Received Intensive Care Unit Care Research Articles

Palliative Medicine and End of Life Care Between Races in an Academic Intensive Care Unit.

Background: Although palliative medicine (PM) is more commonly being integrated into the intensive care unit (ICU), research on racial disparities in this area is lacking. Our objectives were to (a) identify racial disparities in utilization of PM consultation for patients who received ICU care and (b) determine if there were differences in the use of code status or PM consultation over time based on race. Materials and Methods: Retrospective analysis of 571 patients, 18 years and above, at a tertiary care institution who received ICU care and died during their hospital stay. We analyzed two timeframes, 2008-2009 and 2018-2019. Univariate analysis was utilized to evaluate baseline characteristics. A multivariate logistic regression model and interaction P values were employed to assess for differential use of PM consultation, do not resuscitate (DNR) orders, and comfort care (CC) orders between races in aggregate and for changes over time. Results: There was a notable increase in Black/African-American (AA) (54% to 61%) and Hispanic/Latino (2% to 3%) patients over time in our population. Compared to White patients, we found no differences between PM consultation and CC orders. There was a lower probability of DNR orders for Black/AA (adjusted odds ratio [aOR] 0.569; P = .049; confidence interval [CI]: 0.324-0.997) and other/unknown/multiracial patients (aOR: 0.389; P = .273; CI: 0.169-0.900). Comparing our earlier time period to the later time period, we found an increased usage of PM for all patients. Interaction P values suggest there were no differences between races regarding PM, DNR, and CC orders. Conclusions: PM use has increased over time at our institution. Contrary to the previous literature, there were no differences in the frequency of utilization of PM consultation between races. Further analysis to evaluate the usage of PM in the ICU setting in varying populations and geographic locations is warranted.

Hospital factors that influence ICU admission decision-making: a qualitative study of eight hospitals.

Some hospitals in the United States (US) use intensive care 20 times more than others. Since intensive care is lifesaving for some but potentially harmful for others, there is a need to understand factors that influence how intensive care unit (ICU) admission decisions are made. A qualitative analysis of eight US hospitals was conducted with semi-structured, one-on-one interviews supplemented by site visits and clinical observations. A total of 87 participants (24 nurses, 52 physicians, and 11 other staff) were interviewed, and 40h were spent observing ICU operations across the eight hospitals. Four hospital-level factors were identified that influenced ICU admission decision-making. First, availability of intermediate care led to reallocation of patients who might otherwise be sent to an ICU. Second, participants stressed the importance of ICU nurse availability as a key modifier of ICU capacity. Patients cared for by experienced general care physicians and nurses were less likely to receive ICU care. Third, smaller or rural hospitals opted for longer emergency department patient-stays over ICU admission to expedite interhospital transfer of critically ill patients. Fourth, lack of clarity in ICU admission policies led clinicians to feel pressured to use ICU care for patients who might otherwise not have received it. Health care systems should evaluate their use of ICU care and establish institutional patterns that ensure ICU admission decisions are patient-centered but also account for resources and constraints particular to each hospital.

Severity of Hospitalized Children with Anti-NMDAR Autoimmune Encephalitis.

Background: Information on the clinical characteristics and severity of autoimmune encephalitis with antibodies against the N-methyl-d-aspartate receptor (NMDAR) in children is attracting more and more attention in the field of pediatric research. Methods: In this retrospective cohort study, all cases (n = 67) were enrolled from a tertiary children's hospital, from 2017 to 2020. We compared severe cases that received intensive care unit (ICU) care with nonsevere cases that did not receive ICU care and used machine learning algorithm to predict the severity of children, as well as using immunologic and viral nucleic acid tests to identify possible pathogenic triggers. Results: Mean age of children was 8.29 (standard deviation 4.09) years, and 41 (61.19%) were girls. Eleven (16.42%) were admitted to the ICU, and 56 (83.58%) were admitted to neurology ward. Ten individual parameters were statistically significant differences between severe cases and nonsevere cases (P < .05), including headache, abnormal mental behavior or cognitive impairment, seizures, concomitant tumors, sputum/blood pathogens, blood globulin, blood urea nitrogen, blood immunoglobulin G, blood immunoglobulin M, and number of polynucleated cells in cerebrospinal fluid. Random forest regression model presented that the overall prediction power of severity reached 0.806, among which the number of polynucleated cells in cerebrospinal fluid contributed the most. Potential pathogenic causes exhibited that the proportion of mycoplasma was the highest, followed by Epstein-Barr virus. Conclusion: Our findings provided evidence for early identification of autoimmune encephalitis in children, especially in severe cases.

Clinical characteristics, multiorgan dysfunction and outcomes of patients with COVID-19: a prospective case series.

