Lower ICU Admission Research Articles

Phenotypes of Dialysis-Requiring Acute Kidney Injury and Associations with Mortality in a South American Population.

Acute kidney injury (AKI) is a complex syndrome typically classified into strict categories. Alternatively, it may be more accurate to consider it as an intermediate event between an initiating cause and its outcome. Therefore, we investigated the burden of clinical scenarios associated with dialysis-requiring AKI (AKI-D) using latent class analysis (LCA) and examined the etiological spectrum and clinical phenotypes across different life stages. We analyzed 17,158 AKI-D patients from 170 medical facilities in Rio de Janeiro, Brazil (2002-2012). Utilizing survival curves and mixed-effects Cox regression for survival estimation, LCA classified patients based on clinical characteristics and outcomes, focusing on etiological variation over the human lifespan. The median age was 75 (IQR 59-83). Infections were the most common cause (44.2%), particularly community-acquired pneumonia (23.8%). Cardiovascular issues, especially ischemic heart disease (9.0%) and acute heart failure (8.1%), were also significant. LCA identified four distinct patient classes with varying clinical and outcome profiles. Class 1 patients were younger (median age 66), predominantly male, with lower ICU admission and higher rates of community-acquired AKI (60.8%). They had the lowest mortality (39.5%) and highest recovery rates. Class 2 had intermediate mortality (67.4%) and the highest comorbidity burden (mean Charlson score: 3.39). Classes 3 and 4 had the highest mortality (82.8% and 78.6%), requiring more mechanical ventilation and vasopressor use. Class 3 had a high prevalence of sepsis (92.7%) with lower comorbidities, while Class 4 had high chronic heart disease (76.3%) and perfusion factors (79.4%). Despite high mortality, Class 3 recovered better than Class 2 and 4. Survival analyses revealed diverse outcomes across etiological groups, with liver-related conditions being the most severe. This study highlights the complexity of AKI and the utility of LCA in revealing its clinical heterogeneity. It underscores distinct etiological trends across ages, suggesting future research should integrate clinical profiles with advanced diagnostics to understand AKI's clinical and molecular phenotypes throughout life.

Current practice of screening and antimicrobial prophylaxis to prevent Gram-negative bacterial infection in high-risk haematology patients: results from a pan-European survey.

Bacterial infections frequently occur in haematological patients, especially during prolonged neutropenia after intensive chemotherapy, often leading to bloodstream infections and pneumonia. Routine antimicrobial prophylaxis (AMP) for high-risk haematology patients is still debated while prevalence of multi-drug resistant (MDR) Gram-negative bacteria (GNB) is rising globally. We aimed to assess the current practice of AMP in this population. Cross-sectional observational survey study. Haematologists and infectious diseases physicians Europewide were invited to an online survey including questions on routine screening for GNB, incidence of MDR-GNB colonization, antimicrobial prophylaxis practices, rates of bloodstream infections (BSI), ICU admission and mortality differentiated by infections due to GNB versus MDR-GNB. 120 haematology centres from 28 countries participated. Screening for MDR-GNB is performed in 86.7% of centres, mostly via rectal swabs (58.3%). In 39.2% of routine AMP is used, mostly with fluoroquinolones. Estimates of GNB-BSI yielded higher rates in patients not receiving anti-GNB prophylaxis than in those who do for E. coli (10% vs 7%) Klebsiella spp. (10% vs 5%), and Pseudomonas spp. (5% vs 4%). Rates for MDR-GNB infection were estimated lower in centres that administer AMP for MDR E. coli (5% vs 3%) Klebsiella spp. (5% vs 3%), and Pseudomonas spp. (2% vs 1%). In an exploratory analysis, Southern and Eastern European countries expected higher rates of MDR-GNB infections with lower ICU admission and mortality rates which may be subject to estimation bias. Screening for MDR-GNB is frequently performed. AMP against GNB infections is still often implemented. Estimated BSI rates are rather low, while the rate of MDR-GNB infections rises. Tailored prophylaxis including antimicrobial stewardship becomes more important.

Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study.

IntroductionEmergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database.MethodsThis was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit.ResultsOf the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72–0.84), and lower costs (adjusted difference, −5,198 New Taiwan dollars, 95% CI, −6,224 to −4,172).ConclusionPatients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.

Effectiveness of prone position in spontaneously breathing patients with COVID-19: A prospective cohort study.

We present a single centre study describing the effect of awake prone position (PP) on oxygenation and clinical outcomes in spontaneously breathing patients with novel coronavirus disease (COVID-19). Between 1st March and 30th April 2020, forty eight of 138 patients managed outside of the critical care unit with facemask oxygen, high flow nasal oxygen (HFNO) or continuous positive airway pressure (CPAP), underwent PP. Prone position was associated with significant improvement in oxygenation, lower ICU admission, tracheal intubation, and shorter ICU length of stay. Lack of response to PP may be an indicator of treatment failure, requiring early escalation.

