Adult Medical Care Research Articles

Health status, functioning and risk profiles for secondary health conditions in adolescents and young adults with spina bifida: a cross-sectional study at time of transition.

The transition from paediatric to adult medical care is a critical period for adolescents with spina bifida, often marked by deteriorating health and functional status. To describe the health status and functioning of individuals with spina bifida at the time of transition from paediatric to adult care and to identify risk profiles for potentially modifiable secondary health conditions (urinary tract infections, pressure injuries, respiratory problems and obesity). Descriptive study of data (derived from medical records) from all adolescents and young adults with spina bifida aged 15-25 years who were referred to a single specialised spinal cord injury centre as part of the transition programme during the period from 1 September 2015 to 31 May 2022. Descriptive statistics were used to describe the study population and to analyse the frequency and co-occurrence of congenital and acquired secondary health conditions. The equality of proportions test was used to test the prevalence of secondary health conditions based on important personal and clinical characteristics. We included 43 adolescents with spina bifida with a mean age of 18.4 years (SD 2.5); in 63% of them the neurological level was lumbar, and around 50% of them were wheelchair-dependent. The median Spinal Cord Injury Measure (SCIM) III score was 72 (IQR 61-89). The mean number of secondary health conditions at time of transition was 8.8. The most prevalent secondary health conditions were lower urinary tract dysfunction, bowel dysfunction, sexual dysfunction and contractures. Respiratory problems were more prevalent in females and in individuals with lower SCIM III scores, whereas no differences were observed in the prevalence of other modifiable secondary health conditions. Clustering of secondary health conditions was mainly seen for urinary tract infection + pressure injury and for urinary tract infection + pressure injury + obesity. The prevalence of secondary health conditions among individuals with spina bifida at time of transition is alarmingly high and functional profiles underscore the need for supporting adolescents and young adults with daily medical issues. The study highlights the critical role of transition programmes and interdisciplinary follow-up care in preventing health problems and improving functioning and independence in everyday life.

Outbreak of New Delhi Metallo-β-lactamase-producing Escherichia coli in a Neonatal Intensive Care Unit, New York State

Background: Outbreaks of carbapenemase-producing (CP) organisms (CPOs), including carbapenem-resistant Enterobacterales (CRE), in neonatal intensive care units (NICUs) are not well documented. The Centers for Disease Control and Prevention (CDC) identifies CP-CRE as an urgent threat to United States (US) healthcare facilities. Wadsworth Center, the New York State (NYS) Department of Health’s (NYSDOH’s) public health laboratory, participates in CDC’s Antimicrobial Resistance Laboratory Network to provide CPO identification, characterization, and surveillance. NYSDOH investigated an outbreak of CP-CRE Escherichia coli (E. coli) infections in NICU patients reported by one hospital. Method: Hospital A reported a CRE E. coli outbreak in their NICU to NYSDOH, as required by NYS Sanitary Code. In response, epidemiologists reviewed case data, conducted case finding, and provided infection control guidance to the hospital. Hospital A continued NICU clinical surveillance and conducted colonization screening to detect additional cases of CRE E. coli. The Wadsworth Center Antimicrobial Resistance Laboratory Network tested isolates from affected patients for CP genes and performed whole genome sequencing (WGS) to determine the CP gene variant, multilocus sequence type (MLST), and relatedness by mutation event (ME) analysis. NYSDOH epidemiologists assessed Hospital A’s infection control practices in affected areas and provided recommendations. Result: Hospital A identified two CRE E. coli infections in NICU patients with overlapping admissions in June-July 2023. Retrospective surveillance identified a third CRE E. coli case in an adult medical intensive care unit patient on admission to Hospital A in June 2023, with prior hospitalization April-May 2023. WGS analysis identified the blaNDM-5 gene in all three CRE E. coli patient isolates. The two NICU patients’ isolates had the same MLST (361/650) and differed by 9 MEs, indicating relatedness to each other and not the adult patient’s (MLST 167/2). NICU patient colonization screening identified no additional blaNDM-5 E. coli cases. NYSDOH’s NICU infection control assessment found that both cases were in adjacent isolettes within three feet of each other. Clean isolettes, equipment, and supplies for new admissions were stored in the clinical care space, not in a separate clean area. Conclusion: CP-CRE is an urgent threat to US healthcare facilities, including hospital NICUs. Though the incidence and prevalence of CP-CRE blaNDM-5 E. coli are not well-defined in NY, single healthcare-associated cases in NICU populations represent an outbreak. The Wadsworth Center Antimicrobial Resistance Laboratory Network’s contributions complement traditional epidemiologic surveillance and investigation methods to provide more specific, comprehensive infection

No one really plans to have multiple sclerosis: Transition readiness and quality of life in paediatric multiple sclerosis.

