Marker Of Illness Severity Research Articles

Clinician and Visitor Activity Patterns in an Intensive Care Unit Room: A Study to Examine How Ambient Monitoring Can Inform the Measurement of Delirium Severity and Escalation of Care.

The early detection of the acute deterioration of escalating illness severity is crucial for effective patient management and can significantly impact patient outcomes. Ambient sensing technology, such as computer vision, may provide real-time information that could impact early recognition and response. This study aimed to develop a computer vision model to quantify the number and type (clinician vs. visitor) of people in an intensive care unit (ICU) room, study the trajectory of their movement, and preliminarily explore its relationship with delirium as a marker of illness severity. To quantify the number of people present, we implemented a counting-by-detection supervised strategy using images from ICU rooms. This was accomplished through developing three methods: single-frame, multi-frame, and tracking-to-count. We then explored how the type of person and distribution in the room corresponded to the presence of delirium. Our designed pipeline was tested with a different set of detection models. We report model performance statistics and preliminary insights into the relationship between the number and type of persons in the ICU room and delirium. We evaluated our method and compared it with other approaches, including density estimation, counting by detection, regression methods, and their adaptability to ICU environments.

Predictors of the length of stay in psychiatric inpatient units: a retrospective study for the Paris Psychiatry Hospital Group.

Shortening the length of hospital stay (LOS) has become a major challenge for psychiatric hospitals in reducing unnecessary costs and improving the patient healthcare experience. We investigated the key factors associated with a long psychiatric hospitalization. This was a retrospective study of 8,870 full-time psychiatric hospital stays (6,216 patients) in the Paris Psychiatry Hospital Group, with a discharge in 2022. We used machine learning tools and univariate and multivariate methods to explore the impact of demographic, pathway-related, and clinical variables on the LOS. LOS >30 days was associated with age >55 years {odds ratio [OR] =2 [95% confidence interval 1.7-2.3]}, admission from outside the sectorization zone [OR=1.2 (1.1-1.3)], admission via a psychiatric emergency unit [OR, 1.2 (1.1-1.4)], and some clinical severity markers, such as psychotic disorder diagnosis [OR, 1.5 (1.3-1.7)], mandatory care [request of a third party, OR, 2.5 (2.1-2.9); case of imminent danger, OR, 2.3 (1.9-2.7)], the presence of seclusion and mechanical restraint measures (highlighting the positive effect of restraint duration), the somatic comorbidity for female sex [OR, 1.4 (1.2-1.7)], and treatment resistance [OR, 1.4 (1.2-1.6)]. Conversely, LOS ≤30 days was associated with being in a relationship [OR, 0.6 (0.5-0.8)], admission during a travel-related psychiatric episode [OR, 0.5 (0.3-0.6)], and personality and behavior disorders [OR, 0.7 (0.6-0.9)]. We found no significant association for features such as sex and a lack of treatment compliance. To our knowledge, this is the first recent study to investigate and highlight the impact of factors related to various illness severity markers, medication adherence, and patient journeys on the length of psychiatric hospital stay. A better understanding of long-stay risk factors might be helpful for optimizing the allocation of medical resources and anticipating tailored therapeutic programs.

The choice of blood transfusion strategy in severe traumatic brain injury

Traumatic brain injury (TBI) remains one of the leading causes of long-term disability, especially among young and middle-aged people. One of the main directions of treatment for patients with TBI is to prevent the development of secondary brain damage due to systemic dysfunction. Anemia occupies an important place among them. Anemia is considered a marker of illness severity in critically ill patients and is included in the list of parameters for risk prediction in intensive care units. However, the relationship between anemia and adverse outcomes in patients with TBI is controversial. Aim. The purpose of the work is to analyze the effect of anemia on the course of severe TBI, to determine the position of anemia in the pathophysiological mechanisms of brain damage, the development of blood transfusion-associated complications, to evaluate different blood transfusion strategies (liberal and restrictive) and their impact on treatment results, taking into account individual tolerance to anemia. Studies suggest that the restrictive transfusion strategy could be useful in reducing complications and length of hospital stay. However, the lack of clear evidence for optimal hemoglobin levels as a trigger to initiate blood transfusions reinforces the need for further clinical studies. The use of multimodal neuromonitoring allows to evaluate the latest approaches to assessing individual hemoglobin thresholds. These methods could help in identifying patients at increased risk of complications and determining optimal strategies to manage anemia. Conclusions. The problem of tolerance to anemia in patients with severe TBI remains a controversial topic, and determining hemoglobin thresholds for blood transfusion in this group of patients requires further studies, special attention should therefore be paid to an individual approach to resolving the issue of red blood cell transfusion, in particular, integrating clinical status of a patient and concomitant pathology. The risk of possible brain damage worsening associated with anemia due to deterioration of cerebral oxygenation should always be weighed against the risk of developing transfusion-associated complications.