Risk factors associated with severe outcomes in adult hospitalized patients according to influenza type and subtype.

Seasonal influenza is a cause of hospitalization, especially in people with underlying disease or extreme age, and its severity may differ depending on the types and subtypes of circulating viruses. We investigated the factors associated with ICU admission or death in hospitalized patients with severe laboratory-confirmed influenza according to the viral type and subtype. An observational epidemiological study was carried out in patients aged ≥18 years from 12 Catalan hospitals between 2010 and 2016. For each reported case we collected demographic, virological and clinical characteristics. A mixed-effects logistic regression model was used to estimate crude and adjusted ORs. 1726 hospitalized patients were included: 595 (34.5%) were admitted to the ICU and 224 (13.0%) died. Lower ICU admission was associated with age ≥75 years in all influenza types and subtypes and with age 65–74 years for type A. In contrast, the 65–74 and ≥75 years age groups were associated with an increased risk of death in all types and subtypes, especially for type B (aOR 27.42, 95% CI: 4.95–151.93 and 15.96; 95% CI: 3.01–84.68). The comorbidity most closely associated with severe outcomes was immune deficiency, which was associated with death for type B (aOR 9.02, 95% CI: 3.05–26.69) and subtype A(H1N1)pdm09 (aOR 3.16, 95% CI: 1.77–5.66). Older age was a differential factor for ICU admission and death: it was associated with lower ICU admission but a risk factor for death. The comorbidity with the closest association with death was immune deficiency, mainly in influenza type B patients.

The impact of palliative care training for oncologists and integrative palliative service in a public-funded hospital cluster-a retrospective cohort study.

Oncological care of advanced cancer patients was provided by multiple departments in Hong Kong. One of these departments, the clinical oncology department (COD), introduced systematic palliative care training for its oncologists since 2002. The COD was recognized as a European Society for Medical Oncology (ESMO) Designated Centre of Integrated Oncology and Palliative Care since 2009. This retrospective cohort study aims to review the impact of integrative training and service on palliative care coverage and outcome. Clinical information, palliative service provision, and end-of-life outcomes of patients who passed away from lung, colorectal, liver, stomach, or breast cancer in the Hong Kong West public hospital network during July 2015 to December 2015 were collected. A total of 307 patients were analyzed. Around half (49.2%) were attended primarily by COD, and 68.9% received palliative service. There are significantly fewer patients referred to palliative care from other departments (p < 0.001), with only 19.9% of this patient group receiving palliative referral. COD patients had longer palliative coverage before death (median 65days versus 24days, p < 0.001), higher chance of receiving end-of-life care at hospice units (36.4 versus 21.2%, p = 0.003), lower ICU admission (0.66 versus 5.1%, p = 0.02), and higher percentage of receiving strong opioid in the last 30days of life (51.0 versus 28.9%, p < 0.001) compared to other departments. In multivariable analysis, COD being the primary care team (odds ratio 12.2, p < 0.001) was associated with higher palliative care coverage. The study results suggested that systematic palliative care training of oncologists and integrative palliative service model was associated with higher palliative service coverage and improved palliative care outcomes.

Activation of a Medical Emergency Team Using an Electronic Medical Recording–Based Screening System*

To evaluate the efficacy of a medical emergency team activated using 24-hour monitoring by electronic medical record-based screening criteria followed by immediate intervention by a skilled team. Retrospective cohort study. Academic tertiary care hospital with approximately 2,700 beds. A total of 3,030 events activated by a medical emergency team from March 1, 2008, to February 28, 2010. None. We collected data for all medical emergency team activations: patient characteristics, trigger type for medical emergency team (electronic medical record-based screening vs calling criteria), interventions during each event, outcomes of the medical emergency team intervention, and 28-day mortality after medical emergency team activation. We analyzed data for 2009, when the medical emergency team functioned 24 hours a day, 7 days a week (period 2), compared with that for 2008, when the medical emergency team functioned 12 hours a day, 7 days a week (period 1). The commonest cause of medical emergency team activation was respiratory distress (43.6%), and the medical emergency team performed early goal-directed therapy (21.3%), respiratory care (19.9%), and difficult airway management (12.3%). For patients on general wards, 51.3% (period 1) and 38.4% (period 2) of medical emergency team activations were triggered by the electronic medical record-based screening system (electronic medical record-triggered group). In 23.4%, activation occurred because of an abnormality in laboratory screening criteria. The commonest activation criterion from electronic medical record-based screening was respiratory rate (39.4%). Over half the patients were treated in the general ward, and one third of the patients were transferred to the ICU. The electronic medical record-triggered group had lower ICU admission with an odds ratio of 0.35 (95% CI, 0.22-0.55). In surgical patients, the electronic medical record-triggered group showed the lower 28-day mortality (10.5%) compared with the call-triggered group (26.7%) or the double-triggered group (33.3%) (odds ratio 0.365 with 95% CI, 0.154-0.867, p = 0.022). We successful managed the medical emergency team with electronic medical record-based screening criteria and a skilled intervention team. The electronic medical record-triggered group had lower ICU admission than the call-triggered group or the double-triggered group. In surgical patients, the electronic medical record-triggered group showed better outcome than other groups.