We sought to explore the experiences and perceptions of the quality of life of adolescents with pediatric-onset multiple sclerosis and assess their readiness for academic, employment and/or health care-related transitions. Adolescents with pediatric-onset multiple sclerosis face unique challenges in managing a chronic illness while navigating future scholastic, social and occupational goals. We conducted a qualitative study with in-depth, semi-structured interviews from July 2017 to March 2019. Adolescents with pediatric-onset multiple sclerosis were recruited from a pediatric neurology subspeciality practice until reaching data saturation. A total of 17 interviews were completed via telephone with participants ages 15 through 26. Through content analysis of the interviews, we identified five major themes: (1) receiving a new diagnosis; (2) adapting to life with pediatric-onset multiple sclerosis; (3) evaluating education/career transition preparedness; (4) adjusting within family life and establishing support systems; and (5) assessing current medical services and preparedness for adult medical care. Autonomy in health care management, adequate control of physical symptoms and sufficient family support impacted perceptions of quality of life. Implementing a dedicated transition visit, including the parent(s) of those with pediatric-onset multiple sclerosis, early in adolescence may provide an avenue for appropriate anticipatory guidance regarding available services, independent medical management and continuity of care.

Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN).

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus characterized by symptoms of esophageal dysfunction and histologically by predominantly eosinophilic infiltration of the squamous epithelium. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published a guideline in 2014; however, the rapid evolution of knowledge about pathophysiology, diagnostic criteria, and therapeutic options have made an update necessary. A consensus group of pediatric gastroenterologists from the ESPGHAN Working Group on Eosinophilic Gastrointestinal Diseases (ESPGHAN EGID WG) reviewed the recent literature and proposed statements and recommendations on 28 relevant questions about EoE. A comprehensive electronic literature search was performed in MEDLINE, EMBASE, and Cochrane databases from 2014 to 2022. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of evidence and formulate recommendations. A total of 52 statements based on the available evidence and 44 consensus-based recommendations are available. A revision of the diagnostic protocol, options for initial drug treatment, and the new concept of simplified empiric elimination diets are now available. Biologics are becoming a part of the potential armamentarium for refractory EoE, and systemic steroids may be considered as the initial treatment for esophageal strictures before esophageal dilation. The importance and assessment of quality of life and a planned transition to adult medical care are new areas addressed in this guideline. Research in recent years has led to a better understanding of childhood EoE. This guideline incorporates the new findings and provides a practical guide for clinicians treating children diagnosed with EoE.

Cost and non-cost factors associated with delays in receiving medical care in adults with atherosclerotic cardiovascular disease.

The study aims to compare cost and non-cost factors associated with delays in receiving medical care in adults with atherosclerotic cardiovascular disease (ASCVD). Using 2014-2018 data from the Centers for Disease Control and Prevention (CDC) Behaviour Risk Factor Surveillance System (BRFSS) survey (N = 508,203), multivariate logistic regression models were developed to compute the adjusted odds ratio of reasons for delays in medical care in adults with ASCVD. Our study population of 61,227 adults with ASCVD (9.1%) had higher odds of any medical care delay (aOR 1.50, 95% CI 1.43-1.57), delay due to cost (aOR 1.55, 95% CI 1.45-1.65), long clinic wait times (aOR 1.21, 95% CI 1.04-1.39) and lack of transportation (aOR 1.64, 95% CI 1.47-1.84) than those without ASCVD. Novel public health and health policy approaches are urgently needed to reduce the cost- and non-cost-related barriers that adults with ASCVD encounter when accessing healthcare services.

Overcoming challenges in real-world evidence generation: An example from an Adult Medical Care Coordination program.