Background:Characterizing the multiorgan manifestations and outcomes of patients hospitalized with COVID-19 will inform resource requirements to address the long-term burden of this disease. We conducted a descriptive analysis using prospectively collected data to describe the clinical characteristics and spectrum of organ dysfunction, and in-hospital and longer-term clinical outcomes of patients hospitalized with COVID-19 during the first wave of the pandemic at a Canadian centre.Methods:We conducted a prospective case series involving adult patients (aged ≥ 18 yr) with COVID-19 admitted to 1 of 2 hospitals in London, Ontario, from Mar. 17 to June 18, 2020, during the first wave of the pandemic. We recorded patients’ baseline characteristics, physiologic parameters, measures of organ function and therapies administered during hospitalization among patients in the intensive care unit (ICU) and in non-ICU settings, and compared the characteristics of hospital survivors and nonsurvivors. Finally, we recorded follow-up thoracic computed tomography (CT) and echocardiographic findings after hospital discharge.Results:We enrolled 100 consecutive patients (47 women) hospitalized with COVID-19, including 32 patients who received ICU care and 68 who received treatment in non-ICU settings. Respiratory sequelae were common: 23.0% received high-flow oxygen by nasal cannula, 9.0% received noninvasive ventilation, 24.0% received invasive mechanical ventilation and 2.0% received venovenous extracorporeal membrane oxygenation. Overall, 9.0% of patients had cerebrovascular events (3.0% ischemic stroke, 6.0% intracranial hemorrhage), and 6.0% had pulmonary embolism. After discharge, 11 of 19 patients had persistent abnormalities on CT thorax, and 6 of 15 had persistent cardiac dysfunction on echocardiography.Interpretation:This study provides further evidence that COVID-19 is a multisystem disease involving neurologic, cardiac and thrombotic dysfunction, without evidence of hepatic dysfunction. Patients have persistent organ dysfunction after hospital discharge, underscoring the need for research on long-term outcomes of COVID-19 survivors.

Association between the presence of delirium during intensive care unit admission and cognitive impairment or psychiatric problems: the Korean ICU National Data Study

ObjectiveDelirium in the intensive care unit (ICU) may be a preventable risk factor for cognitive impairment or psychiatric problems. We aimed to evaluate the association between the presence of delirium during hospitalization involving ICU care and post-discharge cognitive impairment or psychiatric problems.DesignA retrospective cohort study.SettingA database of nationwide insurance claims data.PatientsAll adult patients aged 18 years or older who were admitted to an ICU between January 1, 2008, and May 31, 2015, and had no history of previous cognitive impairment or psychiatric problems were included in the study.InterventionsNone.Measurements and main resultsOf 306,011 patients who met the inclusion criteria, the proportion of those who experienced delirium during hospitalization was 55.0% (n = 168,190). The patients with delirium during hospitalization had significantly increased odds for cognitive impairment (adjusted hazard ratio [HR] 1.17; 95% confidence interval [CI] 1.05–1.29) and psychiatric problems (adjusted HR 1.78; 95% CI 1.67–1.90) after discharge compared with patients without delirium. In patients who had delirium, the incidence of cognitive impairment was 210.8 per 1000 person-years. In 19,496 patients who were diagnosed with cognitive impairment, depression (n = 3233, 16.5%), sleep disorder (n = 1791, 9.2%), and anxiety (n = 1683, 8.6%) were commonly co-diagnosed. The most common psychiatric problem was sleep disorder (148.7 per 1000 person-years), followed by depression (133.3 per 1000 person-years).ConclusionsAmong patients received ICU care, those who experienced delirium during hospitalization had an increased risk of developing cognitive impairment or psychiatric problems post-discharge. Many patients showed multiple cognitive impairment and psychiatric problems during the follow-up period. Efforts to decrease these problems should be made to increase the quality of life of these ICU survivors.

Clinical outcomes of initially asymptomatic patients with COVID-19: a Korean nationwide cohort study

Background This study was performed to compare severe clinical outcome between initially asymptomatic and symptomatic infections and to identify risk factors associated with high patient mortality among initially asymptomatic patients. Methods In this retrospective, nationwide cohort study, we included 5621 patients who had been discharged from isolation or died from COVID-19 by 30 April 2020. The mortality rate and admission rate to intensive care unit (ICU) were compared between initially asymptomatic and symptomatic patients. We established a prediction model for patient mortality through risk factor analysis among initially asymptomatic patients. Results The prevalence of initially asymptomatic patients upon admission was 25.8%. The mortality rates were not different between groups (3.3% vs. 4.5%, p = .17). However, initially symptomatic patients were more likely to receive ICU care compared to initially asymptomatic patients (4.1% vs. 1.0%, p < .0001). The age-adjusted Charlson comorbidity index score (CCIS) was the most potent predictor for patient mortality in initially asymptomatic patients. Conclusions The mortality risk was not determined by the initial presence of symptom among hospitalized COVID-19 patients. The CCIS was the most potent predictors for mortality. The clinicians should predict the risk of death by evaluating age and comorbidities but not the initial presence of symptom. Key messages The mortality rate was not different between initially asymptomatic and symptomatic patients. Symptomatic patients were more likely to admitted to the intensive care unit. Age and comorbidities were the potent risk factors for mortality.

