Prospective Evaluation of a Dynamic Acuity Score for Regularly Assessing a Critically Ill Patient's Risk of Mortality

OBJECTIVE

Predictive models developed for use in ICUs have been based on retrospectively collected data, which does not take into account the challenges associated with live, clinical data. This study sought to determine if a previously constructed predictive model of ICU mortality (ViSIG) is robust when using data collected prospectively in near real-time.

DESIGN

Prospectively collected data were aggregated and transformed to evaluate a previously developed rolling predictor of ICU mortality.

SETTING

Five adult ICUs at Robert Wood Johnson-Barnabas University Hospital and one adult ICU at Stamford Hospital.

PATIENTS

One thousand eight hundred and ten admissions from August to December 2020.

MEASUREMENTS AND MAIN RESULTS

The ViSIG Score, comprised of severity weights for heart rate, respiratory rate, oxygen saturation, mean arterial pressure, mechanical ventilation, and values for OBS Medical's Visensia Index. This information was collected prospectively, whereas data on discharge disposition was collected retrospectively to measure the ViSIG Score's accuracy. The distribution of patients' maximum ViSIG Score was compared with ICU mortality rate, and cut points determined where changes in mortality probability were greatest. The ViSIG Score was validated on new admissions. The ViSIG Score was able to stratify patients into three groups: 0-37 (low risk), 38-58 (moderate risk), and 59-100 (high risk), with mortality of 1.7%, 12.0%, and 39.8%, respectively ( p < 0.001). The sensitivity and specificity of the model to predict mortality for the high-risk group were 51% and 91%. Performance on the validation dataset remained high. There were similar increases across risk groups for length of stay, estimated costs, and readmission.

CONCLUSIONS

Using prospectively collected data, the ViSIG Score produced risk groups for mortality with good sensitivity and excellent specificity. A future study will evaluate making the ViSIG Score visible to clinicians to determine whether this metric can influence clinician behavior to reduce adverse outcomes.

Improving elementary students' knowledge and behavior to prevent traumatic injury: the impact of a behavioral skills training model delivered by aspirational role models

Trauma is the leading cause of childhood morbidity and mortality annually in the USA, accounting for 11% of deaths, most commonly due to car crashes, suffocation, drowning, and falls. Prevention is paramount for reducing the incidence of these injuries. As an adult level 1 and pediatric level 2 trauma center, there is a commitment to injury prevention through outreach and education. The Safety Ambassadors Program (SAP) was developed as part of this aim. Safety Ambassadors (SA) are high schoolers who teach elementary school students about safety/injury prevention. The curriculum addresses prevalent areas of injury risk: car/pedestrian safety, wheeled sports/helmets, and fall prevention. The study group hypothesized that participation in SAP leads to improved safety knowledge and behaviors and ultimately reduces childhood preventable injuries. Educational material was delivered by high school students (ages 16-18 years old). First and second-grade participants (ages 6-8 years old) completed pre- and post-course exams to assess knowledge (12 questions) and behavior (4 questions). Results were retrospectively reviewed, and pre/post training mean scores were calculated. Scores were calculated based on number of correct answers on pre/post exam. Comparisons were made using the Student t-test. All tests were 2-tailed with significance set at 0.05. Pre- and post-training results were assessed for 2016-2019. Twenty-eight high schools and 37 elementary schools were enrolled in the program with 8832 student participants in SAP. First graders demonstrated significant improvement in safety knowledge (pre 9 (95% CI 8.9-9.2) vs post 9.8 (95%CI 9.6-9.9), (p < 0.01)) and behavior modification (pre 3.2 (95%CI 3.1-3.2) vs post 3.6 (95% CI 3.5-3.6), (p < 0.01)). Similar findings were seen in 2nd graders: safety knowledge (pre 9.6 (95% CI 9.4-9.9) vs post 10.1 (95% CI 9.9-10.2), (p < 0.01)) and behavior (pre 3.3 (95% CI 3.1-3.4) vs post 3.5 (95%CI 3.4-3.6), (p < 0.01)).    Conclusion: SAP is a novel evidence-based educational program delivered to elementary school students by aspirational role models. This model is impactful, relatable, and engaging when provided by participants' older peer mentors. On a local level, it has demonstrated improved safety knowledge and behavior in elementary school students. As trauma is the leading cause of pediatric death and disability, enhanced education may lead to life-saving injury prevention in this vulnerable population. What is Known: • Preventable trauma is the leading cause of pediatric death in the USA and education has contributed to improvements in both safety knowledge and behavior. • The ideal delivery method for injury prevention education in children continues to be under investigation. What is New: • Our data suggest that a peer-based injury prevention model is both an effective education delivery method and easily instituted within existing school systems. • This study supports implementation of peer-based injury prevention programs to improve safety knowledge and practices. • With more widespread institution and research, we hope to ultimately reduce preventable childhood injury.

