Diagnostic value of bedside lung ultrasound and 12-zone score in the 65 cases of neonatal respiratory distress syndrome and its severity

OBJECTIVE

To explore the predictive value of bedside lung ultrasound score in the severity of neonatal respiratory distress syndrome (NRDS) and mechanical ventilation and extubation.

METHODS

The clinical data of 65 neonates with NRDS and invasive mechanical ventilation diagnosed in the neonatal intensive care unit of our hospital from July 2021 to July 2022 were retrospectively analyzed. 65 neonates were included in the NRDS group, and 40 neonates with other common lung diseases were selected as the other lung disease groups. All neonates underwent lung ultrasound and X-ray examination. The correlation between lung ultrasound scores and arterial blood gas indexes was analyzed by Pearson. The efficacy of successful evacuation of mechanical ventilation was evaluated by lung ultrasound analysis by ROC curve analysis.

RESULTS

The positive rates of lung consolidation and white lung in NRDS group were higher than the other lung disease groups (P < 0.05). The positive rates of bronchial inflation sign and double lung points were lower than these in the other lung disease groups (P < 0.05). The ultrasound scores of both lungs, left lung, right lung, bilateral lung and double basal lung in the NRDS group were significantly higher than those in the other lung disease groups (P < 0.05). There was a significant positive correlation between lung ultrasound score and X-ray grade (r = 0.841, P < 0.001). The area under the curve (AUC) of lung ultrasound score for the differential diagnosis of NRDS and common lung diseases was 0.907. The AUC of lung ultrasound score in the differential diagnosis of mild and moderate, and moderate and severe NRDS were 0.914 and 0.933, respectively, which had high clinical value. The lung ultrasound score was positively correlated with the level of PaCO2 (r = 0.254, P = 0.041), and negatively correlated with the levels of SpO2 and PaO2 (r = - 0.459, - 0.362, P = 0.001, 0.003). The AUC of successful mechanical ventilation withdrawal predicted by the pulmonary ultrasound score before extubation was 0.954 (95% CI 0.907-1.000). The predictive value of successful extubation was 10 points of the pulmonary ultrasound score, with a sensitivity of 93.33% and a specificity of 88.00%.

CONCLUSION

The bedside lung ultrasound score can intuitively reflect the respiratory status of neonates, which provides clinicians with an important basis for disease evaluation.

Association Between Race/Ethnicity and Severity of Illness in Pediatric Cardiomyopathy and Myocarditis

INTRODUCTION

Previous reports demonstrate racial/ethnic differences in survival for children hospitalized with cardiomyopathy and myocarditis. The impact of illness severity, a potential mechanism for disparities, has not been explored.

METHODS

Using the Virtual Pediatric Systems (VPS, LLC), we identified patients ≤ 18 years old admitted to the intensive care unit (ICU) for cardiomyopathy/myocarditis. Multivariate regression models were used to evaluate the association between race/ethnicity and Pediatric Risk of Mortality (PRISM 3). Multivariate logistic and competing risk regression was used to examine the relationship between race/ethnicity and mortality, CPR, and ECMO.

RESULTS

Black patients had higher PRISM 3 scores on first admission (𝛽 = 2.02, 95% CI: 0.15, 3.90). There was no difference in survival across race/ethnicity over multiple hospitalizations. Black patients were less likely to receive a heart transplant (SHR = 0.65, 95% CI: 0.45-0.92). Black and unreported race/ethnicity had higher odds of CPR on first admission (OR = 1.64, 95% CI: 1.01-2.45; OR = 2.12, 95% CI: 1.11-4.08, respectively).

CONCLUSION

Black patients have higher severity of illness on first admission to the ICU, which may reflect differences in access to care. Black patients are less likely to receive a heart transplant. Additionally, Black patients and those with unreported race/ethnicity had higher odds of CPR, which was not mediated by severity of illness, suggesting variations in care may persist after admission.

Patient Characteristics and Severity Trajectories in a Pediatric Intermediate Care Unit

OBJECTIVES

To describe the characteristics of patients admitted to Pediatric Intermediate Care Units (PImCU) and to assess their illness severity trajectories.

METHODS

This prospective, observational, multicentre cohort study was conducted in seven French PImCUs between September 2012 and January 2014. All consecutive patients aged under 18 were included. The severity of illness was evaluated through the Paediatric Advanced Warning Score (PAWS), measured every 8 h for each patient. A latent class mixed model was used to identify severity trajectory classes.

RESULTS

A total of 2868 patients were included. The median [interquartile range] age was 29 [5-103] mo and the median length of stay was 1 [1-3] d. The primary indication for admission was respiratory (44%). Almost 3% of the patients were subsequently transferred to a pediatric intensive care unit. Three severity trajectory classes were identified. In one class, comprising the largest proportion of patients, the PAWS was low on admission and did not change markedly over time. In this class, patients were older and had a shorter length of stay. The other two classes were characterized by a higher PAWS on admission and rapid or slow improvement. These patients were more severely ill, mostly due to respiratory failure.

CONCLUSIONS

A large proportion of patients had a stable profile and no signs of severity which suggests that the stay in PImCU was not indicated but a part of these patients have remained stable perhaps because of the advanced monitoring and intensive nursing in these units.

CLINICAL TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov Protocol, Identifier: NCT02304341, ClinicalTrials.gov .

Biological age is superior to chronological age in predicting hospital mortality of the critically ill

Biological age is increasingly recognized as being more accurate than chronological age in determining chronic health outcomes. This study assessed whether biological age, assessed on intensive care unit (ICU) admission, can predict hospital mortality. This retrospective cohort study, conducted in a tertiary multidisciplinary ICU in Western Australia, used the Levine PhenoAge model to estimate each patient's biological age (also called PhenoAge). Each patient's PhenoAge was calibrated to generate a regression residual which was equivalent to biological age unexplained by chronological age in the local context. PhenoAgeAccel was a dichotomized measure of the residuals, and its presence suggested that one was biologically older than the corresponding chronological age. Of the 2950 critically ill adult patients analyzed, 291 died (9.9%) before hospital discharge. Both PhenoAge and its residuals (after regressing on chronological age) had a significantly better ability to differentiate between hospital survivors and non-survivors than chronological age (area under the receiver-operating-characteristic curve 0.648 and 0.654 vs. 0.547 respectively). Being phenotypically older than one's chronological age was associated with an increased risk of mortality (PhenoAgeAccel hazard ratio [HR] 1.997, 95% confidence interval [CI] 1.568-2.542; p = 0.001) in a dose-related fashion and did not reach a plateau until at least a 20-year gap. This adverse association remained significant (adjusted HR 1.386, 95% CI 1.077-1.784; p = 0.011) after adjusted for severity of acute illness and comorbidities. PhenoAgeAccel was more prevalent among those with pre-existing chronic cardiovascular disease, end-stage renal failure, cirrhosis, immune disease, diabetes mellitus, or those treated with immunosuppressive therapy. Being phenotypically older than one's chronological age was more common among those with comorbidities, and this was associated with an increased risk of mortality in a dose-related fashion in the critically ill that was not fully explained by comorbidities and severity of acute illness.

Influences on treatment-seeking and antibiotic use for common illnesses in eastern China

BACKGROUND

Antibiotic resistance rates remain high in China where antibiotics are widely used for common illnesses. This study aimed to investigate the influences on people's decisions on treatment and antibiotic use for common illnesses in eastern China.