LINAS-Score: prognostic model for mortality assessment in patients with cirrhotic liver and infected ascites.

Patients with liver cirrhosis often face a grave threat from infected ascites (IA). However, a well-established prognostic model for this complication has not been established in routine clinical practice. Therefore, we aimed to assess mortality risk in patients with liver cirrhosis and IA. We conducted a retrospective study across three tertiary hospitals, enrolling 534 adult patients with cirrhotic liver and IA, comprising 465 with spontaneous bacterial peritonitis (SBP), 34 with bacterascites (BA), and 35 with secondary peritonitis (SP). To determine the attributable mortality risk linked to IA, these patients were matched with 122 patients with hydropic decompensated liver cirrhosis but without IA. Clinical, laboratory, and microbiological parameters were assessed for their relation to mortality using univariable analyses and a multivariable random forest model (RFM). Least absolute shrinkage and selection operator (Lasso) regression model was used to establish an easy-to-use mortality prediction score. The in-hospital mortality risk was highest for SP (39.0%), followed by SBP (26.0%) and BA (25.0%). Besides illness severity markers, microbiological parameters, such as Candida spp., were identified as the most significant indicators for mortality. The Lasso model determined 15 parameters with corresponding scores, yielding good discriminatory power (area under the receiver operating characteristics curve=0.89). Counting from 0 to 83, scores of 20, 40, 60, and 80 corresponded to in-hospital mortalities of 3.3%, 30.8%, 85.2%, and 98.7%, respectively. We developed a promising mortality prediction score for IA, highlighting the importance of microbiological parameters in conjunction with illness severity for assessing patient outcomes.

Erratum for Rothe et al., "Are enterococcal bloodstream infections an independent risk factor for a poorer 5-year survival or just a marker for severity of illness?-The Munich multicentric enterococci cohort".

Erratum for Rothe et al., "Are enterococcal bloodstream infections an independent risk factor for a poorer 5-year survival or just a marker for severity of illness?-The Munich multicentric enterococci cohort".

Current State of Application of Formal Thought Disorder Screening Methods in First-Degree Relatives of Patients With Schizophrenia: A Narrative Review

Abstract: Historically, formal thought disorder (FTD) has been considered one of the distinctive key symptoms of schizophrenia and is still regarded as an important early warning sign and a marker of illness severity with solid predictive value. Recent studies are able to found that the presence of FTD is predictive of the subsequent diagnosis of schizophrenia and often precedes the frank clinical picture by several months. Much effort has been put into developing scales that can reliably detect FTD and can be readily applied in routine clinical practice. This narrative review investigated the use of FTD as a screening tool to assess risk in first-degree relatives of patients with schizophrenia. The results show that the use of these scales in firstdegree relatives of schizophrenic individuals during clinical contact and counseling is still an exception, despite their uniquely heightened vulnerability profile. To our knowledge, this is the first time that the application of FTD screening methods in first-degree relatives of schizophrenic individuals has been reviewed in a structured way.

Macrophage activation markers are associated with infection and mortality in patients with acute liver failure.