C-reactive protein and albumin association with mortality of hospitalised SARS-CoV-2 patients: A tertiary hospital experience

The objective was to study hospitalised COVID-19 patients' mortality and intensive care unit (ICU) admission with covariates of interest (age, gender, ethnicity, clinical presentation, comorbidities and admission laboratory findings). Logistic regression analyses were performed for patients admitted to University Hospital, University Hospitals Coventry and Warwickshire NHS Trust, between 24 January 2020 - 13 April 2020. There were 321 patients hospitalised. Median age was 73 years and 189 (59%) were male. Ethnicity was divided between Caucasian (77%), and black, Asian, and minority ethnic (BAME) groups (23%). Commonest symptoms were dyspnoea (62.9%), fever (59.1%) and cough (56%). Gastrointestinal symptoms amounted to 11.8%.Forty-four patients (13.7%) received ICU care. ICU male to female ratio was 3:1 (p=0.027; odds ratio (OR) 2.3; 95% confidence interval (CI) 1.1-4.9), BAME (p=0.008; OR 2.5; 95% CI 1.3-4.9), age >65 years (p=0.026; OR 0.28; 95% CI 0.09-0.93), heart disease (p=0.009; OR 0.2; 95% CI 0.1-0.6) and elevated C-reactive protein (CRP; p<0.001; OR 1.004; 95% CI 1.002-1.008) were associated with ICU admission.One-hundred and four patients (32.4%) died. Age >65 years (p=0.011; OR 5; 95% CI 1.6-21.9), neutrophils (p=0.047), neutrophil:lymphocyte ratio (NLR; p=0.028), CRP (p<0.001) and albumin (p=0.002) were associated with mortality. When analysis adjusted for age, CRP (p<0.001; OR 1.006; 95% CI 1.004-1.008) and albumin (p=0.005; OR 0.94; 95% CI 0.90-0.98) remained associated with mortality. COVID-19 has high mortality. BAME and male patients were associated with ICU admission. High CRP and low albumin (after correcting for age) were associated with mortality.

Risk of severe COVID-19 disease with ACE inhibitors and angiotensin receptor blockers: cohort study including 8.3 million people

BackgroundThere is uncertainty about the associations of angiotensive enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) drugs with COVID-19 disease. We studied whether patients prescribed these drugs had altered risks...

COVID-19 and cardiac arrhythmias

BackgroundEarly studies suggest that coronavirus disease 2019 (COVID-19) is associated with a high incidence of cardiac arrhythmias. Severe acute respiratory syndrome coronavirus 2 infection may cause injury to cardiac myocytes and increase arrhythmia risk.ObjectivesThe purpose of this study was to evaluate the risk of cardiac arrest and arrhythmias including incident atrial fibrillation (AF), bradyarrhythmias, and nonsustained ventricular tachycardia (NSVT) in a large urban population hospitalized for COVID-19. We also evaluated correlations between the presence of these arrhythmias and mortality.MethodsWe reviewed the characteristics of all patients with COVID-19 admitted to our center over a 9-week period. Throughout hospitalization, we evaluated the incidence of cardiac arrests, arrhythmias, and inpatient mortality. We also used logistic regression to evaluate age, sex, race, body mass index, prevalent cardiovascular disease, diabetes, hypertension, chronic kidney disease, and intensive care unit (ICU) status as potential risk factors for each arrhythmia.ResultsAmong 700 patients (mean age 50 ± 18 years; 45% men; 71% African American; 11% received ICU care), there were 9 cardiac arrests, 25 incident AF events, 9 clinically significant bradyarrhythmias, and 10 NSVTs. All cardiac arrests occurred in patients admitted to the ICU. In addition, admission to the ICU was associated with incident AF (odds ratio [OR] 4.68; 95% confidence interval [CI] 1.66–13.18) and NSVT (OR 8.92; 95% CI 1.73–46.06) after multivariable adjustment. Also, age and incident AF (OR 1.05; 95% CI 1.02–1.09) and prevalent heart failure and bradyarrhythmias (OR 9.75; 95% CI 1.95–48.65) were independently associated. Only cardiac arrests were associated with acute in-hospital mortality.ConclusionCardiac arrests and arrhythmias are likely the consequence of systemic illness and not solely the direct effects of COVID-19 infection.