METHODS

Semi-structured interviews were conducted with 29 patients recruited through convenience sampling between July 2020 and January 2021 in one hospital in County A in Zhejiang Province, and one hospital and one village clinic in County B in Jiangsu Province, respectively. All interviews were audio-recorded, transcribed verbatim and thematically analysed. This study is nested in a larger interdisciplinary mixed method project and we also compared our qualitative findings with quantitative results from a household survey conducted as part of this wider project.

RESULTS

Participants' decisions about treatment-seeking and antibiotic use for common illnesses were found to be influenced by four interactive domains. (i) Self-evaluation of illness severity: Participants tend to self-treat minor conditions with ordinary medicines first and do not resort to antibiotics unless the condition worsens or is considered inflammation- related. Visiting healthcare facilities is seen as the final option. (ii) Access to and trust in care: These treatment-seeking practices are also associated with the perception, in contrast with retail pharmacies, hospitals provide professional and trustworthy care but are difficult to access, and hence require visiting only for severe illness. (iii) Prior experience: previous medical treatment and experiences of self-medication also influence participants' treatment decisions including the use of antibiotics. (iv) Medication characteristics: Participants view antibiotics as powerful medicines with harms and risks, requiring consumers to carefully trade off benefits and harms before use.

CONCLUSIONS

People's treatment decisions in relation to antibiotic use in eastern China are influenced by an interplay of lay conceptual models of illnesses and antibiotics and broader organisational, social, and contextual factors. Interventions focusing on individual education to incorporate biomedical knowledge into lay understandings, and reducing situational and social incentives for self-medicating with antibiotics by strengthening access to quality professional care, would be helpful in promoting antibiotic stewardship.

Severity of illness and risk of mortality in Mayo Clinic's virtual hybrid advanced care at home program: a retrospective cohort study

BACKGROUND

In July 2020, Mayo Clinic launched Advanced Care at Home (ACH), a high-acuity virtual hybrid hospital-at-home model (HaH) of care at Mayo Clinic Florida and Northwest Wisconsin, an urban destination medical center and a rural community practice respectively. This study aims to describe demographic characteristics of ACH patients as well as their acuity of illness using severity of illness (SOI) and risk of mortality (ROM), to illustrate the complexity of patients in the program, taking into account the different diagnostic related groups.

METHODS

Mayo Clinic uses All Patient Refined-Diagnosis Related Groups (APR-DRG) to calculate SOI and ROM on hospitalized patients. APR-DRG data, including SOI and ROM, were gathered from individual chart reviews from July 6, 2020, to March 31, 2022.

RESULTS

 Out of 923 patients discharged from ACH, the average APR-DRG SOI was 2.89 (SD 0.81) and ROM was 2.73. (SD 0.92). Mean age was 70.88 (SD 14.46) years, 54.6% were male patients and the average length of stay was 4.10 days. The most frequent diagnosis was COVID-19 infection with 162 patients (17.6%), followed by heart failure exacerbation (12.7%) and septicemia (10.9%). The 30-day readmission rate after discharge from ACH was 11.2% (n = 103) and the 30-day mortality rate was 1.8% (n = 17). There were no in-program patient deaths.

CONCLUSIONS

SOI and ROM from patients at the ACH program have been shown to be in the range of "moderate/major" according to the APR-DRG classification. The ACH program is capable of accepting and managing highly complex patients that require advanced therapeutic means. Furthermore, the ACH program has an in-program mortality rate of 0 to date. Therefore, ACH is rising as a capable alternative to the brick-and-mortar hospital.

The relationship between leukocyte to albumin ratio and atrial fibrillation severity

BACKGROUND

An increased leukocyte count is a sign of inflammation and has been demonstrated to be a predisposing factor and complication of atrial fibrillation. Similarly, albumin, the major protein in the serum, is also considered an acute phase reactant protein that has osmotic and anti-inflammatory properties, and a low albumin level is a known factor associated with severity in many pathologies, including atrial fibrillation. The neutrophil percentage-to-albumin ratio (NPAR) and other emerging leukocyte counts/albumin ratios have been reliable systemic inflammation-based predictors of mortality and complications in various diseases, but they have not yet been used with atrial fibrillation. This study's aim was to explore whether the leukocyte to albumin ratio could also serve as a useful index in estimating atrial fibrillation severity, including the severity of atrial fibrillation secondary to stroke, to provide a new and more objective tool than the conventional and medical history-based CHA2DS2-VASc score.

MATERIALS AND METHODS

Data were retrospectively collected from the Wuhan University Zhongnan Hospital database from January 1st to December 31st, 2021. The patients were classified into 2 groups: Group 1-low severity and Group 2- moderate to high severity, and diverse statistical analyses were conducted to evaluate the relationship between the leukocyte-to-albumin ratio and AF severity.

RESULTS

Only 2329 test subjects met the inclusion criteria. We had 727 test subjects (381 males and 346 females) categorized into the low severity cohort and 1601 test subjects (932 males and 670 females) in the moderate to high severity group. The difference in mean age between the two groups was significant (95% CI [-2.682 to -0.154] p = 0.028), and the difference in the LAR mean rank between the two groups was significant (p = 0.00). The Chi-square test of association yielded the following results: the relationship between the LAR level and category of severity was statistically significant (p = 0.00), and the Mantel‒Haenszel statistic association odds ratio was OR = 0.657. 95% CI OR [0.549-0.787] p = 0.000. The association between sex and atrial fibrillation severity also reached statistical significance. However, sex and LAR were found to be independent factors in atrial fibrillation (Chi-square p value = 0.564).

CONCLUSION

It has been demonstrated throughout this investigation that the leukocyte to albumin ratio could provide key clues in clinical practice and contribute to thromboembolism risk assessment in the setting of atrial fibrillation.

Severity of illness and mortality among children admitted to a tertiary referral hospital in Botswana: A secondary data analysis of a prospective cohort study

Objectives

Data on triage practices of children admitted to Princess Marina Hospital in Gaborone, Botswana is limited. The inpatient triage, assessment, and treatment score was developed for low resource settings to predict mortality in children. We assess its performance among children admitted to Princess Marina Hospital and their demographic, clinical, and risk factors for death.

Methods

This was a secondary data analysis of a prospective cohort study comprising 299 children ages 1 month to 13 years admitted June to September 2018. Descriptive statistics, bivariate analysis, and multivariate logistic regression were used. Sensitivity and specificity data were generated for the inpatient triage, assessment, and treatment score.

Results

Thirteen children died (13/284, 4.6%). Comorbidity (adjusted odds ratio 4.0, p = 0.020) and high inpatient triage, assessment, and treatment score (adjusted odds ratio 5.0, p = 0.017) increased odds of death. The area under the receiver operating characteristic curve was 0.81. Using inpatient triage, assessment, and treatment cutoff of 4, the sensitivity, specificity, and likelihood ratio were 31%, 94%, and 5.0, respectively.

Conclusion

Implementing the inpatient triage, assessment, and treatment score in low resource settings may improve identification, treatment, and evaluation of the sickest children.

Comparison of the prognostic performance of the CURB-65 and a modified version of the pneumonia severity index designed to identify high-risk patients using the International Community-Acquired Pneumonia Collaboration Cohort

BACKGROUND

Although the PSI and CURB-65 represent well-validated prediction rules for pneumonia prognosis, PSI was designed to identify patients at low risk and CURB- 65 patients at high risk of mortality. We compared the prognostic performance of a modified version of the PSI designed to identify high-risk patients (i.e., PSI-HR) to CURB-65 in predicting short-term mortality.