Acute liver failure is a multisystem disorder with a high mortality and frequent need for emergency liver transplantation. Following massive innate immune system activation, soluble markers of macrophage activation are released during liver damage and their association with disease severity and prognosis requires exploration. Patients ALF from the United States Acute Liver Failure Study Group (USALFSG, n = 224) and King's College Hospital (n = 40) together with healthy controls (HC, n = 50) were recruited. Serum from early (Days 1-3) and late (>Day 3) time points were analysed for MAMs by enzyme-linked immunosorbent assay correlated to markers of illness severity and 21-day spontaneous survival. Surface expression phenotyping was performed via Flow Cytometry on CD14+ monocytes. All MAMs serum concentrations were significantly higher in ALF compared to controls (p < .0001). sCD206 concentration was higher in early and late stages of the disease in patients with bacteraemia (p = .002) and infection in general (p = .006). In MELD-adjusted multivariate modelling, sCD206 and sCD163 were independently associated with mortality. CD14+ monocyte expression of CD206 (p < .001) was higher in patients with ALF compared with controls and correlated with SOFA score (p = .018). sCD206 was independently validated as a predictor of infection in an external cohort. sCD206 is increased in serum of ALF patients with infections and poor outcome and is upregulated on CD14+ monocytes. Later measurements of sCD163 and sCD206 during the evolution of ALF have potential as mechanistic predictors of mortality. sCD206 should be explored as a biomarker of sepsis and mortality in ALF.

The relationship between visual hallucinations, functioning, and suicidality over the course of illness: a 10-year follow-up study in first-episode psychosis

Visual hallucinations in psychosis are under-researched despite associations with increased illness severity, functional impairments, and suicidality in the few existing studies. Further, there are no long-term longitudinal studies, making it impossible to conclude if these associations are state or trait phenomena. In the current prospective longitudinal study, 184 individuals with first-episode psychosis were assessed with semi-structured clinical interviews and self-report questionnaires at baseline and 10-year follow-up. Participants were grouped based on lifetime experience of visual hallucinations: before or at baseline (VH+/+), first during follow-up (VH−/+), or never (VH−/−). Associations with functioning, suicide attempts, childhood trauma and other markers of illness severity were tested using multinomial logistic regression analysis. At baseline, the VH+/+ group (37.5%), but not VH−/+ (12.5%), had poorer functioning, higher symptom severity, a lower age at onset, and included more individuals with a history of multiple suicide attempts than the VH−/− group (50%). At follow-up, the VH−/+ group, but not VH+/+, had poorer functioning and higher symptom severity than the VH−/− group. However, the number of participants who committed multiple suicide attempts during the follow-up period was again significantly higher in the VH+/+ group. There was no association with childhood trauma. Hence, visual hallucinations are associated with impaired functioning and higher symptom severity, but only in the short-term. However, visual hallucinations that arise early in the course of illness are a risk indicator for repeated suicide attempts throughout the illness course. These findings highlight the relevance of assessing visual hallucinations and monitoring their development over time.

COVID-19−Associated Acute Kidney Injury and Longitudinal Kidney Outcomes

COVID-19 infection is associated with a high incidence of acute kidney injury (AKI). Although rapid kidney function decline has been reported in the first few months after COVID-19-associated AKI (COVID-AKI), the longer-term association of COVID-AKI with kidney function remains unknown. To assess long-term kidney outcomes of patients who had COVID-19-associated AKI. This was a retrospective longitudinal multicenter cohort study conducted in a large hospital system using electronic health records data on adult hospitalized patients with AKI and COVID-19 or other illnesses. Included patients were hospitalized during the COVID-19 pandemic (March 2020-June 2022), were screened for SARS-CoV-2, had AKI, and survived to discharge, or had been hospitalized during the 5 years before the pandemic (October 2016-January 2020), had a positive influenza A or B test result, had AKI, and survived to discharge. Patients were followed up for a maximum of 2 years after hospital discharge. Data analyses were performed from December 2022 to November 2023. COVID-19 and influenza. The primary outcome was major adverse kidney events (MAKE), defined as a composite of mortality and worsened kidney function (estimated glomerular filtration rate [eGFR] decline by ≥25% from discharge eGFR or kidney failure requiring dialysis). Multivariable time-to-event analyses were performed to compare MAKE between individuals with COVID-AKI and those who had AKI associated with other illnesses hospitalized during the same period. For further comparison, this outcome was assessed for a historic cohort of patients with influenza-associated AKI. The study cohort included 9624 hospitalized patients (mean [SD] age, 69.0 [15.7] years; 4955 [51.5%] females) with AKI, including 987 patients with COVID-AKI, 276 with influenza-associated AKI, and 8361 with AKI associated with other illnesses (other-AKI). Compared with the other 2 groups, patients with COVID-19-associated AKI were slightly younger in age, had a higher baseline eGFR, worse baseline comorbidity scores, higher markers of illness severity, and longer hospital stay. Compared with the other-AKI group, the COVID-AKI group had lower MAKE (adjusted hazard ratio [aHR], 0.67; 95% CI, 0.59-0.75) due to lower all-cause mortality (aHR, 0.31; 95% CI, 0.24-0.39) and lower rates of worsened kidney function (aHR, 0.78; 95% CI, 0.69-0.88). The findings of this multicenter cohort study indicate that survivors of hospitalization with COVID-AKI experience lower rates of MAKE, long-term kidney function decline, and mortality compared with patients with AKI associated with other illnesses.