The Adult Medical Care Coordination program ("the program") was implemented at Mayo Clinic to promote patient self-management and improve 30-day unplanned readmission for patients with high risk for readmission after hospital discharge. This study aimed to evaluate the impact of the program compared to usual care using a pragmatic, stepped wedge cluster randomized trial ("stepped wedge trial"). However, several challenges arose including large differences between the study arms. Our goal is to describe the challenges and present lessons learned on how to overcome such challenges and generate evidence to support practice decisions. We describe the challenges encountered during the trial, the approach to addressing these challenges, and lessons learned for other learning health system researchers facing similar challenges. The trial experienced several challenges in implementation including several clinics dropping from the study and care disruptions due to COVID-19. Additionally, there were large differences in the patient population between the program and usual care arms. For example, the mean age was 76.8 for the program and 68.1 for usual care. Due to these differences, we adapted the methods using the propensity score matching approach that is traditionally applied to observational designs and adjusted for differences in observable characteristics. When conducting pragmatic research, researchers will encounter factors beyond their control that may introduce bias. The lessons learned include the need to weigh the tradeoffs of pragmatic design elements and the potential value of adaptive designs for pragmatic trials. Applying these lessons would promote the successful generation of evidence that informs practice decisions.

Two Weeks Versus One Week of Maximal Patient-Intensivist Continuity for Adult Medical Intensive Care Patients: A Two-Center Target Trial Emulation.

To compare outcomes for 2 weeks vs. 1 week of maximal patient-intensivist continuity in the ICU. Retrospective cohort study. Two U.S. urban, teaching, medical ICUs where intensivists were scheduled for 2-week service blocks: site A was in the Midwest and site B was in the Northeast. Patients 18 years old or older admitted to a study ICU between March 1, 2017, and February 28, 2020. None. We applied target trial emulation to compare admission during an intensivist's first week (as a proxy for 2 wk of maximal continuity) vs. admission during their second week (as a proxy for 1 wk of maximal continuity). Outcomes included hospital mortality, ICU length of stay, and, for mechanically ventilated patients, duration of ventilation. Exploratory outcomes included imaging, echocardiogram, and consultation orders. We used inverse probability weighting to adjust for baseline differences and random-effects meta-analysis to calculate overall effect estimates. Among 2571 patients, 1254 were admitted during an intensivist's first week and 1317 were admitted during a second week. At sites A and B, hospital mortality rates were 25.8% and 24.2%, median ICU length of stay were 4 and 2 days, and median mechanical ventilation durations were 3 and 3 days, respectively. There were no differences in adjusted mortality (odds ratio [OR], 1.01 [95% CI, 0.96-1.06]) or ICU length of stay (-0.25 d [-0.82 d to +0.32 d]) for 2 weeks vs. 1 week of maximal continuity. Among mechanically ventilated patients, there were no differences in adjusted mortality (OR, 1.00 [0.87-1.16]), ICU length of stay (+0.06 d [-0.78 d to +0.91 d]), or duration of mechanical ventilation (+0.37 d [-0.46 d to +1.21 d]) for 2 weeks vs. 1 week of maximal continuity. Two weeks of maximal patient-intensivist continuity was not associated with differences in clinical outcomes compared with 1 week in two medical ICUs.

Transitioning from paediatric to adult care in epilepsy: A qualitative study of adolescent experiences

ObjectiveTransition into adulthood and adult medical care is an important step in the life of young people with epilepsy. We aimed to gain a better insight into the lived experience of the transition to adulthood and adult medical care in epilepsy in Sweden, to improve future transitional care. MethodsA cross-sectional observational study with digital focus-group meetings and interviews with young people with epilepsy (16–22 years, n = 37) prior to, or after the transfer to adult care, or their primary caregivers if they had intellectual disability. We used reflexive thematic analysis to analyse the experiences and expectations on the transition to adulthood and adult medical care. ResultsThe results of the thematic analysis included four key areas during transition to adulthood and adult care for young persons with epilepsy: (I) worries on coming changes and future, (II) transfers are not smooth and adult care is less integrated, (III) epilepsy is part of a bigger picture, and (IV) parental roles change. In those with intellectual disability, parents experienced a stressful process and had to increase their efforts to coordinate all care contacts in adult care. Here, epilepsy was often experienced as a minor part of a more complex disease picture, where neurodevelopmental issues were often the primary concern. SignificanceTransition in epilepsy is often complex due to the large burden of co-occurring disease, specifically intellectual disability and neuropsychiatric diagnoses. Transfer to adult care is experienced as unplanned and participants experience uncertainty, indicating a need for an improved transition process. As effective interventions are known in other chronic diseases, future studies should focus on the evaluation of how these approaches can be feasible and effective in young people with epilepsy.