METHODS

Using data from 6 pneumonia cohorts, we designed PSI-HR as a 6-class prediction rule using the original prognostic weights of all PSI variables and modifying the risk score thresholds to define risk classes. We calculated the proportion of low-risk and high-risk patients using CURB-65 and PSI-HR and 30-day mortality in these subgroups. We compared the rules' sensitivity, specificity, positive and negative predictive values for mortality at all risk class thresholds and assessed discriminatory power using areas under their receiver operating characteristic curves (AUROCs).

RESULTS

Among 13,874 patients with pneumonia, 1,036 (7.5%) died. For PSI-HR versus CURB-65, aggregate mortality was lower in low-risk patients (1.6% vs. 2.2%, p = 0.005) and higher in high-risk patients (36.5% vs. 32.2%, p = 0.27). PSI-HR had higher sensitivities than CURB-65 at all thresholds; PSI-HR also had higher specificities at the 3 lowest thresholds and specificities within 0.5% points of CURB-65 at the 2 highest thresholds. The AUROC was larger for PSI-HR than CURB- 65 (0.82 vs. 0.77, p < 0.0001).

CONCLUSIONS

PSI-HR demonstrated superior prognostic accuracy to CURB-65 at the lower end of the severity spectrum and identified high-risk patients with nonsignificant higher short-term mortality at the higher end.

Peripheral blood neutrophil-to-lymphocyte ratio is associated with mortality across the spectrum of cardiogenic shock severity

PURPOSE

To evaluate the association between the neutrophil-to-lymphocyte ratio (NLR) and mortality across the cardiogenic shock (CS) severity spectrum, defined using the Society of Cardiovascular Interventions and Angiography (SCAI) shock stages.

MATERIALS AND METHODS

We retrospectively analyzed cardiac intensive care unit (CICU) patients between 2007 and 2015. Predictors of in-hospital mortality were analyzed using logistic regression.

RESULTS

We included 8280 patients aged 67.3 ± 15.2 years (37.2% females). Elevated NLR (≥7) was present in 45% of patients. NLR increased with worsening SCAI stage and was associated with higher in-hospital mortality in shock stages A to C (all p < 0.001). After multivariable adjustment, NLR remained associated with higher in-hospital mortality (adjusted odds ratio 1.05 per 3.5 NLR units, 95% CI 1.03-1.08, p < 0.001), with an optimal cut-off of ≥7 (in-hospital mortality 13.1% vs. 4.1%, adjusted odds ratio 1.44, 95% CI 1.14-1.81, p = 0.002). Patients in SCAI stage A or B with NLR ≥7 had higher in-hospital mortality than patients in SCAI stage B or C with NLR <7, respectively.

CONCLUSIONS

Elevated NLR is associated with higher in-hospital mortality in CICU patients with or at risk for CS, emphasizing the importance of systemic inflammation as a determinant of outcomes in CS patients.

The effect of ultraviolet radiation on the incidence and severity of major mental illness using birth month, birth year, and sunspot data

Background and objectives

The evaluation of the severity of patients afflicted with major mental illness (MMI) has been problematic because of confounding variables and genetic variability. There have been multiple studies that suggest several human diseases, especially schizophrenia, are predisposed to be born in certain months or seasons. This observation implied an epigenetic effect of sunlight, likely ultraviolet radiation (UVR), which is damaging to DNA, especially in an embryo. This paper outlines a method to evaluate the severity of schizophrenia (SZ), bipolar disorder (BPD), and schizoaffective disorder (SZ-AFF) using the month/year of birth of those affected compared to the month/year of birth of the general population (GP).

Relevance

Our previous research found that more intense UVR (equal to or greater than 90 sunspot number (SSN)) had a negative effect on the average human lifespan. Also, human birth rates vary in frequency by month of birth reflecting variables like availability of food, sunlight, and other unknown epigenetic factors. We wanted to see if the patient month of birth varied from the average birth months of the general population and if UVR has an epigenetic effect promoting these diseases.

Methods

We obtained the month and year of birth of 1,233 patients admitted over a 15-year period to Maine's largest state psychiatric hospital and counted the months of birth for each diagnosis of SZ, BPD, and SZ-AFF, and compared these results to the general population's birth months of 4,265,555 persons from U. S. Census Year 2006. The number of patients in each month was normalized to August and compared with the normalized birth months of the general population (GP). Plots of the normalized months were considered rates of change (e.g., derivatives) and their respective integrals gave domains of each mental illness relative to the GP. Normalizing the GP to unity was then related to the factor 1.28, e.g., 28% more entropy, deduced from the Sun's fractal dimension imprinted on biological organisms.

Results

The percent of patients meeting our criterion for severity: SZ = 27%; BPD = 26%; SZ-AFF = 100%.

Conclusions

High UVR intensity or a rapid increase in UVR in early gestation are likely epigenetic triggers of major mental illness. BPD is more epigenetically affected than SZ or SZ-AFF disorders. We found that 52% of 1,233 patients comprised the core function of a tertiary-care psychiatric hospital. Also, mental illness exacerbated when the median SSN doubled. This work also validates the Kraeplinian dichotomy.

What is new in this research

This paper offers a new paradigm for evaluating the severity of MMI and supports significant epigenetic effects from UVR.

Past, present, and future of mortality risk scores in the contemporary cardiac intensive care unit

Risk stratification dates to the dawn of the cardiac intensive care unit (CICU). As the CICU has evolved from a dedicated unit caring for patients with acute myocardial infarction to a complex healthcare environment encompassing a broad array of acute and chronic cardiovascular pathology, an expanding array of risk scores are available that can be applied to CICU patients. Most of these scores were designed for use either in patients with a specific acute cardiovascular diagnosis or unselected critically ill patients, and risk scores developed in other populations often underperform in the CICU. More recently, risk scores have been developed specific to the CICU population, demonstrating improved performance. All existing risk scores have relevant limitations, both in terms of performance and applicability to patient care. Risk scores have been predominantly developed to predict short-term mortality, either by quantifying severity of illness or by incorporating other risk factors for mortality. It is essential to distinguish mortality risk attributable to severity of illness, which may be modifiable through intervention, from mortality risk attributable to non-modifiable risk factors. This review discusses established risk scores applicable to the CICU population, details how risk score performance is characterized, describes how new risk scores can be developed, explains how the information provided by risk scores can be used in clinical practice, and highlights how novel risk stratification approaches can be developed.

Intensive care unit strain and mortality risk in patients admitted from the ward in Australia and New Zealand

PURPOSE

ICU strain (low number of available beds) may be associated with a delay and altered threshold for ICU admission and adverse patient outcomes. We aimed to investigate the impact of ICU strain on hospital mortality in critically ill patients admitted from wards across Australia and New Zealand.

MATERIALS AND METHODS

Ward patient admitted to ICU and ICU bed data at 137 hospitals were accessed between January 2013 and December 2016. ICU strain was classified as low (≤0.5 patients admitted per available ICU bed in a 6-h block), medium (0.5 to ≤1) or high (>1). Logistic regression models were used to examine the relationship between ICU strain and hospital mortality.