Is there a basis for a weight cut-off point? A large-scale investigation of atypical anorexia and anorexia nervosa subtypes among patients at a residential treatment centre.

There is debate surrounding how to differentiate between anorexia nervosa (AN) and atypical AN (atypAN) as diagnostic entities, and whether a distinction based on BMI is warranted. Better understanding eating disorder (ED) and emotional symptoms across atypAN and AN subtypes [AN-restricting (AN-R), AN-binge/purge (AN-BP)], with and without controlling for BMI, can elucidate how atypAN differs from AN subtypes and whether there is a basis for a BMI cut-off. 1810 female patients at an ED treatment centre completed intake surveys. ANCOVAs assessed differences across AN-R (n=853), AN-BP (n=726), and atypAN (n=231) groups on ED, depressive, and anxiety symptoms, anxiety sensitivity, experiential avoidance, and mindfulness, with and without controlling for BMI. Relative to AN-R, atypAN and AN-BP groups endorsed significantly higher ED and depressive symptoms, anxiety sensitivity, experiential avoidance, and significantly lower mindfulness (all p<0.001), but atypAN and AN-BP groups did not differ from one another. When controlling for BMI, all previously significant differences between atypAN and AN-R did not remain significant. Individuals with atypAN who have a higher BMI experience more pronounced ED and emotional symptoms, suggesting that relying solely on BMI as a marker of illness severity may be problematic.

1032. Are enterococcal blood stream infections an independent risk factor for a poorer 5-year survival or just a marker for severity of illness? - The Munich Multi-Centric Enterococci cohort

Abstract Background To assess the long-term survival of patients with enterococcal bloodstream infections (BSI), encompassing various species and resistance patterns, in comparison to Escherichia coli (E. coli) BSI. Recruitment process Graphical Abstract Methods Between 2010 and 2019, 3,290 enterococcal and 3,415 E. coli BSI were retrospectively screened in seven hospitals in Munich, Germany. All vancomycin (VRE), vancomycin/linezolid (LVRE), and linezolid (LRE) resistant Enterococcus faecium (ECFM) BSI were included. Enterococcus faecalis (ECFA), vancomycin/Linezolid-susceptible ECFM, and E. coli BSI were randomly assigned. Cox-regression models were used to assess survival as the primary endpoint and were adjusted for limiting prognostic factors, which were measured for their importance using a random forest model (RFM). Results 952 patients with 916 episodes of enterococcal BSI and 193 E. coli BSI episodes were analysed. RFM identified multimorbidity and markers for disease severity as most indicative of low survival in enterococcal BSI. The 5-year survival was significantly lower for enterococcal BSI than for E. coli BSI (23.9% vs. 42.3%; p&amp;lt; 0.001). This difference remained significant in the Cox-regression analysis after adjusting for 17 prognostic factors and excluding patients with limited life expectancy (metastatic tumour disease, Charlson comorbidity index ≥5). Adjusted 5-year survival between E. coli and ECFA was similar but significantly different between ECFA and ECFM BSI (29.2% vs. 21.7%; p=0.002). The analysis conducted on monomicrobial ECFM and VRE BSI indicated that their respective 5-year survival was similar (19.6% vs. 21.2%; p=0.753). Conclusion ECFM BSI seems to be an independent risk factor for poor long-term survival. However, additional vancomycin resistance does not appear to be a contributing factor. Disclosures Jochen Schneider, MD, JS reports grants, personal fees, and nonfinancial support from AbbVie, Gilead Sciences, Janssen-Cilag, GSK/ViiV Healthcare, and MSD, Dr. Falk Pharma: Grant/Research Support Karl Dichtl, MD, KD reports grants from Euroimmun Medizinische Labordiagnostika and Fujifilm Wako Chemicals Europe outside of this study.: Advisor/Consultant Ulrich Seybold, MD, reports personal fees and nonfinancial support from Gilead Sciences, ViiV Healthcare, Janssen-Cilag, Falk Foundation, Sanofi-Aventis.: Advisor/Consultant Christoph Spinner, MD, AbbVie, Gilead Sciences, Janssen-C,MSD, Cepheid, GSK, ViiV Healthcare, AstraZeneca, Apeiron, Braun, Pfizer, Novartis, Lilly, Biontech…: Advisor/Consultant|AbbVie, Gilead Sciences, Janssen-C,MSD, Cepheid, GSK, ViiV Healthcare, AstraZeneca, Apeiron, Braun, Pfizer, Novartis, Lilly, Biontech…: Board Member|AbbVie, Gilead Sciences, Janssen-C,MSD, Cepheid, GSK, ViiV Healthcare, AstraZeneca, Apeiron, Braun, Pfizer, Novartis, Lilly, Biontech…: Grant/Research Support|CDS reports grants and personal fees from AbbVie, grants, fees and non-financial support from Gilead Sciences, grants and personal fees from Janssen-C: Advisor/Consultant|CDS reports grants and personal fees from AbbVie, grants, fees and non-financial support from Gilead Sciences, grants and personal fees from Janssen-C: Board Member|CDS reports grants and personal fees from AbbVie, grants, fees and non-financial support from Gilead Sciences, grants and personal fees from Janssen-C: Grant/Research Support