Age Is But a Number: Damage Control Surgery Outcomes in Geriatric Emergency General Surgery

BACKGROUND

Damage control surgery (DCS) with temporary abdominal closure (TAC) is increasingly utilized in emergency general surgery (EGS). As the population ages, more geriatric patients (GP) are undergoing EGS operations. Concern exists for GP's ability to tolerate DCS. We hypothesize that DCS in GP does not increase morbidity or mortality and has similar rates of primary closure compared to non-geriatric patients (NGP).

METHODS

A retrospective chart review from 2014-2020 was conducted on all non-trauma EGS patients who underwent DCS with TAC. Demographics, admission lab values, fluid amounts, length of stay (LOS), timing of closure, post-operative complications and mortality were collected. GP were compared to NGP and results were analyzed using Chi square and Wilcox signed rank test.

RESULTS

Ninety-eight patients (n = 50, <65 y; n = 48, ≥65 y) met inclusion criteria. There was no significant difference in median number of operations (3 versus 2), time to primary closure (2.5 versus 3 d), hospital LOS (19 versus 17.5 d), ICU LOS (11 versus 8 d), rate of primary closure (66% versus 56%), post op ileus (44% versus 48%), abscess (14% versus 10%), need for surgery after closure (32% versus 19%), anastomotic dehiscence (16% versus 6%), or mortality (34% versus 42%). Average time until take back after index procedure did not vary significantly between young and elderly group (45.8 versus 38.5 h; P = 0.89). GP were more likely to have hypertension (83% versus 50%; P ≤ 0.05), atrial fibrillation (25% versus 4%; P ≤ 0.05) and lower median heart rate compared to NGP (90 versus 103; P ≤ 0.05).

CONCLUSIONS

DCS with TAC in geriatric EGS patients achieves similar outcomes and mortality to younger patients. Indication, not age, should factor into the decision to perform DCS.

External validation of urinary C-C motif chemokine ligand 14 (CCL14) for prediction of persistent acute kidney injury

Background

Persistent acute kidney injury (AKI) portends worse clinical outcomes and remains a therapeutic challenge for clinicians. A recent study found that urinary C–C motif chemokine ligand 14 (CCL14) can predict the development of persistent AKI. We aimed to externally validate urinary CCL14 for the prediction of persistent AKI in critically ill patients.

Methods

This was a secondary analysis of the prospective multi-center SAPPHIRE study. We evaluated critically ill patients with cardiac and/or respiratory dysfunction who developed Kidney Disease: Improving Global Outcomes (KDIGO) stage 2–3 AKI within one week of enrollment. The main exposure was the urinary concentration of CCL14 measured at the onset of AKI stage 2–3. The primary endpoint was the development of persistent severe AKI, defined as  ≥ 72 h of KDIGO stage 3 AKI or death or renal-replacement therapy (RRT) prior to 72 h. The secondary endpoint was a composite of RRT and/or death by 90 days. We used receiver operating characteristic (ROC) curve analysis to assess discriminative ability of urinary CCL14 for the development of persistent severe AKI and multivariate analysis to compare tertiles of urinary CCL14 and outcomes.

Results

We included 195 patients who developed KDIGO stage 2–3 AKI. Of these, 28 (14%) developed persistent severe AKI, of whom 15 had AKI  ≥ 72 h, 12 received RRT and 1 died prior to  ≥ 72 h of KDIGO stage 3 AKI. Persistent severe AKI was associated with chronic kidney disease, diabetes mellitus, higher non-renal APACHE III score, greater fluid balance, vasopressor use, and greater change in baseline serum creatinine. The AUC for urinary CCL14 to predict persistent severe AKI was 0.81 (95% CI, 0.72–0.89). The risk of persistent severe AKI increased with higher values of urinary CCL14. RRT and/or death at 90 days increased within tertiles of urinary CCL14 concentration.