Lymphopenia in severe coronavirus disease-2019 (COVID-19): systematic review and meta-analysis

ObjectiveClinical and laboratory biomarkers to predict the severity of coronavirus disease 2019 (COVID-19) are essential in this pandemic situation of which resource allocation must be urgently prepared especially in the context of respiratory support readiness. Lymphocyte count has been a marker of interest since the first COVID-19 publication. We conducted a systematic review and meta-analysis in order to investigate the association of lymphocyte count on admission and the severity of COVID-19. We would also like to analyze whether patient characteristics such as age and comorbidities affect the relationship between lymphocyte count and COVID-19.MethodsComprehensive and systematic literature search was performed from PubMed, SCOPUS, EuropePMC, ProQuest, Cochrane Central Databases, and Google Scholar. Research articles in adult patients diagnosed with COVID-19 with information on lymphocyte count and several outcomes of interest, including mortality, acute respiratory distress syndrome (ARDS), intensive care unit (ICU) care, and severe COVID-19, were included in the analysis. Inverse variance method was used to obtain mean differences and its standard deviations. Maentel-Haenszel formula was used to calculate dichotomous variables to obtain odds ratios (ORs) along with its 95% confidence intervals. Random-effect models were used for meta-analysis regardless of heterogeneity. Restricted-maximum likelihood random-effects meta-regression was performed for age, gender, cardiac comorbidity, hypertension, diabetes mellitus, COPD, and smoking.ResultsThere were a total of 3099 patients from 24 studies. Meta-analysis showed that patients with poor outcome have a lower lymphocyte count (mean difference − 361.06 μL [− 439.18, − 282.95], p < 0.001; I2 84%) compared to those with good outcome. Subgroup analysis showed lower lymphocyte count in patients who died (mean difference − 395.35 μL [− 165.64, − 625.07], p < 0.001; I2 87%), experienced ARDS (mean difference − 377.56 μL [− 271.89, − 483.22], p < 0.001; I2 0%), received ICU care (mean difference − 376.53 μL [− 682.84, − 70.22], p = 0.02; I2 89%), and have severe COVID-19 (mean difference − 353.34 μL [− 250.94, − 455.73], p < 0.001; I2 85%). Lymphopenia was associated with severe COVID-19 (OR 3.70 [2.44, 5.63], p < 0.001; I2 40%). Meta-regression showed that the association between lymphocyte count and composite poor outcome was affected by age (p = 0.034).ConclusionThis meta-analysis showed that lymphopenia on admission was associated with poor outcome in patients with COVID-19.

Clinical Features and Treatment of 221 Patients with COVID-19 in Wuhan, China

Background: In late December 2019, an outbreak of acute respiratory illness, now officially named as COVID-19, or coronavirus disease 2019, emerged in Wuhan, China. We aimed to study the epidemiology and clinical features of patients diagnosed as coronavirus disease 2019 (COVID-19) and their treatment and outcome in Wuhan, China. Methods: We did a single center, retrospective case series study in patients from Zhongnan Hospital of Wuhan University, Wuhan, China. 221 admitted patients with laboratory confirmed SARS-CoV-2 infection, including 55 severe patients and 166 non-severe patients, were recruited from January 2, 2020 to February 10, 2020. Data of epidemiology, clinic, laboratory exams, radiology and treatment were collected from standardized case report forms and compared between the severe and non-severe patients with COVID-19. Specifically, the outcome of corticosteroid therapy was analyzed in the severe patients in intensive care unit (ICU). Findings: Of the 221 patients with COVID-19, 108 (48.9%) of them were male and only 8 (3.6%) patients had a history of exposure to the Huanan Seafood Market. Compared to the non-severe patients, the median age of the severe patients was significantly older (62.0 vs 51.0 years), and they were more likely to have chronic comorbidities, including hypertension, cardiovascular disease and cerebrovascular disease. Most common symptoms in severe patients were high fever, anorexia and dyspnea. On admission, 73 (33.0%) of the 221 patients showed leukopenia and 163 (73.8%) showed lymphopenia. The laboratory results showed more severity of aberrant coagulation pathway, hepatic injury, myocardial injury and kidney injury in the severe patients. In addition, the severe patients suffered a higher rate of co-infections with bacteria or fungus and they were more likely to developing complications, including acute respiratory distress syndrome (ARDS), arrhythmia, acute cardiac injury, shock and acute kidney injury. As of Feb 15, 2020, a total of 42 (19.0%) patients had been discharged and 12 (5.4%) patients died. In the 55 severe patients, 44 (80%) of them received ICU care, and 23 of them transferred to the general wards due to relieved symptoms, and the mortality rate was 21.8%. Interpretation: In this single-center case series of 221 hospitalized patients with confirmed COVID-19 in Wuhan, China, 55 severe patients with elder age and chronic comorbidities, developed more than one complication. The mortality rate was significantly higher in the severe patients compared to that in the non-severe patients (21.8% vs 0.0%). Older and male patients with higher APACHE II & SOFA scores, elevated PCT level, excessive fluid volume input, as well as the delayed use of corticosteroid might increase the risk of death in ICU. Funding Statement: This work was supported by the National Natural Science Foundation of China (grant no. 81700493 to Dr. Pan; grant no. 81971816 to Dr. Peng). Declaration of Interests: The authors declared no conflicts. Ethics Approval Statement: This study was approved by the National Health Commission of China and Ethics Commission of Zhongnan Hospital. Written informed consent was waived by the Ethics Commission for emerging infectious disease.