P089 Comprehensive comparison of current guidelines in the management of Systemic Lupus Erythematosus in children, with a focus on Lupus Nephritis

Abstract Background/Aims Lupus nephritis (LN) is a common complication of systemic lupus erythematosus (SLE); LN affects 50-60% of those with a diagnosis of childhood-SLE (cSLE). Currently one set of paediatric recommendations exists for the diagnosis and treatment of LN, published by the Single Hub and Access point for Paediatric Rheumatology in Europe (SHARE). This paper compares SHARE recommendations against two current sets of adult guidelines, published by the British Society of Rheumatology (BSR) and the European Alliance of associations for Rheumatology (EULAR). This paper aims to identify similarities and differences between the three sets of guidelines, and to evaluate the evidence base used to formulate them. Methods Paediatric SHARE recommendations were recorded within a spreadsheet. The recommendations were separated into recommendations for diagnosis and recommendations for treatment. The BSR paper was then examined for equivalent guidelines. The evidence level was recorded for each guideline. In the second phase, the EULAR 2019 guidelines were assessed for corresponding guidelines to the SHARE recommendations. EULAR levels of evidence were recorded. A Likert score of similarity (0-10) was assigned to each trio of guidelines (the trio consisting of one each from SHARE, BSR and EULAR). If a comparable guideline couldn’t be found in either the BSR or EULAR papers, this is made clear in the table. Results When comparing six diagnostic SHARE recommendations for paediatric LN with equivalent BSR and EULAR guidelines, the Likert similarity score ranged between 0-9. Only 50% of the 20 treatment SHARE recommendations had a Likert score ≥5 with their equivalent BSR and EULAR guidelines. Three SHARE treatment recommendations had no comparable guidelines, these are clearly identified in the results tables. All SHARE recommendations were based on level 3 or 4 evidence. Level 3 evidence comes from descriptive studies, whilst level 4 evidence comes from expert opinion and is considered the lowest level of evidence. Conclusion The quantity of differences noted in this paper leads to questioning whether transitional guidelines should be developed for care of young adults with LN to ensure safe transition as they move from paediatric to adult medical care. LN is a chronic condition that will impact a child’s entire life. Optimising care from as early in life as possible and continuing this into the future is essential to maximising quality of life and reducing adverse outcomes associated with renal involvement. Disclosure J.A. Day: None. M.W. Beresford: None.

Transition to Adult Rheumatology Care: A Disease-Specific Guide.

Young adults with childhood-onset rheumatic diseases are more frequently establishing and continuing care with adult rheumatologists. The transfer of care can be challenging for both the young adult patients and their adult rheumatologists, in large part due to differences between pediatric-onset rheumatic diseases and their adult-onset counterparts, or due to the rarity of some pediatric-onset rheumatic conditions. Other challenges are due to cultural differences between pediatric and adult medical care and to the young adult needing to increasingly perform self-management skills that were previously managed by parents or other caregivers. In this review, we will provide a summary of strategies for working effectively with young adults as they transition to adult care. We will then discuss a subset of childhood-onset rheumatic diseases-including juvenile idiopathic arthritis, localized scleroderma, autoinflammatory diseases, pediatric-onset systemic lupus erythematosus, juvenile-onset dermatomyositis, and autoimmune encephalitis-for which clinical manifestations, management, and prognosis frequently differ between pediatric onset and adult onset. Our aim is to highlight differences that make caring for this population of transitioning young adults unique, providing tools and knowledge to empower the adult rheumatologist to care for these young adults in ways that are evidence-based, effective, efficient, and rewarding.