Air Pollution And Environmental Tobacco Smoking During Infancy May Increase The Risk Of Bronchiolitis

M O N D A Y 623 Asthma and Risk of Community-Associated Blood Stream Infection Due to Staphylococcus aureus: A Population-Based Case-Control Study J. Lee, H. Yang, W. Atrouni, L. Baddour, B. Yawn, Y. Juhn; Department of Pediatrics,Samsung Changwon Hospital, Changwon-si, REPUBLIC OF KOREA, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, Department of Pediatrics,Soonchunhyang University Hospital, Seoul, REPUBLIC OF KOREA, Division of Infectious Diseases, Department of Internal Medicine,University of Kansas Medical Center, Kansas, KS, Division of Infectious Diseases, Department of Medicine,Mayo Clinic, Rochester, MN, Department of Research, Olmsted Medical Center, Rochester, MN. RATIONALE: Patients with asthma harbor an increased risk of invasive pneumococcal infection (IPD). It is unknown whether there is a similar association between asthma and community-associated blood stream infection (BSI) caused by Staphylococcus aureus. METHODS: Subjects were adult residents of Olmsted County, MN, who developed community-associated BSI caused by S. aureus between 1998 and 2005; three ageand sex-matched controls were also evaluated. The associations between asthma and community-associated BSI caused by S. aureus were assessed by Fischer exact test. RESULTS: Of the 43 BSI cases, 70% were male, 86% were Caucasians, and the median age was 59 years. Five (11.6%) of them were asthmatics as compared to 9 (7%) of 129 controls (p50.34). Compared to non-asthmatics, asthmatics had a lower ICU admission rate (34% vs 0%, p50.3) and lower Pitt-bacteremia scores (2.362.7 vs. 0.860.5, p50.13), a shorter hospital stay (13.6614.7 days vs. 11.462.1 days,p50.59), and lower mortality rates (13.0% vs. 0.0%, p51.0), but these differences were not statistically significant. CONCLUSIONS: Unlike IPD, asthma is not significantly associated with risk and severity of BSI caused by S. aureus. Designation of specific pathogenmay be one of several key factors in an association of asthmawith risk and severity of BSI. However, a small sample size significantly limited the current investigation.

Asthma and Severity of Blood Stream Infection Caused by Escherichia coli: A Population-Based Study

M O N D A Y 623 Asthma and Risk of Community-Associated Blood Stream Infection Due to Staphylococcus aureus: A Population-Based Case-Control Study J. Lee, H. Yang, W. Atrouni, L. Baddour, B. Yawn, Y. Juhn; Department of Pediatrics,Samsung Changwon Hospital, Changwon-si, REPUBLIC OF KOREA, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, Department of Pediatrics,Soonchunhyang University Hospital, Seoul, REPUBLIC OF KOREA, Division of Infectious Diseases, Department of Internal Medicine,University of Kansas Medical Center, Kansas, KS, Division of Infectious Diseases, Department of Medicine,Mayo Clinic, Rochester, MN, Department of Research, Olmsted Medical Center, Rochester, MN. RATIONALE: Patients with asthma harbor an increased risk of invasive pneumococcal infection (IPD). It is unknown whether there is a similar association between asthma and community-associated blood stream infection (BSI) caused by Staphylococcus aureus. METHODS: Subjects were adult residents of Olmsted County, MN, who developed community-associated BSI caused by S. aureus between 1998 and 2005; three ageand sex-matched controls were also evaluated. The associations between asthma and community-associated BSI caused by S. aureus were assessed by Fischer exact test. RESULTS: Of the 43 BSI cases, 70% were male, 86% were Caucasians, and the median age was 59 years. Five (11.6%) of them were asthmatics as compared to 9 (7%) of 129 controls (p50.34). Compared to non-asthmatics, asthmatics had a lower ICU admission rate (34% vs 0%, p50.3) and lower Pitt-bacteremia scores (2.362.7 vs. 0.860.5, p50.13), a shorter hospital stay (13.6614.7 days vs. 11.462.1 days,p50.59), and lower mortality rates (13.0% vs. 0.0%, p51.0), but these differences were not statistically significant. CONCLUSIONS: Unlike IPD, asthma is not significantly associated with risk and severity of BSI caused by S. aureus. Designation of specific pathogenmay be one of several key factors in an association of asthmawith risk and severity of BSI. However, a small sample size significantly limited the current investigation.