Abstract 102: Early Bolus Epinephrine Administration During Pediatric Cardiopulmonary Resuscitation for Bradycardia With Poor Perfusion

Introduction: Though epinephrine is recommended during CPR for children with bradycardia with poor perfusion, a registry study identified an association between epinephrine administration and worse outcomes. Our objective was to use granular data from the ICU-RESUScitation (ICU-RESUS) trial, including markers of illness severity not available in registries, to further investigate epinephrine use in this population. We hypothesized that when controlling for patient characteristics, early epinephrine administration would be associated with superior outcomes in children receiving CPR for bradycardia with poor perfusion. Methods: Prespecified secondary analysis of ICU-RESUS, a multicenter cluster randomized trial of pediatric (&lt;19 years) IHCA in 18 PICUs. Index events (October 2016 to March 2021) lasting 2 minutes with an initial rhythm of bradycardia with poor perfusion were included. Early administration of bolus epinephrine (first 2 minutes of CPR) was chosen as the exposure since pulselessness during CPR for bradycardia with poor perfusion develops at a median of 3 minutes. The association between early epinephrine and outcomes was evaluated with Poisson multivariable regression controlling for a priori pre-arrest characteristics including Pediatric Risk of Mortality (PRISM) score and vasoactive inotropic score (VIS). Results: Of 452 patients, 322 (71.2%) received early epinephrine. The early epinephrine group had higher PRISM and VIS and more frequently received calcium and sodium bicarbonate. On univariate analysis, the early epinephrine group had lower, but not statistically significantly, rates of survival to discharge (174/322 [54%] vs 82/130 [63%], p=0.093) and survival with favorable neurologic outcome (164/322 [51%] vs 75/130 [58%], p=0.212). In multivariable analysis, early epinephrine was not associated with survival to discharge (RR 0.97, 95% CI 0.82, 1.14) or survival with favorable neurologic outcome (RR 0.99, 95% CI 0.82, 1.18). Conclusion: In this cohort of pediatric IHCA with an initial rhythm of bradycardia with poor perfusion, early bolus epinephrine was not associated with outcomes when controlling for illness severity. Further work should focus on which patients with this rhythm benefit from epinephrine.

Are enterococcal bloodstream infections an independent risk factor for a poorer 5-year survival or just a marker for severity of illness?-The Munich multicentric enterococci cohort.