Hypervirulent Klebsiella pneumoniae-related bacteremia in intensive care unit: A retrospective cohort study

IntroductionHypervirulent Klebsiella pneumoniae (hvKP) bloodstream infections (BSI) have rarely been reported in critically ill patients. MethodsWe conducted a retrospective study of KP-BSI between January 2016 and December 2020 in an adult medical intensive care unit (ICU) of our tertiary care hospital. Hypervirulent phenotype was defined by the detection of both rmpA and iutA. ResultsSeventy patients diagnosed with K. pneumonia BSI were included, of whom 9 (13 %) had hvKP infection. Pneumonia accounted for 56 % of hvKP-BSI and for 28 % of those with cKP. Fifty-six percent of patients with hvKP-BSI were homeless, versus 2 % of those with cKP-BSI (p < 0.001). The 30-day mortality rate reached 44 % for hvKP-BSI and 34 % for cKP-BSI (p = 0.7) and did not appear related to the hypervirulent phenotype in multivariable analysis. DiscussionWe here evidenced a new clinical entity of hvKP-BSI associated with pulmonary infection in homeless patients, which exhibits high mortality.

Effectiveness of Pressure Relief Pads in Preventing Bi-Level Positive Airway Pressure- Related Injuries: A Secondary Database Analysis

&lt;p&gt;目的：透過雙相型陽壓呼吸器(BiPAP)通報資料庫分析，探討減壓墊於BiPAP相關壓傷之預防成效。方法：方便取樣南部某區域教學醫院成人內科加護病房之BiPAP通報資料庫，次級資料分析減壓墊於BiPAP相關壓傷之預防成效。結果：減壓墊組的壓傷發生率為6.06%，無減壓墊組為7.78%，兩組無統計顯著差異(p =.5863)。壓傷個案相關變項比較，減壓墊組比無減壓墊組平均延緩21.18小時產生壓傷(p =.8660)，平均減少0.12個壓傷(p =.5501)、減少1.96 cm2的壓傷表面積(p =.7334)，較低的重度壓傷發生風險(risk ratio = 0.44, p =.1666)，然礙於臨床發生壓傷的個案數偏少，故成效比較尚未達顯著差異。結論：兩組比較雖未達顯著差異，但次級資料庫的真實世界數據顯示減壓墊組具有較佳的預防壓傷臨床效益，建議臨床仍可善用減壓墊於預防BiPAP相關壓傷。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;&amp;quot;Purpose: To compare the effectiveness of pressure relief pads in preventing bi-level positive airway pressure-related injuries by analyzing data from a medical reporting database. Methods: The authors took a convenience sample of records from the medical reporting database of the adult medical intensive care unit of a regional teaching hospital in southern Taiwan. Secondary database analysis was employed to examine the effectiveness of pressure relief pads in preventing pressure injuries. Results: The incidence of pressure-related injuries in the pressure relief pads group was 6.06%, whereas the incidence in the no relief pads group was 7.78% (p = .5863). Pressure relief pads delayed the occurrence of pressure injuries by 21.18 hours (p = .8660), reduced the number of pressure injury lesions by 0.12 (p = .5501), reduced the surface area of pressure injuries by 1.96 cm2 (p = .7334), and reduced the risk of severe pressure injury (risk ratio = 0.44, p = .1666). Due to the small number of clinical incident pressure injuries reported, the comparison of effectiveness did not reach statistical significance. Conclusion: Although no significant difference was observed between the two groups, real-world data from the secondary database revealed that the pressure relief pads effectively and safely prevented pressure injuries.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Screening for Alcohol Use Disorder and Management of Alcohol Withdrawal Syndrome in Critical Care Patients.

Evidence-based research indicates that subjective questionnaires should be eliminated in screening for alcohol use disorder and management of alcohol withdrawal syndrome in critical care patients. However, transitioning clinicians away from these screening tools remains challenging. To improve screening for alcohol use disorder and management of alcohol withdrawal syndrome in the critical care setting by implementing an evidence-based alcohol use disorder screening tool and alcohol withdrawal syndrome protocol for critical care patients. The project site was a 17-bed adult medical intensive care unit in a large, southeastern US teaching hospital. Interventions consisted of the elimination of previously used tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised and implementation of the Prediction of Alcohol Withdrawal Severity Scale for alcohol use disorder screening and the Richmond Agitation-Sedation Scale and symptom-triggered benzodiazepine administration for alcohol withdrawal syndrome management. Alcohol use disorder screening among the critical care patient population increased by 49% from before to after the intervention. Of the patients at risk for withdrawal, 79% had an order for monitoring with the new intensive care unit alcohol withdrawal protocol in the postintervention group, compared with 35% who had an order for monitoring with the Clinical Institute Withdrawal Assessment for Alcohol-Revised in the preintervention group. The elimination of previously used tools and the implementation of the Prediction of Alcohol Withdrawal Severity Scale and the new intensive care unit alcohol withdrawal protocol improved alcohol use disorder screening and alcohol withdrawal syndrome management among critical care patients.