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China

In December 2019, novel coronavirus (2019-nCoV)-infected pneumonia (NCIP) occurred in Wuhan, China. The number of cases has increased rapidly but information on the clinical characteristics of affected patients is limited. To describe the epidemiological and clinical characteristics of NCIP. Retrospective, single-center case series of the 138 consecutive hospitalized patients with confirmed NCIP at Zhongnan Hospital of Wuhan University in Wuhan, China, from January 1 to January 28, 2020; final date of follow-up was February 3, 2020. Documented NCIP. Epidemiological, demographic, clinical, laboratory, radiological, and treatment data were collected and analyzed. Outcomes of critically ill patients and noncritically ill patients were compared. Presumed hospital-related transmission was suspected if a cluster of health professionals or hospitalized patients in the same wards became infected and a possible source of infection could be tracked. Of 138 hospitalized patients with NCIP, the median age was 56 years (interquartile range, 42-68; range, 22-92 years) and 75 (54.3%) were men. Hospital-associated transmission was suspected as the presumed mechanism of infection for affected health professionals (40 [29%]) and hospitalized patients (17 [12.3%]). Common symptoms included fever (136 [98.6%]), fatigue (96 [69.6%]), and dry cough (82 [59.4%]). Lymphopenia (lymphocyte count, 0.8 × 109/L [interquartile range {IQR}, 0.6-1.1]) occurred in 97 patients (70.3%), prolonged prothrombin time (13.0 seconds [IQR, 12.3-13.7]) in 80 patients (58%), and elevated lactate dehydrogenase (261 U/L [IQR, 182-403]) in 55 patients (39.9%). Chest computed tomographic scans showed bilateral patchy shadows or ground glass opacity in the lungs of all patients. Most patients received antiviral therapy (oseltamivir, 124 [89.9%]), and many received antibacterial therapy (moxifloxacin, 89 [64.4%]; ceftriaxone, 34 [24.6%]; azithromycin, 25 [18.1%]) and glucocorticoid therapy (62 [44.9%]). Thirty-six patients (26.1%) were transferred to the intensive care unit (ICU) because of complications, including acute respiratory distress syndrome (22 [61.1%]), arrhythmia (16 [44.4%]), and shock (11 [30.6%]). The median time from first symptom to dyspnea was 5.0 days, to hospital admission was 7.0 days, and to ARDS was 8.0 days. Patients treated in the ICU (n = 36), compared with patients not treated in the ICU (n = 102), were older (median age, 66 years vs 51 years), were more likely to have underlying comorbidities (26 [72.2%] vs 38 [37.3%]), and were more likely to have dyspnea (23 [63.9%] vs 20 [19.6%]), and anorexia (24 [66.7%] vs 31 [30.4%]). Of the 36 cases in the ICU, 4 (11.1%) received high-flow oxygen therapy, 15 (41.7%) received noninvasive ventilation, and 17 (47.2%) received invasive ventilation (4 were switched to extracorporeal membrane oxygenation). As of February 3, 47 patients (34.1%) were discharged and 6 died (overall mortality, 4.3%), but the remaining patients are still hospitalized. Among those discharged alive (n = 47), the median hospital stay was 10 days (IQR, 7.0-14.0). In this single-center case series of 138 hospitalized patients with confirmed NCIP in Wuhan, China, presumed hospital-related transmission of 2019-nCoV was suspected in 41% of patients, 26% of patients received ICU care, and mortality was 4.3%.

Clinical Features and Outcomes of 98 Patients Hospitalized with SARS-CoV-2 Infection in Daegu, South Korea: A Brief Descriptive Study.

Although some information on the epidemiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and a few selected cases has been reported, data on the clinical characteristics and outcomes of patients hospitalized therewith in South Korea are lacking. We conducted a retrospective single-center study of 98 consecutive hospitalized patients with confirmed SARS-CoV-2 infection at Yeungnam University Medical Center in Daegu, South Korea. Sixty patients were women (61.2%), and the mean age was 55.4±17.1 years. Thirteen patients (13.3%) were treated in the intensive care unit (ICU). The mean interval from symptom onset to hospitalization was 7.7±4.5 days. Patients who received ICU care were significantly older and were more likely to have diabetes mellitus. The National Early Warning Score on the day of admission was significantly higher in patients requiring ICU care. Acute respiratory distress syndrome (13/13 patients; 100%), septic shock (9/13; 69.2%), acute cardiac injury (9/13; 69.2%), and acute kidney injury (8/13; 61.5%) were more common in patients who received ICU care. All patients received antibiotic therapy, and most (97/98 patients; 99.0%) received antiviral therapy (lopinavir/ritonavir). Hydroxychloroquine was used in 79 patients (80.6%), and glucocorticoid therapy was used in 18 patients (18.4%). In complete blood counts, lymphopenia was the most common finding (40/98 patients; 40.8%). Levels of all proinflammatory cytokines were significantly higher in ICU patients. As of March 29, 2020, the mortality rate was 5.1%. Here, we report the clinical characteristics and laboratory findings of SARS-CoV-2 patients in South Korea up to March 29, 2020.