Conclusions

This secondary analysis externally validates urinary CCL14 to predict persistent severe AKI in critically ill patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03618-1.

Fever in the ICU: A Predictor of Mortality in Mechanically Ventilated COVID-19 Patients

PURPOSE

While fever may be a presenting symptom of COVID-19, fever at hospital admission has not been identified as a predictor of mortality. However, hyperthermia during critical illness among ventilated COVID-19 patients in the ICU has not yet been studied. We sought to determine mortality predictors among ventilated COVID-19 ICU patients and we hypothesized that fever in the ICU is predictive of mortality.

MATERIALS AND METHODS

We conducted a retrospective cohort study of 103 ventilated COVID-19 patients admitted to the ICU between March 14 and May 27, 2020. Final follow-up was June 5, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded.

RESULTS

103 patients were included, 40 survived and 63(61.1%) died. Deceased patients were older {66 years[IQR18] vs 62.5[IQR10], (p = 0.0237)}, more often male {48(68%) vs 22(55%), (p = 0.0247)}, had lower initial oxygen saturation {86.0%[IQR18] vs 91.5%[IQR11.5], (p = 0.0060)}, and had lower pH nadir than survivors {7.10[IQR0.2] vs 7.30[IQR0.2] (p < 0.0001)}. Patients had higher peak temperatures during ICU stay as compared to hospital presentation {103.3°F[IQR1.7] vs 100.0°F[IQR3.5], (p < 0.0001)}. Deceased patients had higher peak ICU temperatures than survivors {103.6°F[IQR2.0] vs 102.9°F[IQR1.4], (p = 0.0008)}. Increasing peak temperatures were linearly associated with mortality. Febrile patients who underwent targeted temperature management to achieve normothermia did not have different outcomes than those not actively cooled. Multivariable analysis revealed 60% and 75% higher risk of mortality with peak temperature greater than 103°F and 104°F respectively; it also confirmed hyperthermia, age, male sex, and acidosis to be predictors of mortality.

CONCLUSIONS

This is one of the first studies to identify ICU hyperthermia as predictive of mortality in ventilated COVID-19 patients. Additional predictors included male sex, age, and acidosis. With COVID-19 cases increasing, identification of ICU mortality predictors is crucial to improve risk stratification, resource management, and patient outcomes.

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey

BACKGROUND

A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings.

METHODS

Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact.

RESULTS

Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment.

CONCLUSION

This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.

Surgeons in surge - the versatility of the acute care surgeon: outcomes of COVID-19 ICU patients in a community hospital where all ICU patients are managed by surgical intensivists

Background

Reported characteristics and outcomes of critically ill patients with COVID-19 admitted to the intensive care unit (ICU) are widely disparate with varying mortality rates. No literature describes outcomes in ICU patients with COVID-19 managed by an acute care surgery (ACS) division. Our ACS division manages all ICU patients at a community hospital in New Jersey. When that hospital was overwhelmed and in crisis secondary to COVID-19, we sought to describe outcomes for all patients with COVID-19 admitted to our closed ICU managed by the ACS division.

Methods

This was a prospective case series of the first 120 consecutive patients with COVID-19 admitted on March 14 to May 10, 2020. Final follow-up was May 27, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded.

Results

One hundred and twenty patients were included (median age 64 years (range 25–89), 66.7% men). The most common comorbidities were hypertension (75; 62.5%), obesity (61; 50.8%), and diabetes (50; 41.7%). One hundred and thirteen (94%) developed acute respiratory distress syndrome, 89 (74.2%) had shock, and 76 (63.3%) experienced acute kidney injury. One hundred (83.3%) required invasive mechanical ventilation (IMV). Median ICU length of stay (LOS) was 8.5 days (IQR 9), hospital LOS was 14.5 days (IQR 13). Mortality for all ICU patients with COVID-19 was 53.3% and 62% for IMV patients.

Conclusions

This is the first report of patients with COVID-19 admitted to a community hospital ICU managed by an ACS division who also provided all surge care. Mortality of critically ill patients with COVID-19 admitted to an overwhelmed hospital in crisis may not be as high as initially thought based on prior reports. While COVID-19 is a non-surgical disease, ACS divisions have the capability of successfully caring for both surgical and medical critically ill patients, thus providing versatility in times of crisis.