The present study provides a substantial contribution to literature, showing that patients with enterococcal bloodstream infections (BSI) have a lower survival rate than those with Escherichia coli (E. coli) bloodstream infections after adjusting for 17 limiting prognostic factors and excluding patients with a limited life expectancy [metastatic tumor disease, Charlson Comorbidity Index (CCI) (greater than or equal to) 5]. This difference in the 5-year long-term survival was mainly driven by Enterococcus faecium (ECFM) bloodstream infections, with vancomycin resistance not being a significant contributing factor. Our findings imply that E. faecium bloodstream infections seem to be an independent risk factor for poor long-term outcomes. As such, future research should confirm this relationship and prioritize investigating its causality through prospective studies.

Treatment and care received by children hospitalized with COVID-19 in a large hospital network in the United States, February 2020 to September 2021.

We described care received by hospitalized children with COVID-19 or multi-system inflammatory syndrome (MIS-C) prior to the 2021 COVID-19 Omicron variant surge in the US. We identified hospitalized children <18 years of age with a COVID-19 or MIS-C diagnosis (COVID-19 not required), separately, from February 2020-September 2021 (n = 126 hospitals). We described high-risk conditions, inpatient treatments, and complications among these groups. Among 383,083 pediatric hospitalizations, 2,186 had COVID-19 and 395 had MIS-C diagnosis. Less than 1% had both COVID-19 and MIS-C diagnosis (n = 154). Over half were >6 years old (54% COVID-19, 70% MIS-C). High-risk conditions included asthma (14% COVID-19, 11% MIS-C), and obesity (9% COVID-19, 10% MIS-C). Pulmonary complications in children with COVID-19 included viral pneumonia (24%) and acute respiratory failure (11%). In reference to children with COVID-19, those with MIS-C had more hematological disorders (62% vs 34%), sepsis (16% vs 6%), pericarditis (13% vs 2%), myocarditis (8% vs 1%). Few were ventilated or died, but some required oxygen support (38% COVID-19, 45% MIS-C) or intensive care (42% COVID-19, 69% MIS-C). Treatments included: methylprednisolone (34% COVID-19, 75% MIS-C), dexamethasone (25% COVID-19, 15% MIS-C), remdesivir (13% COVID-19, 5% MIS-C). Antibiotics (50% COVID-19, 68% MIS-C) and low-molecular weight heparin (17% COVID-19, 34% MIS-C) were frequently administered. Markers of illness severity among hospitalized children with COVID-19 prior to the 2021 Omicron surge are consistent with previous studies. We report important trends on treatments in hospitalized children with COVID-19 to improve the understanding of real-world treatment patterns in this population.

Cost Comparison of Treatment Alternatives for Pleural Effusion and Ascites from a Payer Perspective: Are There Cost Savings from Indwelling Catheters?

Background: The presence of pleural effusions and ascites in patients is often considered a marker of illness severity and a poor prognostic indicator. This study aims to compare inpatient and outpatient costs of alternative invasive treatments for ascites and pleural effusions. Methods: The retrospective single-institution study included inpatient cases treated for pleural effusion (J90 and J91) or ascites (R18) at the University Hospital Cologne (UHC) in Germany between January 01, 2020, and December 31, 2021. Costs for punctures and indwelling catheter systems (ICSs) as well as pleurodesis were analyzed in different comparator treatment pathways. Real-world data from the UHC tertiary care center were based on diagnosis-related group fees from 2020 to 2021. A simulation of outpatient expenses was carried out to compare inpatient and outpatient costs for each pathway from a payer perspective. Results: A total of 4323 cases (3396 pleural effusions and 1302 ascites) were analyzed. For ascites, inpatient implantation with home care drainage was found to be the most expensive option, with total costs of €1,918.58 per procedure, whereas outpatient puncture was the least expensive option at €60.02. For pleural effusions, the most expensive treatment pathway was pleurodesis at €8,867.84 compared with the least costly option of outpatient puncture resulting in total costs per procedure of €70.03. A break-even analysis showed that outpatient puncture remains the most inexpensive treatment option, and the ICS comprises a cost-saving potential. Longevity of several months with the use of ICSs results in both enhanced quality of life for patients and increased cost savings.

Association of Chest Radiography With Outcomes in Pediatric Pneumonia: A Population-Based Study.