1707. Invasive Pulmonary Aspergillosis in Patients with Severe Fever with Thrombocytopenia Syndrome

BackgroundSevere fever with thrombocytopenia syndrome (SFTS) is an emerging tick-borne disease often accompanied by immune catastrophic course and subsequent fatal outcome. More than 90% of patients with SFTS had leukopenia and about one-third of those need the admission of intensive care unit (ICU) during the hospital course. So, there has been growing concern about the complications such as invasive pulmonary aspergillosis (IPA) in critical SFTS patients. We thus investigate the incidence and clinical characteristics of IPA in patients with SFTS.MethodsAll patients who were confirmed as SFTS in a tertiary care hospital, Seoul, South Korea, between January 2013 and October 2018 were enrolled. The modified AspICU algorithm was used to identify cases of putative invasive pulmonary aspergillosis (PIPA) and discriminate these invasive diseases from colonization.ResultsOf the 45 PCR-confirmed SFTS patients, 16 (36%) received ICU care. Of these 16 patients, 9 (56%) developed PIPA during hospitalization. The median duration from admission to the first evidence of PIPA was 8 days (range, 2–11 days). None of the PIPA cases met the revised EORTC/MSG criterion. Septic shock and corticosteroid administration preceded more frequently in PIPA group than non-PIPA group (100% vs. 19%, P < 0.0001 and 67% vs. 14%, P = 0.003, respectively). Patients complicated by PIPA showed significantly higher mortality than non-PIPA patients (44% vs. 8%, P = 0.048 by log-rank test). Mortality was lower in patients with PIPA who received antifungal treatment (17% [1/6]) than in those with PIPA who did not (100% [3/3]) (log-rank test, P = 0.002).ConclusionMore than half of patients with SFTS in ICU were complicated by IPA during early hospital course. Cautious scrutiny for IPA in patients with SFTS followed by early appropriate antifungal therapy for IPA is needed. Disclosures All authors: No reported disclosures.

Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study

ObjectiveTo evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI).DesignRetrospective cohort study.Setting1727 acute care hospitals in the United States.ParticipantsMedicare beneficiaries...

Racial Disparities in End-of-Life Care Planning and Hospital Utilization: A Single Center Retrospective Study

Introduction-Some prior studies suggest patients with hematologic malignancies receive more aggressive end-of-life care when compared to patients with solid tumor malignancies. Hematologic malignancies differ from solid tumors because of the continued potential for cure even in advanced disease, and potential difficulty identifying the terminal portion of a patient's illness. Racial/ethnic minorities are reported to have lower rates of hospice care, advanced directive use, and palliative care utilization. We studied differences in hospital utilization patterns and documentation of advance care planning between solid tumor and hematologic malignancy patients. In the subgroup of patients with hematologic malignancy, we also examined differences in these outcomes associated with racial/ethnic minority status.Methods-We conducted a retrospective cohort study of 9,469 patients with a diagnosis of cancer who received care at University of Washington (UW) Medicine and died between 2010 and 2015. Administrative data were available for the following events during the last 30 days of life: emergency department use, hospitalizations, and intensive care unit (ICU) utilization. We also examined death in a hospital and any documentation of advance directives (AD) in the electronic health record. We regressed each outcome on the binary predictor, adjusting for confounders (taken from a pool of potential confounders: age at death, patient gender, racial/ethnic minority status, level of education, insurance type, attributed facility, and number of Dartmouth Atlas chronic conditions). A variable was considered a confounder if its addition to the bivariate model changed the coefficient for the predictor by at least 10%. Binary outcomes were modeled with logistic regression. For count outcomes, we included only patients who had 1 or more days of the relevant type of care and modeled the remaining cases with negative binomial regression. All estimation was done with restricted maximum likelihood. Statistical significance was p <0.05.Results-In the last 30 days of life, decedents with hematologic cancer were significantly more likely to have aggressive hospital-based care, as measured by receipt of inpatient care, hospitalization for 14 or more days, multiple hospital admissions, and more days of hospital care, once admitted, than were those with solid tumor malignancies. They were also significantly more likely to have received ICU care, and to have spent more time in the ICU, once admitted, in the last 30 days of life. Finally, patients with hematologic malignancies were more likely to have died in a hospital rather than in other locations and more likely to have had documentation of AD in their electronic record. Among patients with hematologic malignancies, racial/ethnic minorities were less likely than white non-Hispanics to have documentation of AD and more likely to have 2+ emergency department visits or 14+ days of inpatient care, and had more days of inpatient care and ICU care, once admitted, in the last 30 days of lifeConclusions-Patients with hematologic malignancies received more aggressive care at the end of life as measured by hospital utilization, despite having more documentation of AD than patients with solid tumor malignancy. Racial/ethnic minorities with hematologic malignancies had lower rates of AD documentation and received even more aggressive care than their white counterparts. Although these are administrative data, they suggest opportunities to improve end-of-life care of patients with hematologic malignancies, particularly racial/ethnic minorities. [Display omitted] DisclosuresLee:Mallinckrodt: Honoraria; Amgen: Other: One-time advisory board member; Bristol-Myers-Squibb: Other: One-time advisory board member; Kadmon: Other: One-time advisory board member.