Level of evidence

Level V.

Nutrition Education on the Wards: A Self-Study Module for Improving Medical Student Knowledge of Nutrition Assessment and Interventions

INTRODUCTION

Nutrition plays a key role in the prevention and treatment of disease. Hospitalized patients are often malnourished, which is a major contributor to medical complications, decreased quality of life, lengthened medical stay, increased health care costs, and mortality. However, medical students continue to have inadequate education in nutrition and report feeling poorly trained in nutrition. We proposed an online module that could be used by medical students as a self-study activity to learn about key signs for the diagnosis of malnutrition and the nutrition interventions available in the hospital setting.

METHODS

Third- and fourth-year medical students at Rutgers Robert Wood Johnson Medical School in medicine, surgery, and critical care clerkships were given access to an online nutrition education module discussing the signs of malnutrition in hospitalized patients and the interventions available in the inpatient setting. A premodule and postmodule survey was given via email at the beginning and at the end of the clerkship. A one-sample t test was used to assess the relationship between the mean scores of the pre- and postmodule surveys.

RESULTS

One hundred nine out of 255 students responded to the premodule survey. Thirty-two students completed the module and postmodule survey. There was a significant difference in mean scores between students who completed the module and postmodule survey compared to the overall student population prior to having access to the module.

DISCUSSION

Medical students have limited training in nutrition education, and our findings show that a self-study online module can improve students' knowledge.

Trauma Service Utilization Increases Cost But Does Not Add Value for Minimally Injured Patients

OBJECTIVE

Trauma care provides value to the critically injured. Our aim was to assess whether trauma team involvement adds value to the care of minimally injured patients and to define its costs.

METHODS

Minimally injured patients admitted to a trauma center were propensity matched and compared by involvement versus no involvement of the trauma service (TS). Demographics, injury severity, complications, length of emergency department stay, mortality, and hospital costs and charges were studied.

RESULTS

A total of 1253 patients were enrolled, with 308 propensity matched to the following groups: TS (n = 102) and no TS (n = 206). TS demonstrated a 30% increase in total charges and costs with no difference in complications. TS did demonstrate decreased time in the emergency department but had an increased delay to operation. Findings were similar when stratified for only lower extremity injuries.

CONCLUSIONS

TS involvement for minimally injured patients does not increase value. Reducing TS involvement while avoiding trauma undertriage may reduce costs to the healthcare system without affecting outcomes.

Identification and validation of biomarkers of persistent acute kidney injury: the RUBY study

Purpose

The aim of the RUBY study was to evaluate novel candidate biomarkers to enable prediction of persistence of renal dysfunction as well as further understand potential mechanisms of kidney tissue damage and repair in acute kidney injury (AKI).

Methods

The RUBY study was a multi-center international prospective observational study to identify biomarkers of the persistence of stage 3 AKI as defined by the KDIGO criteria. Patients in the intensive care unit (ICU) with moderate or severe AKI (KDIGO stage 2 or 3) were enrolled. Patients were to be enrolled within 36 h of meeting KDIGO stage 2 criteria. The primary study endpoint was the development of persistent severe AKI (KDIGO stage 3) lasting for 72 h or more (NCT01868724).

Results

364 patients were enrolled of whom 331 (91%) were available for the primary analysis. One hundred ten (33%) of the analysis cohort met the primary endpoint of persistent stage 3 AKI. Of the biomarkers tested in this study, urinary C–C motif chemokine ligand 14 (CCL14) was the most predictive of persistent stage 3 AKI with an area under the receiver operating characteristic curve (AUC) (95% CI) of 0.83 (0.78–0.87). This AUC was significantly greater than values for other biomarkers associated with AKI including urinary KIM-1, plasma cystatin C, and urinary NGAL, none of which achieved an AUC > 0.75.

Conclusion

Elevated urinary CCL14 predicts persistent AKI in a large heterogeneous cohort of critically ill patients with severe AKI. The discovery of CCL14 as a predictor of persistent AKI and thus, renal non-recovery, is novel and could help identify new therapeutic approaches to AKI.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05919-0) contains supplementary material, which is available to authorized users.