RESULTS

57,844 ICU admissions were analysed, with the majority (64.4%) admitted to medium-strain ICUs. Those admitted to high-strain ICUs spent longer in hospital prior to ICU than medium-strain or low-strain ICUs. After adjusting for confounders those admitted to high-strain ICUs [OR 1.24 (95%CI 1.14-1.35)] or medium-strain ICUs [OR 1.18 (95%CI 1.09-1.27)], (p < 0.001) had a higher risk of death compared low-strain ICUs.

CONCLUSION

ICU strain is associated with longer times in hospital prior to ICU admission and was associated with increased risk of death in patients admitted from ward.

Prevalence and correlates of current suicide risk in an international sample of OCD adults: A report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) network and Obsessive Compulsive and Related Disorders Network (OCRN) of the European College of Neuropsychopharmacology

INTRODUCTION

Obsessive-compulsive disorder (OCD), characterized by repetitive anxiety-inducing intrusive thoughts and compulsive behaviors, is associated with higher suicide ideation and suicide attempts than the general population. This study investigates the prevalence and the correlates of current suicide risk in adult outpatients in an international multisite cross-sectional sample of OCD outpatients.

METHODS

Data were derived from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) network's cross-sectional data set (N = 409). Current suicide risk (assessed by Item C of the MINI) and diagnoses of psychiatric disorders were based on DSM-IV. Chi-squared test for categorical variables and t-test for continuous variables were used to make statistical inferences about main features associated with current suicide risk. P < .05 was considered as statistically significant.

RESULTS

The prevalence of current suicidal risk was 15.9%, with equal likelihood in sociodemographic variables, including age and gender. Increased rates of major depression and generalized anxiety disorder were associated to higher current suicide risk. Current suicide risk was also associated with higher severity of OCD, depressive comorbidity, and higher levels of disability. There were no significant differences in treatment correlates-including type of treatment and psychiatric hospitalizations-between the groups of individuals with and without current suicide risk.

CONCLUSION

Our findings suggest that current suicide risk is common in patients with OCD and associated with various forms of pathology. Our work also provides further empirical data to support what is already known clinically: a worse clinical picture characterized by a high severity of OCD, high distress related to obsessions and compulsions, and the presence of comorbidities such as major depression and generalized anxiety disorder should be considered as relevant risk factors for suicide risk.

Correlation between PCT, 25(OH)D, PTX-3, AMS levels and the severity of diabetic ketoacidosis complicated by pancreatitis

BACKGROUND

This study aims to explore the correlation between procalcitonin (PCT), 25-hydroxyvitamin D3 (25(OH)D), pentraxin-3 (PTX-3), amylase (AMS) levels and severity of diabetic ketoacidosis complicated by pancreatitis.

METHODS

A retrospective analysis of 198 patients with diabetic ketoacidosis admitted to our hospital from January 2015 to February 2020 were included. According to whether the patients with pancreatitis, subjects were divided into diabetic ketoacidosis with pancreatitis (DKA-AP) group and diabetic ketoacidosis (DKA) group. Healthy controls admitted to the hospital for physical examinations were included as a control group. Clinical outcomes were collected.

RESULTS

On the first day after admission, the levels of PCT, PTX-3, and AMS in DKA-AP group were significantly higher than those in DKA group and control group, and 25(OH)D levels in DKA-AP group were lower than those in DKA group and control group. PCT, PTX-3, and AMS levels were significantly increased, and 25(OH)D levels were decreased in the DKA group compared with the control group. Furthermore, the levels of PCT, 25(OH)D, PTX-3, and AMS in the DKA-AP group were correlated with the disease severity of of diabetic ketoacidosis complicated by pancreatitis. The levels of PCT, PTX-3, and AMS in the DKA-AP group on day 1 were significantly higher and 25(OH)D levels were significantly lower than those on days 3-7 after admission. The levels of PCT, PTX-3, and AMS in the DKA group on day 1 were significantly higher and 25(OH)D levels were significantly lower than those on days 2-7 after admission. The levels of these indicators returned to normal levels on day 3 or day 7 in DKA or DKA-AP group, respectively. PCT, PTX-3, and AMS levels in the DKA-AP group were significantly increased, while 25(OH)D levels in the DKA-AP group were decreased compared with DKA group on days 1-6 after admission. The duration of hospital stay, patients of ICU care, duration of ICU stay, and cost in DKA-AP group were all higher than those in the DKA group.

CONCLUSION

Blood levels of PCT, 25(OH)D, PTX-3, and AMS were correlated with diabetic ketoacidosis complicated by pancreatitis, and have certain application value in assessment of the disease severity.

Predictive value of chest CT scoring in COVID-19 patients in Wuhan, China: A retrospective cohort study

BACKGROUND

Computed tomography (CT) findings of COVID-19 patients were demonstrated by cases series and descriptive studies, but quantitative analysis performed by clinical doctors and studies on its predictive value were rarely seen. The aim of the study is to analyze CT score in COVID-19 patients and explore its predictive value.

MATERIALS AND METHODS

We conducted a retrospective cohort study among confirmed COVID -19 patients with available CT images between February 8, 2020 and March 7, 2020. The lung was divided into six zones by the level of tracheal carina and the level of inferior pulmonary vein bilaterally on CT. Ground-glass opacity (GGO), consolidation, crazy-paving pattern and overall lung involvement were rated by Likert scale of 0-4 or binary as 0 or 1. Global severity score for each targeted pattern was calculated as total score of six zones.

RESULTS

There were 53 patients and 137 CT scans included in the study. There were 18(34%) of the patients classified as moderate cases while 35(66%) patients were severe/critical cases. Severe/critical patients had higher CT scores in several types of abnormalities than moderate patients from the second week to the fourth week post symptom onset. Overall lung involvement score in the second week demonstrated predictive value for severity with a sensitivity of 81.0% and specificity of 69.2%.

CONCLUSIONS

Our modified semi-quantitative CT scoring system for COVID-19 patients demonstrated feasibility. Overall lung involvement score on the second week had predictive value for clinical severity and could be indicator for further treatment.

Use of the BIG score to predict mortality in pediatric trauma

OBJECTIVE

The BIG score, which is comprised of admission base deficit (B), International Normalized Ratio (I), and GCS (G), is a severity of illness score that can be used to rapidly predict in-hospital mortality in pediatric patients presenting following traumatic injury. We sought to compare the mortality prediction of the pediatric trauma BIG score with other well-established pediatric trauma severity of illness scores: the pediatric logistic organ dysfunction (PELOD); the pediatric index of mortality 2 (PIM2); and the pediatric risk of mortality (PRISM III).

METHODS

In this retrospective cohort study, data from 2009 to 2015 was collected using a multi-institutional database. All pediatric patients admitted following traumatic injury with a recorded initial GCS were included. BIG, PELOD, PIM2, and PRISM III scores were calculated, and Receiver Operator Characteristic curves were derived for all severity of illness scores. Mortality prediction performance for each score was compared by the area under the curve (AUC).

RESULTS

A total of 29,204 patients were included in this analysis. AUC for BIG, PELOD, PIM2, and PRISM III scores were 0.97 (0.97-0.98), 0.98 (0.98-0.98), 0.98 (0.97-0.98), and 0.99 (0.98-0.99), respectively. At the optimum cut-off point of 16, the BIG score had a sensitivity of 0.937, specificity of 0.938, positive predictive value of 0.514, and negative predictive value of 0.995.

CONCLUSIONS

In this massive cohort of pediatric trauma patients, the BIG score using imputation of missing variables performed similarly to the PELOD, PIM2, and PRISM III, further validating the score as a predictor of mortality.

