatal intensive care unit (NICU) status. The 95% confidence interval (CI) around each standardized ratio (SR) of the observed-to-predicted cesarean rate was used to assess statistical significance. Observed cesarean rates were significantly higher than predicted rates for small hospitals (23.1% and 20.4%, respectively, SR 1.13, 95% CI 1.08-1.19), teaching hospitals (23.7% and 22.5%, respectively, SR 1.05, 95% CI 1.02-1.08), black women (25.1% and 22.8%, respectively, SR 1.10, 95% CI 1.05-1.14), and other minorities (22.7%, and 21.6%, respectively, SR 1.05, 95% CI 1.01-1.09). No significant differences between observed and predicted cesarean rates were found across hospital locations or NICU status. Significant differences found for non-managed care beneficiaries were attributed to teaching status of the hospitals in which they delivered. Clinical case mix does not adequately account for the relatively high rates of cesarean delivery observed for small hospitals and teaching hospitals and among black women in the study population. Further study is recommended to identify additional clinical and nonclinical factors that should be considered when comparing performance across institutions, health plans, or individual providers.

Determinants of hospital mortality of adult recipients of right lobe live donor liver transplantation.

To define the technical factors that might contribute to hospital mortality of recipients of right lobe live donor liver transplantation (LDLT) so as to perfect the design of the operation. Right lobe LDLT has been accepted as one of the treatments for patients with terminal hepatic failure, but the design and results of the reported series vary and the technical factors affecting hospital mortality have not been known. The data of 100 adult-to-adult right lobe LDLT performed between 1996 and 2002 were prospectively collected and retrospectively analyzed. All grafts except one contained the middle hepatic vein, which was anastomosed to the recipient middle/left hepatic vein in the first 84 recipients and directly into the inferior vena cava (with the right hepatic vein in form of venoplasty) in the subsequent 15 patients. Venovenous bypass was used routinely in the first 29 patients but not subsequently. Eight patients died within the same hospital admission for liver transplantation. There was no hospital mortality in the last 53 recipients. Comparison of data of patients with or without hospital mortality showed that graft weight/body weight ratio, graft weight/estimated standard liver weight ratio, technical error resulting in occlusion/absence of the middle hepatic vein, use of venovenous bypass, the lowest body temperature recorded during surgery, the volume of intraoperative blood transfusion, fresh frozen plasma, and platelet infusion were significantly different between the two groups. However, the pretransplant intensive care unit status of the recipients, cold and warm ischemic time of the graft, and occurrence of biliary complications were not. By multivariate analysis, low body temperature recorded during operation, low graft weight/estimated standard liver weight ratio (</=0.35), and the middle hepatic vein occlusion were independent significant factors in determining hospital mortality. To achieve a uniformly successful right lobe LDLT, the right lobe graft must contain a patent middle hepatic vein. With a completely patent middle hepatic vein, a graft size of >35% of the estimated standard graft weight may be sufficient for recipient survival. Hypothermia, which predisposes to coagulopathy and is enhanced by the use of venovenous bypass and massive blood, and blood product transfusion must be avoided.

Supernumerary status: definition, operationalisation and its effect in practice.

This paper presents an evaluation of the implementation of supernumerary status in intensive care units in the Greater Belfast area. The evaluation focused on three questions, what did staff understand by the term supernumerary status. How was supernumerary status implemented in the Trusts? What effect did supernumerary status have on the staff/Trusts involved? The results of the evaluation are presented here and issues for further development identified. The study was qualitative in nature and used semi-structured interviews and focus group interviews to collect data. Participants were purposefully selected by virtue of their experience of supernumerary status. Interviews and focus groups were audiotaped and transcribed verbatim. These transcripts were then analysed line-by-line and coded. Data analysis described 10 common themes. In general, the concept of supernumerary status was well received and was supported by all involved who believed that its goal of producing adequately trained and skilled practitioners in an intensive care environment was a worthwhile exercise that benefited both staff and patients. Overall, exploring the operationalisation of a supernumerary status programme helps us to explore the challenges of supporting neophyte nurses in all areas of practice and challenges service providers to consider creative approaches to providing such support. However, whilst making a positive contribution to the recruitment and development of nurses new to the intensive care environment, further study is required to gauge the long-term effect of this programme on retention of staff.