A review of early warning systems for prompt detection of patients at risk for clinical decline

Early Warning Scores (EWS) are a composite evaluation of a patient's basic physiology, changes of which are the first indicators of clinical decline and are used to prompt further patient assessment and when indicated intervention. These are sometimes referred to as "track and triggers systems" with tracking meant to denote periodic observation of physiology and trigger being a predetermined response criteria. This review article examines the most widely used EWS, with special attention paid to those used in military and trauma populations.The earliest EWS is the Modified Early Earning Score (MEWS). In MEWS, points are allocated to vital signs based on their degree of abnormality, and summed to yield an aggregate score. A score above a threshold would elicit a clinical response such as a rapid response team. Modified Early Earning Score was subsequently followed up with the United Kingdom's National Early Warning Score, the electronic cardiac arrest triage score, and the 10 Signs of Vitality score, among others.Severity of illness indicators have been in military and civilian trauma populations, such as the Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity. The sequential organ failure assessment score and its attenuated version quick sequential organ failure assessment were developed to aggressively identify patients near septic shock.Effective EWS have certain characteristics. First, they should accurately capture vital signs information. Second, almost all data should be derived electronically rather than manually. Third, the measurements should take into consideration multiple organ systems. Finally, information that goes into an EWS must be captured in a timely manner. Future trends include the use of machine learning to detect subtle changes in physiology and the inclusion of data from biomarkers. As EWS improve, they will be more broadly used in both military and civilian environments. LEVEL OF EVIDENCE: Review article, level I.

AAST Critical Care Committee clinical consensus: ECMO, nutrition

The American Association for the Surgery of Trauma Critical Care Committee has developed clinical consensus guides to help with practical answers based on the best evidence available. These are focused in areas in which the levels of evidence may not be that strong and are based on a combination of expert consensus and research. Overall, quality of the research is mixed, with many studies suffering from small numbers and issues with bias. The first two of these focus on the use of extracorporeal membrane oxygenation in trauma patients and nutrition for the critically ill surgical/trauma patient.

Increased Healthcare-Associated Infections in a Surgical Intensive Care Unit Related to Boarding Non-Surgical Patients

Background: Hospital over-capacity often forces boarding patients outside of their designated intensive care unit (ICU). Anecdotal evidence suggested medical intensive care unit (MICU) patients boarding in the surgical intensive care unit (SICU) were responsible for increases in healthcare-associated infection (HAI) rates. We studied the effect of ICU boarding on rates of SICU HAIs. Methods: This single-center, retrospective two-year database study compared primary SICU patients (Home) to MICU patients boarding in the SICU (Boarders). Variables studied included age, gender, Acute Physiology and Chronic Health Evaluation III (APACHE III) scores, and comorbidities. Healthcare-associated infections included Clostridium difficile infection, catheter-associated urinary tract infections, central line-associated blood stream infection, and ventilator-associated pneumonia. Student t-test, Fisher exact testing, and a multivariable regression model were used to determine the significance of associations. Results: A total of 2,562 patients were included in the study; 328 (12.8%) were Boarders and 2,234 (87.2%) were Home. Univariable analysis demonstrated that Boarders were older (64.0 ± 16.9 vs. 60.2 ± 17.4), more severely ill (APACHE III score 70.5 ± 31.1 vs. 53.4 ± 21.9), more likely to have cirrhosis, coronary artery disease, and asthma/chronic obstructive pulmonary disease, but less likely to have hypertension. On univariable analysis boarding was associated with an increase HAI rate (19 HAI/1,000 patient days vs. 6.2, p < 0.001). Multivariable regression modeling demonstrated boarding status remained independently associated with HAI (odds ratio [OR] 1.83 95% confidence interval [CI] 1.02-3.27). Cost estimates demonstrated an additional cost of $83,303 per 1,000 patient days. Conclusion: The practice of hospital boarding is associated with development of HAI and increased hospital costs. Efforts at determining the cause of this increase and then reducing HAIs will improve patient care and help hospital budgets.

Case report of EUS-guided endoscopic transduodenal necrosectomy in a patient with sleeve gastrectomy

BACKGROUND

After an acute attack of pancreatitis, walled-off pancreatic fluid collections (PFC) occur in approximately 10 % of cases. Drainage of the cavity is recommended when specific indications are met. Endoscopic drainage has been adopted as the main intervention for symptomatic walled-off PFC. Altered gastric anatomy in these patients poses an interesting challenge. We present the first case of a patient with sleeve gastrectomy who underwent successful endoscopic transduodenal necrosectomy (TDN).