Male-female patient differences in the association between end-of-life discussions and receipt of intensive care near death.

Patient gender plays a significant role in patient-physician communication, patients' understanding of illness, and the aggressiveness of end-of-life (EoL) care. However, little is known about the extent to which gender differences in the effects of EoL discussions on EoL care contribute to gender differences in EoL care. The current study was aimed at determining whether gender differences exist in the receipt of intensive care unit (ICU) care near death and in the association between EoL discussions and the receipt of EoL ICU care. This was a multisite, prospective cohort study of patients (n = 353) with metastatic cancers who were identified as terminally ill at study enrollment and were interviewed at a median of 4.1 months before their deaths. Postmortem chart reviews and caregiver interviews documented ICU stays in the last week of life. Patients who received ICU care at the EoL were more likely to be male than those who did not (73% vs 52%, P = .02). After adjustments for potential confounders, male patients reporting an EoL discussion were less likely to have an ICU stay in the last week of life than male patients with no EoL discussion (adjusted odds ratio, 0.26, 95% confidence interval, 0.07-0.91; P = .04). There was no association between EoL discussions and ICU stays near death among female patients. Men with advanced cancers are more likely than women to receive aggressive, nonbeneficial ICU care near death. Gender differences in the effects of EoL discussions on EoL care likely contribute to and may even explain gender differences in the receipt of ICU care in the last week of life.

The UK ALLR3 Chemotherapy Regimen for Relapsed/Refractory Acute Lymphoblastic Leukemia of Childhood: A Multi-Institutional Retrospective Study of Treatment Related Adverse Events

▪Background: The Therapeutic Advances in Childhood Leukemia & Lymphoma (TACL) Consortium and Children’s Oncology Group (COG) have recently adopted a modified UK ALLR3 (R3) re-induction regimen as a chemotherapy backbone to test novel agents in multiply relapsed pediatric acute lymphoblastic leukemia (ALL). A detailed toxicity profile of this platform has not previously been published, nor have data using this regimen beyond 1st relapse. Such baseline data with this backbone would be helpful in the design, conduct and assessment of future clinical trials of R3 in combination with novel agents.Methods: This was a multi-institutional, retrospective study to investigate adverse events (AEs) and outcome following R3 re-induction chemotherapy (vincristine, mitoxantrone, dexamethasone, and asparaginase) in pediatric relapsed/refractory (R/R) ALL. The objectives of the study were to: 1) establish baseline treatment related AEs during re-induction block 1; and 2) analyze the complete remission (CR) rate and minimal residual disease (MRD) status at the end of re-induction. Patients were identified using medical records from 5 pediatric oncology centers. The study was approved by IRBs at all sites. Data about diagnosis, relapse, prior therapy, AEs, and response to R3 block 1 were extracted from medical records and de-identified. AEs were graded according to the NCI CTCAE v4.0.Results: 59 patients were included in the study (Table 1). The median number of prior treatment attempts in multiply relapsed patients was 2.5 (range 2-4). Grade ≥ 3 infection was reported in 54/59 patients (92%) and 41 (76%) of these had an infectious source identified by culture, biopsy, and/or imaging. Poly-microbial infection was detected in 18 patients. Bacterial infections occurred most frequently, followed by viral and fungal infections (Table 2). The only grade 5 event in re-induction was due to sepsis. 9 patients (15%) were admitted to the intensive care unit (ICU) due to infection. The most common site of infection was blood, followed by gastrointestinal (GI) and pulmonary. Other grade ≥ 3 non-hematologic toxicities were metabolic derangements (39%), GI (22%), and pain (8%). There was no difference in the grade > 3 toxicities between 1st relapsed vs. multiply relapsed patients. 36 patients were discharged home prior to neutrophil count recovery. Among these patients, 92% (33/36) had hospital readmission, 7 (19%) required ICU care, and 10 (28%) required chemotherapy modification. In contrast, only 9% (2/23) of patients who remained hospitalized until count recovery received ICU care or had chemotherapy modifications. The median duration from the start of block 1 to block 2 was 39 days (range 28-115 days). 53 patients achieved CR after block 1; 5 had refractory disease; and 1 died of septic shock prior to disease evaluation.Conclusion: Our study confirmed that R3 block 1 is a highly active re-induction chemotherapy regimen for children with R/R ALL. However, it was associated with very high risk of life-threatening infections. Toxicity reported from this study should be used as a reference for future combination clinical trials using R3 as a backbone in pediatric R/R ALL. Hospitalization until blood count recovery may reduce the need for ICU care and chemotherapy modification.Table 1Patient Characteristics and ResponseAll Patients1st Relapse> 2nd RelapseN594316Median Age (yrs)7 (0.4 – 19)7 (0.4 – 19)6.5 (2 – 15)GenderMale41 (69%)30 (70%)11 (69%)Female18 (31%)13 (30%)5 (31%)Site of RelapseIsolated BM32 (54%)22 (51%)10 (63%)Isolated EM15 (25%)11 (26%)4 (25%)Combined12 (20%)10 (23%)2 (13%)Induction Death1 (2%)1 (2%)0Response DataCR/CRi53 (90%)41 (95%)12 (75%)MRD -30 (59%)*23 (59%)*7 (58%)MRD +21 (41%)16 (41%)5 (42%)Refractory Disease5 (8%)1 (2%)4 (25%)Subsequent HSCTYes24 (41%)14 (33%)10 (63%)No35 (59%)29 (67%)6 (38%)BM = bone marrow; EM = extra medullary; CRi = CR with incomplete blood count recovery;HSCT = hematopoietic stem cell transplant *MRD was not performed in 2 patients.Table 2Organism identifiedBiopsy/Culture confirmed or Suspected Infection by Imaging*65Bacterial Infection44 (68%)Gram +18Gram -19Other7Fungal Infection11 (17%)Biopsy/Culture confirmed7Suspected by CT/MRI4Viral Infection10 (15%)Parasite1*Eighteen patients had > 1 organism identified DisclosuresNo relevant conflicts of interest to declare.