Impact of family health insurance and other environmental factors on universal hearing screen program effectiveness.

The study objective was to evaluate the relationship among health insurance type, other demographic factors, and newborn hearing screen compliance and outcomes. The cohort consisted of 39,153 infants screened in Rhode Island between July 1, 1995 and June 30, 1998. Multivariate analyses were completed to evaluate relationships between health insurance type and completion of the in-hospital hearing screen and the rescreen, if indicated. Successful newborn screen rates ranged from 98.1% to 99.8%. Infants with traditional Medicaid insurance were more likely to not be screened (p<0.0001) and to not return for a rescreen (p<0.0001). Infants in families with managed care Medicaid had screen compliance similar to infants with commercial health insurance. Multivariate analyses revealed that Medicaid insurance, no insurance, neonatal intensive care unit status, and out-of-state address predicted no initial screen (p<0.001) and no rescreen (p<0.0001). In population-based health services, it is important that the effects of socioeconomic and demographic variables on outcomes be evaluated.

Renal replacement therapy and orthotopic liver transplantation: the role of continuous veno-venous hemodialysis.

The need for renal replacement therapy (RRT) either before or after orthotopic liver transplant (OLTX) has been reported to be a poor prognostic indicator for survival. Use of continuous veno-venous hemodialysis (CVVHD) for RRT has been reported in three series of OLTX patients with high 90-day mortality rates of 57-60%. We have examined our patient population to determine the effect of necessity and type of RRT on patient survival after OLTX. We analyzed 1535 OLTX that were performed at our institution from 1985 through 1999, 1037 from 1985 to 1995 (period I) and 498 from 1996 to 1999 (period II). Combined liver-kidney transplants were excluded from analysis. Hospital dialysis unit records and a prospectively maintained database on all OLTX patients served as the source of data. Patients were classified into groups defined on whether or not they received RRT, when they received RRT, and the type of RRT. Groups were compared for preoperative intensive care unit status, time on the waiting list, laboratory variables, 90-day postoperative mortality, 1-year patient survival, and absolute survival. Use of RRT increased from 8.29% in period I to 12.45% in period II, along with increased median waiting times. In period I, patients receiving preoperative RRT had a 90-day mortality (0%) and a 1-year survival (89.5%) almost identical to those patients who never required RRT (1.7% and 90.6%). Patients who developed acute renal failure postoperatively requiring RRT, however, had a 90-day mortality of 28.6% and a 1-year survival of 55%. In period II, patients requiring RRT had a 90-day mortality of 39.7% and a 1-year actuarial survival of 54.5% compared with 6.9% and 88.6% in patients never requiring RRT. Patients treated with CVVHD had a 90-day mortality of 42% compared with 25% in patients treated with hemodialysis alone. However, patients receiving CVVHD both pre- and postoperatively had a 90-day mortality of 27.7% vs. 50% in those patients who only received CVVHD postoperatively. Patients who developed acute renal failure postoperatively, which required RRT, regardless of therapy, had a 1-year survival of only 41.0% compared with a 1-year survival of 73.6% in those patients started on RRT preoperatively, P=0.03. The need for RRT has increased along with waiting time in OLTX patients. Patients developing the need for RRT postoperatively have an increased 90-day mortality and lower 1-year survival with the highest being present in patients receiving CVVHD, which was started postoperatively. These findings may reflect a trend toward a sicker population awaiting OLTX and emphasize the negative impact of renal failure on survival after OLTX.

Aetiological investigations of hearing loss in childhood: a review.