CASE PRESENTATION

Forty year old woman with history of morbid obesity status post sleeve gastrectomy in 2009 was found to have symptomatic gallstone disease complicated by severe necrotizing gallstone pancreatitis and further complicated by symptomatic walled off pancreatic necrosis (WOPN). Imaging significant for 10.8 × 7.6 cm fluid collection with necrotic debris in the body and tail of the pancreas and endoscopic necrosectomy was attempted. EGD showed tubular gastric body and antrum, with extrinsic compression in the antrum and duodenal bulb from the pancreatic cyst. Duodenal bulb was selected as the preferred fistula site due to sleeve gastrectomy. Patient underwent successful TDN in two sessions. Patient had symptomatic improvement at follow-up with resolution of WOPN.

CONCLUSION

To our knowledge, this is the first reported case of EUS-guided endoscopic necrosectomy in a patient with sleeve gastrectomy. The duodenal approach was used in our patient due to history of sleeve gastrectomy.

Infectious complications and mortality in an American acute care surgical service

BACKGROUND

Acute care surgery (ACS) services have evolved in an effort to provide 24-h surgical services for a wide array of general surgical emergencies. The formation of ACS services has been shown to improve outcomes and lead to more expeditious care. Despite the advances of ACS, the etiology and timing of patient mortality has yet to be described. We hypothesized that infectious complications occur more frequently in ACS patients that die during their hospitalization.

METHODS

A retrospective review of a local ACS service (non-trauma) registry was conducted. Demographic variables, admission and discharge data, and ICD-9 codes were collected. ICD-9 codes were used to identify patients with sepsis, shock, GI perforation, peritonitis, and other hospital acquired infections (urinary tract, bloodstream, and ventilator-associated pneumonias). Univariate and multivariate logistic regression analysis was performed to model the outcome of death.

RESULTS

1,329 patients were analyzed. 53 % were male with the mean age of 52 years and an average length of stay of 13 days. 106 (8 %) died while in the hospital. Of the patients who died, 34 (32 %) died within 7 days of admission. The majority of mortalities (56 %) occurred after hospital day 14. In ACS patients that died, there were significantly higher rates of sepsis, shock, peritonitis, urinary tract infections, and VAP. After adjustment; age, sepsis on admission, and shock on admission were associated with greater odds of death.

CONCLUSION

ACS patients with sepsis and shock have higher mortality rate than those patients without. The majority of ACS patient deaths occurred after hospital day 14. Further investigation and continued focus on preventing and rapidly treating infectious complications as they arise is warranted.

Validation of cell-cycle arrest biomarkers for acute kidney injury using clinical adjudication

RATIONALE

We recently reported two novel biomarkers for acute kidney injury (AKI), tissue inhibitor of metalloproteinases (TIMP)-2 and insulin-like growth factor binding protein 7 (IGFBP7), both related to G1 cell cycle arrest.

OBJECTIVES

We now validate a clinical test for urinary [TIMP-2]·[IGFBP7] at a high-sensitivity cutoff greater than 0.3 for AKI risk stratification in a diverse population of critically ill patients.

METHODS

We conducted a prospective multicenter study of 420 critically ill patients. The primary analysis was the ability of urinary [TIMP-2]·[IGFBP7] to predict moderate to severe AKI within 12 hours. AKI was adjudicated by a committee of three independent expert nephrologists who were masked to the results of the test.

MEASUREMENTS AND MAIN RESULTS

Urinary TIMP-2 and IGFBP7 were measured using a clinical immunoassay platform. The primary endpoint was reached in 17% of patients. For a single urinary [TIMP-2]·[IGFBP7] test, sensitivity at the prespecified high-sensitivity cutoff of 0.3 (ng/ml)(2)/1,000 was 92% (95% confidence interval [CI], 85-98%) with a negative likelihood ratio of 0.18 (95% CI, 0.06-0.33). Critically ill patients with urinary [TIMP-2]·[IGFBP7] greater than 0.3 had seven times the risk for AKI (95% CI, 4-22) compared with critically ill patients with a test result below 0.3. In a multivariate model including clinical information, urinary [TIMP-2]·[IGFBP7] remained statistically significant and a strong predictor of AKI (area under the curve, 0.70, 95% CI, 0.63-0.76 for clinical variables alone, vs. area under the curve, 0.86, 95% CI, 0.80-0.90 for clinical variables plus [TIMP-2]·[IGFBP7]).