[Comparison of severity classification of Chinese protocol, pneumonia severity index and CURB-65 in risk stratification and prognostic assessment of coronavirus disease 2019]

Objective: To investigate the application of severity classification according to the protocol on the Diagnosis and Treatment of coronavirus disease 2019(COVID-19)by the National Health Commission of China, pneumonia severity index(PSI) and CURB-65　in risk stratification and prognostic assessment of COVID-19. Methods: Clinical data of 234 in-hospital patients with COVID-19 were collected and retrospectively reviewed in Wuhan Tongji Hospital. Patients were divided into 3 groups (common, severe, and critical type) at admission according to the sixth version of the protocol issued by the National Health Commission of China on Diagnosis and Treatment of COVID-19. At the same time, the severity of pneumonia was calculated by PSI and CURB-65, and the patients were stratified into 3 risk groups, namely mild, moderate, and severe groups. The hospital mortality rate was evaluated in each group. Sensitivity, specificity, positive predictive values, negative predictive values, and the area under the receiver operating characteristic(ROC) curve(AUC) for predicting hospital mortality in each rule were assessed. Results: According to the severity classification of Chinese protocol, the proportion of patients with common type, severe type, and the critical type was 15.8%, 75.6%, and 8.5%, respectively. No in-hospital death occurred in the common type. As for PSI and CURB-65, greater proportions of patients were classified as low risk(79.1% and 75.6%, respectively), while smaller proportions of patients were classified as moderate and high risk(16.2%, 15.0%; 4.7%, 9.4%, respectively). In-hospital death occurred in low and moderate risk patients identified by these 2 scoring systems. The mortality of the critical group of the Chinese protocol was 65%, and the sensitivity and specificity of predicting in-hospital mortality were 36.4% and 97.0%, respectively. The mortality in the high risk group of PSI and CURB-65 was 100% and 77.3%. The risk class V of PSI and CURB-65 score 3-5 had high specificity(100% and 97.4%, respectively)but low sensitivity(33.3% and 51.5%, respectively)in predicting in-hospital mortality. The AUC of the Chinese protocol severity classification, PSI, and CURB-65 was 0.735, 0.951, and 0.912. The optimal cut-off point of PSI was risk class Ⅳ, and the sensitivity and specificity for predicting mortality were 90.9% and 90.5%. The optimal cut-off point of CURB-65 was score 2, and the corresponding sensitivity and specificity were 84.8% and 85.6%. Conclusions: PSI and CURB-65 can be used for risk stratification and prognostic assessment in patients with COVID-19.

Institutional review of predictors of in-hospital and 30-day discharge mortality in neurosurgical patients

OBJECTIVE

Risk of adverse events from neurosurgical diagnoses is high. It is not well described whether there are any demographic, admission, or discharge factors that are associated with inpatient or post-discharge mortality outcomes in neurosurgical patients. The aim of this study is to identify the differences in predictors of mortality during inpatient stay and within 30 days of discharge.

METHODS

This was a single-institution, retrospective cohort analysis of mortality. Our patient cohort of 11,477 was defined as all adult patients who were discharged (dead or alive) from an inpatient stay between January 1, 2014, and December 31, 2018, and were either admitted to a neurosurgical service or underwent a neurosurgical procedure during that admission.

RESULTS

Out of 11,477 patients, 224 (1.95 %) and 290 (2.53 %) died inpatient and within 30 days of discharge, respectively. In multivariate analysis, the independent predictors of inpatient mortality were older age, female gender, diagnostic group, high present on admission severity of illness (POA-SOI) and present on admission risk of mortality (POA-ROM), intensive care unit (ICU) care, and palliative care consult (all p < 0.05). The predictors of mortality within 30-day discharge were older age, admission urgency, admission specialty type, palliative care consult, and discharge disposition (all p < 0.01).

CONCLUSION

Older age and palliative care consult were significant predictors of both inpatient and within 30 days of discharge mortality. Admission SOI (>3) and ROM (>3) and ICU care were significant predictors for inpatient mortality while discharge disposition (home health, skilled nursing facility) was important for 30-day mortality.

Analysis of adjunctive serological detection to nucleic acid test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection diagnosis

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused coronavirus disease 2019 (COVID-19) epidemic in China, December 2019. The clinical features and treatment of COVID-19 patients remain largely elusive. However, accurate detection is required for SARS-CoV-2 infection diagnosis. We aimed to evaluate the antibodies-based test and nucleic acid-based test for SARS-CoV-2-infected patients.

METHODS

We retrospectively studied 133 patients diagnosed with SARS-CoV-2 and admitted to Renmin Hospital of Wuhan University, China, from January 23 to March 1, 2020. Demographic data, clinical records, laboratory tests, and outcomes were collected. Data were accessed by SARS-CoV-2 IgM-IgG antibody test and real-time reverse transcriptase PCR (RT-PCR) detection for SARS-CoV-2 nucleic acid in COVID-19 patients.

RESULTS

Of 133 COVID-19 patients, there were 44 moderate cases, 52 severe cases, and 37 critical cases with no differences in gender and age among three subgroups. In RT-PCR detection, the positive rate was 65.9%, 71.2%, and 67.6% in moderate, severe, and critical cases, respectively. Whereas the positive rate of IgM/IgG antibody detection in patients was 79.5%/93.2%, 82.7%/100%, and 73.0%/97.3% in moderate, severe, and critical cases, respectively. Moreover, the IgM and IgG antibodies concentrations were also examined with no differences among three subgroups.

CONCLUSION

The IgM-IgG antibody test exhibited a useful adjunct to RT-PCR detection, and improved the accuracy in COVID-19 diagnosis regardless of the severity of illness, which provides an effective complement to the false-negative results from a nucleic acid test for SARS-CoV-2 infection diagnosis after onsets.

[Validity of predictive power of the Adjusted Morbidity Groups (AMG) with respect to others population stratification tools.]

OBJECTIVE

This work was performed in order to get objective elements of judgment that support the improvement of a national population morbidity grouper based in the Adjusted Morbidity Groups (AMG). The study compared the performance in terms of predictive power on certain health and resource outcomes, in between the AMG and several existing morbidity groupers (ACG®, Adjusted Clinical Groups and CRG®, Clinical Risk Group) used in some Autonomous Regions in Spain (Aragón, Canarias y Castilla y León).

METHODS

Cross-sectional analytical study in entitled/insured population with respect to rights of healthcare. Predictive capacity of the complexity weight obtained with the different stratification tools in the first year of the study period was evaluated using a simple classification method that compares the areas under the curves ROC for the following outcomes that occurred in the second year of the study period: Probability of death; probability of having at least one urgent hospital admission; total number of visits to hospital emergencies; total number of visits to primary care; total number of visits to hospital care and spending in pharmacy.

RESULTS

The results showed that AMG complexity weight were good predictors for almost all the analyzed outcomes (AUC ROC>0.7; p<0.05), for the different Autonomous Regions and compared to ACG® or CRG®. Only for the outcome of visits to hospital emergencies in Aragon and Canarias; and visits to specialized care in Aragon, the predictive power was weak for all the compared stratification tools.

CONCLUSIONS

GMA® is a population stratification tool adequate and as useful as others existing morbidity groupers.