Chest radiograph (CXR) is often performed for the evaluation of community-acquired pneumonia (CAP) in the ED setting. We sought to evaluate the association of undergoing CXR with 7-day hospitalization after emergency department (ED) discharge among patients with CAP. This was a retrospective cohort study including children 3 months to 17 years discharged from any ED within 8 states from 2014 to 2019. We evaluated the association of CXR performance with 7-day hospitalization at both the patient and ED levels using mixed-effects logistic regression models accounting for markers of illness severity. Secondary outcomes included 7-day ED revisits and 7-day hospitalization with severe CAP. Among 206 694 children with CAP, rates of 7-day ED revisit, hospitalization, and severe CAP were 8.9%, 1.6%, and 0.4%, respectively. After adjusting for illness severity, CXR was associated with fewer 7-day hospitalizations (1.6% vs. 1.7%, adjusted odds ratio: [aOR] 0.82, 95% confidence interval [CI]: 0.73-0.92). CXR performance varied somewhat between EDs (median 91.5%, IQR: 85.3%-95.0%). EDs in the highest quartile had fewer 7-day hospitalizations (1.4% vs 1.9%, aOR: 0.78, 95% CI: 0.65-0.94), ED revisits (8.5% vs 9.4%, aOR: 0.88, 95% CI: 0.80-0.96) and hospitalizations for severe CAP (0.3% vs. 0.5%, aOR: 0.70, 95% CI: 0.51-0.97) as compared to EDs with the lowest quartile of CXR utilization. Among children discharged from the ED with CAP, performance of CXR was associated with a small but significant reduction in hospitalization within 7 days. CXR may be helpful in the prognostic evaluation of children with CAP discharged from the ED.

Characteristics and Outcomes of Patients Discharged Directly Home From the Pediatric Intensive Care Unit.

Introduction: Patients admitted to the pediatric intensive care unit (PICU) typically transfer to an acute care floor prior to discharge (ACD). Various circumstances, including rapid clinical improvement, technology dependence, or capacity constraints, may lead to discharge directly to home from a PICU (DDH). This practice has been studied in adult intensive care units, but research is lacking for PICU patients. Methods: We aimed to describe characteristics and outcomes of patients requiring PICU admission who experienced DDH versus ACD. We conducted a retrospective cohort study of patients ≤18 years old admitted to our academic, tertiary care PICU between 1/1/15 and 12/31/20. Patients who died or were transferred to another facility were excluded. Baseline characteristics (including home ventilator dependence) and markers of illness severity, specifically the need for vasoactive infusion or new mechanical ventilation, were compared between groups. Admission diagnoses were categorized using the Pediatric Clinical Classification System (PECCS). Our primary outcome was hospital readmission within 30 days. Results: Of 4042 PICU admissions during the study period, 768 (19%) were DDH. Baseline demographic characteristics were similar, although DDH patients were more likely to have a tracheostomy (30% vs 5%, P < .01) and require a home ventilator at discharge (24% vs 1%, P < .01). DDH was associated with being less likely to have required a vasoactive infusion (7% vs 11%, P < .01), shorter median length of stay (LOS) (2.1 days vs 5.9 days, P < .01) and increased rate of readmission within 30 days of discharge (17% vs 14%, P < .05). However, repeat analysis after removing ventilator-dependent patients at discharge (n = 202) showed no difference in rates of readmission (14% vs 14%, P = .88). Conclusions: Direct discharge home from the PICU is a common practice. DDH and ACD groups had similar 30-day readmission rate when patient admissions with home ventilator dependence were excluded.

Data, Anomalies; a Call to Cease and Desist.

Data, Anomalies; a Call to Cease and Desist.

Critical and non-critical coronavirus disease 2019 patients: which is the most predictive biomarker for disease severity and outcome?