CONCLUSIONS

Urinary [TIMP-2]·[IGFBP7] greater than 0.3 (ng/ml)(2)/1,000 identifies patients at risk for imminent AKI. Clinical trial registered with www.clinicaltrials.gov (NCT 01573962).

The effect of terminal cleaning on environmental contamination rates of multidrug-resistant Acinetobacter baumannii

We evaluated the prevalence of multidrug-resistant Acinetobacter baumannii environmental contamination before and after discharge cleaning in rooms of infected/colonized patients. 46.9% of rooms and 15.3% of sites were found contaminated precleaning, and 25% of rooms and 5.5% of sites were found contaminated postcleaning. Cleaning significantly decreased environmental contamination of A baumannii; however, persistent contamination represents a significant risk factor for transmission. Further studies on this and more effective cleaning methods are needed.

Rosiglitazone may assist with glycemic control in the ICU

INTRODUCTION

Hyperglycemia is a frequent sequela of critical illness. Rosiglitazone is an oral hypoglycemic agent of the thiazolinedione class. Thiazolinediones are known to activate peroxisome proliferator-activated receptor gamma (PPAR-gamma) that decreases inflammation in humans and decreases shock induced by zymosan in mice.

HYPOTHESIS

Rosiglitazone can assist with hyperglycemic control in the intensive care unit (ICU).

METHODS

A hospital billing query identified patients prescribed rosiglitazone while in a major university ICU. Patients who received rosiglitazone as an outpatient prior to hospitalization were excluded. Glycemic control was determined by average daily blood glucose, 24-hour insulin dose, and number of patients requiring an insulin drip. Glycemic control was evaluated on days 0, 3, and 7. Student t test was used to compare means. Fisher exact testing was used to compare insulin regimen before and after starting rosiglitazone.

RESULTS

34 patients were identified. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score was 17.2 +/- 4.4. Sixty-five percent were male, 62% were preexisting diabetics. The mean daily blood glucose was 159 +/- 30 mg/dL on day 0, 146 +/- 37 mg/dL on day 3, and 140 +/- 33 mg/dL on day 7 (P < .03 vs day 0). The mean 24-hour insulin dose was 80.6 +/- 87.9 U on day 0, 72.2 +/- 73.4 U on day 3, and 46.3 +/- 57.2 U on day 7 (P < .003 vs day 0). There was 1 major hypoglycemic event.

CONCLUSION

Rosiglitazone may assist glycemic control in the ICU. Despite recent concerns of cardiac safety, further research should be done to evaluate its potential as a short-term therapeutic agent in the ICU, given its anti-inflammatory and antishock profile.

Gene expression profiles differentiate between sterile SIRS and early sepsis

INTRODUCTION

The systemic inflammatory response syndrome (SIRS) occurs frequently in critically ill patients and presents similar clinical appearances despite diverse infectious and noninfectious etiologies. Despite similar phenotypic expression, these diverse SIRS etiologies may induce divergent genotypic expressions. We hypothesized that gene expression differences are present between sepsis and uninfected SIRS prior to the clinical appearance of sepsis.

METHODS

Critically ill uninfected SIRS patients were followed longitudinally for the development of sepsis. All patients had whole blood collected daily for gene expression analysis by Affymetrix Hg_U133 2.0 Plus microarrays. SIRS patients developing sepsis were compared with those remaining uninfected for differences in gene expression at study entry and daily for 3 days prior to conversion to sepsis. Acceptance criteria for differentially expressed genes required: >1.2 median fold change between groups and significance on univariate and multivariate analysis. Differentially expressed genes were annotated to pathways using DAVID 2.0/EASE analysis.

RESULTS

A total of 12,782 (23.4%) gene probes were differentially expressed on univariate analysis 0 to 48 hours before clinical sepsis. 626 (1.1%) probes met acceptance criteria, corresponding to 459 unique genes, 65 (14.2%) down and 395 (85.8%) up expressed. These genes annotated to 10 pathways that functionally categorized to 4 themes involving innate immunity, cytokine receptors, T cell differentiation, and protein synthesis regulation.

CONCLUSIONS

Sepsis has a unique gene expression profile that is different from uninfected inflammation and becomes apparent prior to expression of the clinical sepsis phenotype.