Letting go/ moving on: A scoping review of relational effects on transition to adult care

ObjectiveThe objective of this scoping review was to assess the extent of the literature on how relational components in pediatric care contribute to the transition process and transfer outcomes. BackgroundRelationships between patients, parents and pediatric providers are a frequently cited barrier in transition to adult care. A scoping review aimed to identify studies focused on how the relationship between patients/parents and pediatric providers related to transition from pediatric to adult healthcare and explore the nature and depth of the evidence. MethodsSearch terms were identified through a combination of medical librarian term harvesting and expert input. Four databases were searched with a combination of keyword and controlled vocabulary: PubMed, CINAHL, PsycINFO, and Web of Science. In order to reduce the risk of bias, each record was reviewed by two independent clinical experts in both the screening and full-text review stages. No database filters were applied during the searching process. ResultsThe initial search strategy resulted in 13,121 records. After removal of duplicates, 271 moved on to full text review, and 152 met inclusion criteria as related to both transition from pediatric to adult medical care and relationships between pediatric providers and patients/families. ConclusionsThis scoping review aimed to identify available literature on relationships between pediatric providers and patients/families. Variable levels of research were identified, with little formal study of interventions. The majority described relationship issues as barriers, either on the part of providers, patients, parents or a combination of these. Several highlighted relationship ties as facilitators in the transition, an important consideration in determining interventions.

Clinical, Sociodemographic, and Psychological Factors Associated with Transition Readiness in Patients with Epilepsy.

The transition to adult care for patients with epilepsy is a complicated clinical issue associated with adverse outcomes, including non-adherence to treatment, dropout of medical care, and worse prognosis. Moreover, youngsters with epilepsy are notably prone to emotional, psychological, and social difficulties during the transition to adulthood. Transition needs depend on the type of epilepsy and the epileptic syndrome, as well as on the presence of co-morbidities. Having a structured transition program in place is essential to reduce poor health consequences. A key strategy to optimize outcomes involves the use of transition readiness and associated factors assessment to implement the recognition of vulnerability and protective aspects, knowledge, and skills of these patients and their parents. Therefore, this study aims to provide a comprehensive framework of clinical and psychosocial aspects associated with the transition from pediatric to adult medical care of patients with epilepsy. Measures examining different aspects of transition readiness and associated clinical, socio-demographic, psychological, and emotional factors were administered to 13 patients with epilepsy (Mage = 22.92, SD = 6.56) with (n = 6) or without (n = 7) rare diseases, and a respective parent (Mage = 56.63, SD = 7.36). patients showed fewer problems in tracking health issues, appointment keeping, and pharmacological adherence as well as low mood symptoms and moderate resiliency. Moreover, they referred to a low quality of sleep. Notably, parents of patients with rare diseases reported a lower quality of sleep as compared to the other group of parents. Increasing awareness around transition readiness is essential to promote self-management skills of patients with epilepsy and their parents. Anticipating the period of transition could be beneficial, especially to prevent problematic sleep patterns and promote independence in health care management. Parents of patients with epilepsy and rare diseases should be monitored for their mental status which can affect patients' well-being.

Stewardship-Guided T2Candida Testing Shortens Time to Antifungal Treatment and Reduces Antifungal Usage Among Medical Intensive Care Unit Patients With Septic Shock.

Diagnosis of invasive candidiasis (IC) is limited by insensitivity and slow turnaround of cultures. Our objectives were to define the performance of T2Candida, a nonculture test, under guidance of a diagnostic stewardship program, and evaluate impact on time to antifungal initiation and antifungal utilization. This was a retrospective study of adult medical intensive care unit (MICU) patients with septic shock for whom T2Candida testing was performed from March 2017 to March 2020. Patients with positive T2Candida results during this period were compared to MICU patients who did not undergo T2Candida testing but had septic shock and blood cultures positive for Candida from January 2016 through March 2020. Overall, 155 T2Candida tests from 143 patients were included. Nine percent of T2Candida tests were positive compared to 4.5% of blood cultures. Sensitivity, specificity, positive predictive value, and negative predictive value of T2Candida for proven and probable IC were 78%, 95%, 50%, and 99%, respectively. Patients who tested positive for T2Candida (n = 14) were diagnosed earlier and initiated on antifungal therapy sooner than patients with IC (n = 14) diagnosed by blood culture alone (median, 5.6 vs 60 hours; P < .0001). Median antifungal days of therapy/1000 patient-days were 23.3/month preimplementation and 15/month postimplementation (P = .007). Following a negative T2Candida result, empiric antifungals were either not administered in 58% or discontinued within 72 hours in 96% of patients. Diagnostic stewardship guided T2Candida testing resulted in reduced time to IC diagnosis, faster initiation of antifungal therapy, and lower antifungal usage among MICU patients with septic shock.