Advances in genetics, improvements in neonatal intensive care and the introduction of universal immunisation programmes have resulted in major changes in the epidemiology of hearing loss in children. Perinatal factors now account for 27% of the child population with hearing loss, compared to 2% about 25 years ago. 1 In the UK, the prevalence of hearing impairment in children with a history of treatment in the neonatal intensive care unit has increased fourfold over a period of 15 years, 2 and is higher than in other European countries. 3 A combination of neonatal intensive care unit status, family history of hearing loss and craniofacial abnormality noticeable at birth may account for up to 64% of all types of hearing loss. 2 The overall prevalence of bilateral hearing loss in children is estimated to be between 0.5/1000 live births 4 to 1.2/1000 2 and up to 2.1/1000 5 in different studies, depending on factors such as methods of hearing loss ascertainment, degree of hearing loss targeted, geographical area and time period of the study. Investigation of the hearing impaired child aims to identify the cause of the hearing loss and to provide information relevant to hearing loss management, coexisting medical problems and prognosis for the child and the family. In addition, these investigations may also help to clarify phenotypes in genetic hearing loss and to provide a more accurate picture of epidemiology, which is necessary for planning effective hearing loss prevention and surveillance programmes. The objective of this paper is to review the current literature on this topic and to assist the clinician in devising an investigative plan for this population.

Hepatorenal syndrome: combined liver kidney transplants versus isolated liver transplant.

As many as 38% of combined liver-kidney transplant (LKTx) procedures performed nationally may be done for the renal diagnosis of hepatorenal syndrome (HRS). This study was designed to compare the national results with those at our medical center and to determine if combined LKTx provides any benefit over isolated liver transplant (LTx) to HRS patients. Data on 29 combined LKTx and 79 HRS patients at our center were collected and compared with the national data on 414 LKTx and 2442 patients with serum creatinine >2.0 mg/dl receiving isolated LTx from 1988 to 1995. United Network of Organ Sharing data revealed 5-year patient survival of 62.2% for LKTx recipients and 50.4% for patients with serum creatinine >2.0 mg/dl receiving isolated LTx (P=0.0001). Our center results demonstrated 5-year patient survival of 48.1% for LKTx patients, 67.1% for HRS patients receiving isolated LTx, and 70.1% for patients with serum creatinine >2.0 mg/dl receiving isolated LTx (P not significant comparing all groups). Intensive care unit status and preoperative dialysis rates were similar in those HRS patients who did and those who did not need future KTx. National data would suggest a survival benefit of combined LKTx over isolated LTx for those patients with poor renal function, specifically those with HRS, whereas our center's results suggest otherwise. Unfortunately, we could not identify any preoperative risk factors in the HRS patients, or in the broader group of patients with renal insufficiency at our center, that would indicate the need for future renal transplantation. We believe that HRS patients can be successfully managed with isolated LTx.

Health status prediction in critically ill children: a pilot study introducing Standardized Health Ratios.

Performance of intensive care is usually quantified by means of standardized mortality rates, where standardization is directed towards the severity of illness on admission. However, as more critically ill patients survive, functional outcome and quality of life of these patients becomes more important. In a prospective study in a 10-bed tertiary paediatric intensive care unit (ICU), admission and follow-up health status were collected for 209 surviving patients. For this cohort of patients, health status 1 year after admission was also predicted, using the quantified health-utility-index (HUI), as a value between 0 and 1. For this purpose, two alternative multiple regression models were constructed. The most important predictors of 1-year health status were the level of sensation, mobility and cognition on admission to which self-care, systolic blood pressure, oxygen, Glascow Coma Scale, glucose and age may be added. The two alternative predictive models performed equally well (R2 = 0.83 and 0.84 respectively), indicating that health status could be predicted to a significant degree. The concept of relating expected future health status (based on base-line health status), with actual (observed) health status is denoted with the Standardized Health Ratio (SHR). In combination with the Standardized Mortality Ratios (SMR), such a ratio may become a new comprehensive indicator of performance in intensive care medicine.