Factors associated with intensive care unit admission in patients with traumatic thoracic injury

To identify factors associated with intensive care unit (ICU) admission in patients with traumatic thoracic injury. Data for consecutive patients with thoracic trauma were collected prospectively. Outcomes were requirement for ICU care and prolonged (>7 days) ICU care. The study included 1333 patients, 484 (36.3%) of whom received ICU care: 125 of these (25.8%) received prolonged ICU care. Head injury, abdominal injury, injury severity score ≥ 16, haemothorax, chest tube placement and spinal surgery were significantly associated with ICU care. Head injury, number of rib fractures, chest drain placement, spinal surgery and extremity surgery were independent risk factors for prolonged ICU care. Associated injury factors played a more prominent role than thoracic factors in the need for ICU and prolonged ICU care. A multidisciplinary trauma team (involving neurosurgeons, abdominal surgeons, orthopaedic surgeons and thoracic surgeons) is essential for the care of patients with traumatic thoracic injury.

Utilization of intensive care resources due to better communication of end-of-life issues.

1 Background: Advanced life support resources are required for optimal care of patients undergoing curative therapy, but their use in patients with terminal disease does not improve patient outcomes. In 2007, our cancer center established the Duffey Pain and Palliative Care team, and one important goal was to help our physicians improve at discussing end-of-life issues with patients. We hypothesized that if this effort was effective, it would result in less utilization of intensive care unit (ICU) management among patients who die in the center. Methods: All inpatient deaths were systematically tabulated and code status displayed at the multidisciplinary Morbidity and Mortality review twice per quarter, beginning in July 2006. Utilization of ICU care, defined as ventilator or dialysis support, was identified from billing data and confirmed by chart review. Survival to discharge among patients who received ICU care was monitored as a component of our patient safety dashboard. Results: From 2008 through 2011, 525 oncology patients died while hospitalized in the cancer center. During this period, among patients who died, there was a gradual increase in no-code status, election of comfort care, or withdrawal of ICU support, from 81% to 95% (OR 1.14 per quarter, p&lt;0.0001). Although the proportion of patients who received any ICU care during their terminal hospitalization did not change, the duration of such care decreased: the proportion with mechanical ventilation for over 14 days decreased from 10% to 5% (OR 0.93 per quarter, p&lt;0.05). There was no decrease in the survival-to-discharge of patients who received ICU care. Conclusions: A multidisciplinary team approach to improve discussion of end-of-life issues, combined with regular feedback to cancer center staff regarding code status at death, resulted in significant changes in patient and family decisions about management at the end of life over a four-year interval. These changes have reduced utilization of ICU care during terminal hospitalizations with no reduction in the survival-to-discharge of all patients who receive ICU care. We propose appropriate establishment of code status and survival-to-discharge of ICU patients as measures of quality oncology care.