[A survey on clinical characteristics and risk factors of severe asthma in China]

Objective: To investigate the clinical characteristics and risk factors of severe bronchial asthma in Chinese people over 14 years old. Methods: According to the multi-stage random cluster sampling methods, a total of 164 215 subjects were visited by a questionnaire in the epidemiology survey from eight provinces (Beijing, Shanghai, Guangdong, Liaoning, Henan, Shanxi, Jiangsu, Sichuan provinces) located in seven regions (north, northeast, east, central China, south, southwest and northwest) of China from February 2010 to August 2012. A total of 2 034 were diagnosed as asthma. The clinical characteristics and related risk factors of patients with severe asthma in China were analyzed. Results: Among all asthma patients, 560 were newly diagnosed, accounting for 27.5% (560/2 034) and the percentage of previously confirmed patients was 72.5% (1 474/2 034). A total of 145 were eligible for severe asthma, accounting for 9.8% (145/1 474) of previously confirmed asthmatics and 7.1% (145/2 034) of all asthmatics. 83.5% (121/145) severe asthmatics had at least one trigger factor. Correlation analysis showed that the risk factors of severe asthma were: smoking (OR=1.543, 95%CI: 1.250-1.814), obesity (OR=2.186, 95%CI: 1.972-2.354), petting (OR=2.135, 95%CI: 1.904-2.283), combined with allergic rhinitis (OR=3.456, 95%CI: 2.721-4.326), gastroesophageal reflux disease (OR=1.842, 95%CI: 1.682-2.140), bronchiectasis (OR=1.665, 95%CI: 1.347-1.912) or chronic obstructive pulmonary disease (OR=1.312, 95%CI: 1.171-1.694). Conclusions: The most common comorbidities in severe asthmatics in China are allergic rhinitis and gastroesophageal reflux disease. The risk factors of severe asthma include obesity, allergic rhinitis, gastroesophageal reflux disease, chronic obstructive pulmonary disease, bronchiectasis, smoking and petting.

Sepsis at ICU admission does not decrease 30-day survival in very old patients: a post-hoc analysis of the VIP1 multinational cohort study

Background

The number of intensive care patients aged ≥ 80 years (Very old Intensive Care Patients; VIPs) is growing. VIPs have high mortality and morbidity and the benefits of ICU admission are frequently questioned. Sepsis incidence has risen in recent years and identification of outcomes is of considerable public importance. We aimed to determine whether VIPs admitted for sepsis had different outcomes than those admitted for other acute reasons and identify potential prognostic factors for 30-day survival.

Results

This prospective study included VIPs with Sequential Organ Failure Assessment (SOFA) scores ≥ 2 acutely admitted to 307 ICUs in 21 European countries. Of 3869 acutely admitted VIPs, 493 (12.7%) [53.8% male, median age 83 (81–86) years] were admitted for sepsis. Sepsis was defined according to clinical criteria; suspected or demonstrated focus of infection and SOFA score ≥ 2 points. Compared to VIPs admitted for other acute reasons, VIPs admitted for sepsis were younger, had a higher SOFA score (9 vs. 7, p < 0.0001), required more vasoactive drugs [82.2% vs. 55.1%, p < 0.0001] and renal replacement therapies [17.4% vs. 9.9%; p < 0.0001], and had more life-sustaining treatment limitations [37.3% vs. 32.1%; p = 0.02]. Frailty was similar in both groups. Unadjusted 30-day survival was not significantly different between the two groups. After adjustment for age, gender, frailty, and SOFA score, sepsis had no impact on 30-day survival [HR 0.99 (95% CI 0.86–1.15), p = 0.917]. Inverse-probability weight (IPW)-adjusted survival curves for the first 30 days after ICU admission were similar for acute septic and non-septic patients [HR: 1.00 (95% CI 0.87–1.17), p = 0.95]. A matched-pair analysis in which patients with sepsis were matched with two control patients of the same gender with the same age, SOFA score, and level of frailty was also performed. A Cox proportional hazard regression model stratified on the matched pairs showed that 30-day survival was similar in both groups [57.2% (95% CI 52.7–60.7) vs. 57.1% (95% CI 53.7–60.1), p = 0.85].

Conclusions

After adjusting for organ dysfunction, sepsis at admission was not independently associated with decreased 30-day survival in this multinational study of 3869 VIPs. Age, frailty, and SOFA score were independently associated with survival.

Severity of illness and the weekend mortality effect: a retrospective cohort study

Background

Weekend admission to the hospital has been found to be associated with higher in-hospital mortality rates, but the cause for this phenomenon remains controversial. US based studies have been limited in their characterization of the weekend patient population, making it difficult to draw conclusions about the implications of this effect.

Methods

A retrospective cohort study, examining de-identified, patient level data from 2015 to 2017 at US academic medical centers submitting data to the Vizient database, comparing demographic and clinical risk profiles, as well as mortality, cost and length of stay, between weekend and weekday patient populations. Between-group differences in mortality were assessed using the chi-square test for categorical measures and Wilcoxon rank-sum test for continuous measures. Logistic regression models were used to test the multivariate association of weekend admission and other patient-level factors with death, LOS, etc.

Results

We analyzed 10,365,605 adult inpatient encounters. Within the weekend patient population, 30.6% of patients were categorized as having either a major or extreme risk of mortality on admission, as compared to 23.7% on weekdays (p < 0.001). We found a significantly increased unadjusted mortality rate associated with weekend admission (OR 1.46; 95% CI 1.45–1.47) which was substantially attenuated after adjusting for disease severity and other demographic covariates, though remained significant (OR 1.05; 95% CI 1.04–1.06). In the subgroup of non-elective admissions, the unadjusted OR for death was 1.14 (95% CI 1.13–1.15), and the adjusted OR was 1.04 (95% CI 1.03–1.05). Weekend admission was associated with a longer median LOS (4 vs 3 days in the weekday group; p < 0.01), but a lower median cost ($8224 vs $9999 dollars in the weekday group; p < 0.01).

Conclusion

The patient population admitted on weekends is proportionally higher risk than the population admitted on weekdays, and the observed weekend mortality effect is largely attributable to this risk imbalance.

Mother's Own Milk Feeding and Severity of Respiratory Illness in Acutely Ill Children: An Integrative Review

PROBLEM

Breastfed infants experience less severe infections while actively breastfeeding. However, little is known about whether a history of prior breastfeeding affects severity of illness. Therefore, the purpose of this integrative review was to examine the relationship between previous exposure to mother's own milk (MOM) feeding and severity of respiratory infectious illness in infants and children.

ELIGIBILITY CRITERIA

Studies meeting the following criteria were included: human subjects, term birth, ages 0-35 months at time of study, diagnosis of pneumonia, bronchiolitis or croup, MOM feeding, and statistical analyses reporting separate respiratory infectious illness outcomes when combined with other infections.

SAMPLE

Twelve articles met eligibility criteria.

RESULTS

Major findings were inconsistent definitions of both dose and exposure period of breastfeeding and the severity of illness. In particular, the severity of illness measure was limited by the use of proxy variables such as emergency room visits or hospitalizations that lacked reliability and validity. However, given this limitation, the data suggested that exclusive breastfeeding for four to six months was associated with reduced severity of illness as measured by frequency of visits to the primary care provider office, emergency department or hospitalization.

CONCLUSIONS

Future research in this area should incorporate reliable and valid measures of MOM dose and exposure period and severity of illness outcomes in the critically ill child.