What is the existing evidence base for adult medical same day emergency care in UK NHS hospitals? A scoping review protocol

ObjectivesSame day emergency care (SDEC) is a new model of care, which has emerged over the past 5 years, building on prior ambulatory care services. The National Health Service (NHS)...

Adults are just big kids: pediatric considerations for adult critical care nephrology.

In recent years, there has been growing attention to pediatric kidney health, especially pediatric acute kidney injury (AKI). However, there has been limited focus on the role of pediatric AKI on adult kidney health, specifically considerations for the critical care physician. We summarize what is known in the field of pediatric AKI to inform adult medical care including factors throughout the early life course, including perinatal, neonatal, and pediatric exposures that impact survivor care later in adulthood. The number of pediatric AKI survivors continues to increase, leading to a higher burden of chronic kidney disease and other long-term co-morbidities later in life. Adult medical providers should consider pediatric history and illnesses to inform the care they provide. Such knowledge may help internists, nephrologists, and intensivists alike to improve risk stratification, including a lower threshold for monitoring for AKI and kidney dysfunction in their patients.

Organization of the specialized medical care in conditions of limited resources (military status) (on the example of the provision of nephrology aid in Ukraine)

The paper considers the features of the provision of pediatric and adult nephrology medical care during martial law in Ukraine from February 2022 to May 2023. The influence of military stages on the nephrology care are presented, territorial zones during the conflict are highlighted, event tracks are shown. Separately, the activity of the Ukrainian Association of Nephrologists/Ukrainian Association of Pediatric Nephrologists, new opportunities for integrating nephrology into the system of medical knowledge are considered. Along with the negative trends, positive results were revealed that made it possible to move forward in the system of specialized medical care, namely an increase in transplant activity, a wider use of “long” treatment regimens with rituximab, and the use of digital kidney biopsy. Statistical data, SWOT analysis at the stages of the military conflict are given, an analysis is presented for refugees who left for the European Union to receive kidney replacement therapy. The enormous role of humanitarian programs for maintaining the structure of nephrological care in Ukraine is emphasized. The accumulated experience is unique and can serve as material for the analysis of similar situations in the world in the future.

Identifying Comorbid Subtypes of Patients With Acute Respiratory Failure.

Patients with acute respiratory failure have multiple risk factors for disability following their intensive care unit stay. Interventions to facilitate independence at hospital discharge may be more effective if personalized for patient subtypes. To identify subtypes of patients with acute respiratory failure requiring mechanical ventilation and compare post-intensive care functional disability and intensive care unit mobility level among subtypes. Latent class analysis was conducted in a cohort of adult medical intensive care unit patients with acute respiratory failure receiving mechanical ventilation who survived to hospital discharge. Demographic and clinical medical record data were collected early in the stay. Clinical characteristics and outcomes were compared among subtypes by using Kruskal-Wallis tests and χ2 tests of independence. In a cohort of 934 patients, the 6-class model provided the optimal fit. Patients in class 4 (obesity and kidney impairment) had worse functional impairment at hospital discharge than patients in classes 1 through 3. Patients in class 3 (alert patients) had the lowest magnitude of functional impairment (P < .001) and achieved the earliest out-of-bed mobility and highest mobility level of all subtypes (P < .001). Acute respiratory failure survivor subtypes identified from clinical data available early in the intensive care unit stay differ in post-intensive care functional disability. Future research should target high-risk patients in early rehabilitation trials in the intensive care unit. Additional investigation of contextual factors and mechanisms of disability is critical to improving quality of life in acute respiratory failure survivors.