BACKGROUND Severe acute respiratory syndrome-coronavirus-2 in coronavirus disease 2019 (COVID-19) patients leads to a wide range of clinical manifestations. The evaluation of mid-regional pro-adrenomedullin (MR-proADM) as a prognostic biomarker in noncritical wards (NON-ICU) and intensive care units (ICU), may have a potential in predicting disease severity and outcomes. OBJECTIVE To assess the difference in the prognostic power of MR-proADM in NON-ICU wards and in ICUs in a prospective multicentre cohort study. DESIGN From January to July 2021, all adult COVID-19 patients requiring admission for more than 48 h. SETTING One primary centre and two secondary centre hospitals. PATIENTS One hundred and twenty-three ICU and 77 NON-ICU patients. INTERVENTION MR-proADM, lymphocyte subpopulations and immunoglobulins were measured within 48 h and on days 3 and 7. A Log-rank test was used to compare survival curves, using a MR-proADM cut-off value of 1.5 nmol l−1. The predictive ability for mortality was compared using the area under the curve and 95% confidence interval (CI) of different receiver-operating characteristic curves. MAIN OUTCOME MEASURES The first 48 h MR-proADM values were significantly higher in the ICU group (median value 1.10 [IQR, 0.80 to 1.73] pg ml−1 vs. 0.90 [0.70 to 1.20] pg ml−1, P = 0.020), and statistically significant changes were observed over time for MR-proADM, CD3+, CD4+ and CD56+. In univariate analysis, MR-proADM was the only biomarker that significantly predicted mortality (P = 0.006). The logistic regression model showed an odds ratio for mortality equal to 1.83 (95% CI, 1.08 to 3.37) P = 0.035 for MR-proADM, 1.37 (1.15 to 1.68) P = 0.001 for MuLBSTA and 1.11 (1.05 to 1.18) P less than 0.001 for SAPS II. CONCLUSION MR-proADM admission values and trends over time appear to be a suitable marker of illness severity and a patient's risk of mortality in both ICU and NON-ICU settings. Lymphocyte subpopulation dysfunction seems to play a role in defining the severity of COVID-19 but is limited to ICU setting. TRIAL REGISTRATION on clinicaltrials.gov, NCT04873388 registered on March 2020.

614: URINE BIOMARKERS, ACUTE KIDNEY INJURY, AND FLUID OVERLOAD IN INFANTS AFTER PEDIATRIC HEART SURGERY

Introduction: Acute kidney injury (AKI) and fluid overload (FO) are common in infants after heart surgery and are associated with increased morbidity and mortality. Urine biomarkers may allow for earlier diagnosis of AKI, but their role, time course, and association with FO in infants is incompletely characterized. We aim to characterize the association between urine neutrophil gelatinase-associated lipocalin (uNGAL), kidney injury molecule-1 (uKIM1), and cystatin C (uCysC) and AKI and FO in infants after heart surgery. Methods: We performed a single-center ancillary prospective cohort study of infants < 1 year old who underwent heart surgery and were enrolled in the STRESS trial (NCT03229538) from June 2019-May 2020. We excluded preterm infants and those who had preoperative AKI, as defined per the modified KDIGO criteria. Our primary outcome was development of any KDIGO defined AKI. Our secondary outcome was development of ≥10% FO 48 hours postoperatively. Urine samples were collected at three time points (preoperative, 0-< 8 hours post-bypass, 8-24 hours post-bypass). We examined the association between standardized urine biomarker values and AKI and FO using multivariable analysis controlling for demographics, surgical factors, and surrogate markers of illness severity. Results: Our cohort included 40 infants with a mean of 2 urine samples each. Median (IQR) age at surgery was 103 (5.5-161) days. A total of 22 (55%) infants were diagnosed with any AKI and 21 infants (53%) developed FO. No infant died. In unadjusted analysis, bypass time was longer (171 [106, 222] v 111 [75, 155] minutes, p=0.01), and vasoactive infusion score was higher (9.5 [6, 11.5] v 5 [2, 9.5], p=0.02) in infants with AKI compared to those without AKI. On multivariable analysis, higher levels of uCysC and uNGAL at 0-8 hours post-bypass were predictive of FO at 48 hours (OR:3.4; 95% CI: 1.3, 8.9; OR: 2.7; 95% CI: 1.2, 6.2, respectively). There was no significant correlation between uCysC, uNGAL, and uKIM1 at any time and AKI. Conclusions: In a single center cohort, uCysC and uNGAL in the early postoperative period were associated with FO at 48 hours postoperatively. UCysC, uNGAL, and uKIM1 were not associated with AKI. Further studies should focus on the role of urine biomarkers in early diagnosis of FO.