IMPLICATIONS

Among many positive outcomes associated with breastfeeding, an additional talking point for encouragement of exclusive breastfeeding for four to six months may be protective against severe respiratory infectious illness after cessation of breastfeeding.

[Effect of obstructive sleep apnea on the severity of acute pulmonary thromboembolism]

Objective: To investigate the effect of obstructive sleep apnea (OSA) on the severity of acute pulmonary thromboembolism (PTE). Methods: Clinical data of patients with acute PTE and OSA who were admitted to Anzhen Hospital from January 2015 to December 2017 were retrospectively analyzed in this study.According to the apnea hypopnea index (AHI), patients were divided into AHI≤15/h group and AHI>15/h group. The levels of oxygen desaturation index (ODI), mean pulse oxygen saturation (MSO(2)), the lowest pulse oxygen saturation (LSaO(2)), oxygen saturation<90% time ratio (Ts90%), hemoglobin, hematocrit (HCT), blood platelet, mean platelet volume (MPV), platelet distribution width (PDW), hypersensitive C-reactive protein (hsCRP), homocysteine (HCY), prothrombin time, activated partial thromboplastin time (APTT), fibrinogen (FIB), D-dimer, fibrin degredation product (FDP), B-type natriuretic peptide, cardiac troponin I (cTnI), arterial partial pressure of oxygen (PaO(2)), arterial partial pressure of carbon dioxide (PaCO(2)) were compared between AHI≤15/h group and AHI>15/h group. Differences in the severity of PTE between the two groups were compared; binary Logistic regression model was used to analyze the risk factors of acute PTE severity. Results: A total of 75 patients with acute PTE and OSA were enrolled. Patients in the AHI>15/h group were significantly older [(68.7±9.9) vs (62.8±12.8) years old, P=0.029], and were more likely to have chronic heart failure and/or lung disease (53.1% vs 23.1%, P=0.012) and elevated Pulmonary Embolism Severity Index scores (61.2% vs 30.8%, P=0.012) than those in the AHI≤15/h group. Compared to the AHI>15/h group, the levels of D-dimer and B-type natriuretic peptide were much lower in the AHI ≤15/h group [243.0 (140.0, 471.5) vs 408.0 (258.0, 1 009.5) μg/L, P=0.01; 48.0 (19.8, 87.5) vs 70.0 (34.5, 201.0) ng/L, P=0.039], while arterial oxygen partial pressure was significantly higher [(79.0±10.6) vs (73.4±8.2) mmHg (1 mmHg=0.133 kPa), P=0.015]. In patients with acute PTE and OSA, AHI (P=0.030) and B-type natriuretic peptide level (P=0.023) were independently associated with an increased risk of acute PTE severity. Conclusion: In patients with PTE and OSA, moderate or severe OSA may aggravate the severity of acute PTE.

Appeal to the Rule of Rescue in health care: discriminating and not benevolent?

Thirty years of debate have passed since the term "Rule of Rescue" has been introduced into medical ethics. Its main focus was on whether or why medical treatment for acute conditions should have priority over preventive measures irrespective of opportunity costs. Recent contributions, taking account of the widespread reluctance to accept purely efficiency-oriented prioritization approaches, advance another objection: Prioritizing treatment, they hold, discriminates against statistical lives. The reference to opportunity costs has also been renewed in a distinctly ethical fashion: It has been stipulated that favoring help for identifiable lives amounts to a lack of benevolence for one's fellow creatures. The present article argues against both objections. It suggests that the debate's focus on consequences (deaths or severe ill health) should be reoriented by asking which aspects of such states of affairs are actually attributable to a decision maker who judges within a specific situation of choice.

[Cytokine profiles of CD4(+) T memory cells in asthma and their relationship with asthma severity]

Objective: To study the phenotype of memory CD4(+) T cells in peripheral blood of asthmatics and its relationship with asthma severity. Methods: From Dec 2014 to Aug 2015, thirty-three asthmatics, twenty-six chronic obstructive pulmonary disease (COPD) patients and twenty-two healthy volunteers were enrolled in Respiratory Clinics of Zhongshan Hospital, Fudan University. Peripheral blood mononuclear cells (PBMCs) were isolated from peripheral blood. Cell surface markers (CD45RO, CRTH2, CD62L, and CCR7) and intracellular protein[interleukin (IL)-5, IL-17, interferon (IFN)-γ]staining was performed using flow-cytometric techniques. CD4(+) T cells were cultured under neutralization and then Th2, Th2+ Lipopolysaccharide (LPS), Th2+ Home dust mite (HDM) conditions for 6 days and then intracellular proteins were analyzed using flow cytometry. Correlation analysis between memory CD4(+) T cells, asthma severity and drug consumption were performed. Results: The percentage of memory CD4(+) T (CD4(+) Tm) cells in circulating white blood cells was higher in asthmatics, than that in healthy subjects (48.0%±5.7% vs 32.0%±4.1%, P<0.05). The cytokine profiles of CD4(+) Tm cells in asthma patients were substantially different from those of COPD and healthy subjects, with increased IL-5 and IL-17 production. For COPD patients, the predominant cytokines were IFN-γ instead. IL-17-producing CD4(+) Tm cells were associated with the severity of disease and the level of medication consumption in asthma patients (R(2)=0.829 6, P<0.05). Conclusions: The cytokine profile is IL-5 and IL-17 predominant in memory CD4(+) T cells from asthmatics. The amount of IL-17(+) CD4(+) memory T cells is positively correlated with asthma severity.

Predicting cardiac arrests in pediatric intensive care units

BACKGROUND

Early identification of children at risk for cardiac arrest would allow for skill training associated with improved outcomes and provides a prevention opportunity.

OBJECTIVE

Develop and assess a predictive model for cardiopulmonary arrest using data available in the first 4 h.

METHODS

Data from PICU patients from 8 institutions included descriptive, severity of illness, cardiac arrest, and outcomes.

RESULTS

Of the 10074 patients, 120 satisfying inclusion criteria sustained a cardiac arrest and 67 (55.9%) died. In univariate analysis, patients with cardiac arrest prior to admission were over 6 times and those with cardiac arrests during the first 4 h were over 50 times more likely to have a subsequent arrest. The multivariate logistic regression model performance was excellent (area under the ROC curve = 0.85 and Hosmer-Lemeshow statistic, p = 0.35). The variables with the highest odds ratio's for sustaining a cardiac arrest in the multivariable model were admission from an inpatient unit (8.23 (CI: 4.35-15.54)), and cardiac arrest in the first 4 h (6.48 (CI: 2.07-20.36). The average risk predicted by the model was highest (11.6%) among children sustaining an arrest during hours >4-12 and continued to be high even for days after the risk assessment period; the average predicted risk was 9.5% for arrests that occurred after 8 PICU days.

CONCLUSIONS

Patients at high risk of cardiac arrest can be identified with routinely available data after 4 h. The cardiac arrest may occur relatively close to the risk assessment period or days later.

Creation of an empiric tool to predict ECMO deployment in pediatric respiratory or cardiac failure

PURPOSE

To create a real-time prediction tool to predict probability of ECMO deployment in children with cardiac or pulmonary failure.

MATERIALS AND METHODS

Patients ≤18 years old admitted to an ICU that participated in the Virtual Pediatric Systems database (2009-2015) were included. Logistic regression models using adaptive lasso methodology were used to identify independent factors associated with ECMO use.

RESULTS

A total of 538,202 ICU patients from 140 ICUs qualified for inclusion. ECMO was deployed in 3484 patients (0.6%) with a mortality of 1450 patients (41.6%). The factors associated with increased probability of ECMO use included: younger age, pulmonary hypertension, congenital heart disease, high-complexity cardiac surgery, cardiomyopathy, acute lung injury, shock, renal failure, cardiac arrest, use of nitric oxide, use of either conventional mechanical ventilation or high frequency oscillatory ventilation, and higher annual ECMO center volume. The area under the receiver operating curve for this model was 0.90 (95% CI: 0.85-0.93). This tool can be accessed at https://soipredictiontool.shinyapps.io/ECMORisk/.

CONCLUSIONS

Here, we present a tool to predict ECMO deployment among critically ill children; this tool will help create real-time risk stratification among critically ill children, and it will help with benchmarking, family counseling, and research.

Utility of the Dependence Scale in dementia: validity, meaningfulness, and health economic considerations

Background

The concept of dependence has been proposed as a unified representation of disease severity to quantify and stage disease progression in a manner more informative to patients, caregivers, and healthcare providers.

Methods

This paper provides a review of the Dependence Scale (DS) as a quantitative measure of Alzheimer’s disease severity, its properties as an outcome measure, a metric of disease progression, and a correlate of medical costs.

Results

The literature supports the notion that the DS is related to, but distinct from, key severity measures, including cognition, function, and behavior, and captures the full spectrum of patient needs. It also presents as a useful measure for assessing disease progression.

Conclusions

Results underscore the importance of the DS as a unique endpoint in Alzheimer’s disease clinical trials, providing important information about the impact of therapeutic interventions. The DS also is a useful measure for economic evaluation of novel interventions aimed at delaying progression.

Worldwide audit of blood transfusion practice in critically ill patients

Background

The aim was to describe transfusion practice in critically ill patients at an international level and evaluate the effects of red blood cell (RBC) transfusion on outcomes in these patients.

Methods

This was a pre-planned sub-study of the Intensive Care Over Nations audit, which involved 730 ICUs in 84 countries and included all adult patients admitted between 8 May and 18 May 2012, except admissions for routine postoperative surveillance.

Results

ICU and hospital outcomes were recorded. Among the 10,069 patients included in the audit, data related to transfusion had been completed for 9553 (mean age 60 ± 18 years, 60% male); 2511 (26.3%) of these had received a transfusion, with considerable variation among geographic regions. The mean lowest hemoglobin on the day of transfusion was 8.3 ± 1.7 g/dL, but varied from 7.8 ± 1.4 g/dL in the Middle East to 8.9 ± 1.9 g/dL in Eastern Europe. Hospital mortality rates were higher in transfused than in non-transfused patients (30.0% vs. 19.6%, p < 0.001) and increased with increasing numbers of transfused units. In an extended Cox proportional hazard analysis, the relative risk of in-hospital death was slightly lower after transfusion in the whole cohort (hazard ratio 0.98, confidence interval 0.96–1.00, p = 0.048). There was a stepwise decrease in the hazard ratio for mortality after transfusion with increasing admission severity scores.

Conclusions

More than one fourth of critically ill patients are transfused during their ICU stay, with considerable variations in transfusion practice among geographic regions. After adjustment for confounders, RBC transfusions were associated with a slightly lower relative risk of in-hospital death, especially in the most severely ill patients, highlighting the importance of taking the severity of illness into account when making transfusion decisions.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2018-9) contains supplementary material, which is available to authorized users.

Parent-Rated Severity of Illness and Anxiety among Caregivers of Children Born with a Disorder of Sex Development Including Ambiguous Genitalia

BACKGROUND/AIMS

Parents of children born with disorders of sex development (DSD) often experience anxiety, but risk factors, including parental perception of the severity of their child's DSD, have not been examined. We hypothesized that severity of illness (SOI) ratings would relate to parental anxiety, and would be higher for parents of children with a potentially life-threatening DSD (e.g., 21-hydroxylase deficiency).

METHODS

Eighty-nine parents (Mage = 33.0, 56.2% mothers) of 51 children (Mage in months = 8.7) with a DSD including ambiguous genitalia were recruited from 12 specialized DSD clinics. Parents completed questionnaires prior to genitoplasty, 6 months post-genitoplasty, and 12 months post-genitoplasty (if completed). Data were analyzed with linear mixed modeling.

RESULTS

Parental anxiety decreased over time, χ2(1) = 10.14, p < 0.01. A positive relationship between SOI and anxiety was found, with SOI being a strong predictor of anxiety (b = 0.53, p < 0.01; χ2[1] = 5.33, p < 0.05). An SOI by time interaction indicated SOI had an increasing effect on anxiety over time, b = 0.06, p < 0.05; χ2(1) = 6.30, p < 0.05. There was no diagnosis by SOI interaction.

CONCLUSION

Parental anxiety decreased over time, but those with higher SOI ratings reported greater initial anxiety followed by slower resolution over time. Underlying etiology of DSD had no effect on the relationship between SOI and anxiety.

A novel mortality prediction model for the current population in an adult intensive care unit

BACKGROUND

The accurate and reliable mortality prediction is very useful, in critical care medicine. There are various new variables proposed in the literature that could potentially increase the predictive ability for death in ICU of the new predictive scoring model.

OBJECTIVE

To develop and validate a new intensive care unit (ICU) mortality prediction model, using data that are routinely collected during the first 24 h of ICU admission, and compare its performance to the most widely used conventional scoring systems.

METHODS

Prospective observational study in a medical/surgical, multidisciplinary ICU, using multivariate logistic regression modeling. The new model was developed using data from a medical record review of 400 adult intensive care unit patients and was validated on a separate sample of 36 patients, to accurately predict mortality in ICU.

RESULTS

The new model is simple, flexible and shows improved performance (ROC AUC = 0.85, SMR = 1.25), compared to the conventional scoring models (APACHE II: AUC = 0.76, SMR = 2.50, SAPS III: AUC = 0.76, SMR = 1.50), as well as higher predictive capability regarding ICU mortality (predicted mortality: 41.63 ± 31.61, observed mortality: 41.67%).

CONCLUSION

The newly developed model is a quite simple risk-adjusted outcome prediction tool based on 12 routinely collected demographic and clinical variables obtained from the medical record data. It appears to be a reliable predictor of ICU mortality and is proposed for further investigation aiming at its evaluation, validation and applicability to other ICUs.

Impact of duration of hypotension prior to norepinephrine initiation in medical intensive care unit patients with septic shock: A prospective observational study

PURPOSE

To determine the impact of duration of hypotension prior to norepinephrine initiation on outcomes in MICU patients with septic shock. We hypothesized increased duration of hypotension prior to norepinephrine initiation would be associated with an increased risk for ICU mortality.

MATERIALS AND METHODS

We conducted a prospective-observational study in the MICU of a single-center tertiary academic medical center. We enrolled 160 adults ≥18years old with septic shock. Descriptive statistics were computed for demographic and outcome variables. Primary logistic regression analysis was adjusted for severity of illness.

RESULTS

The mean age of our patients was 59years (±17); 42% were female; the mean APACHE II score was 24.1 (±8.0), and the mean SOFA score was 9.6 (±4.0). Median duration of hypotension prior to norepinephrine initiation was 3.6h (IQR 1.6-9.9). Duration of hypotension prior to norepinephrine did not increase the risk for ICU mortality (OR 1.03 per hour after hypotension, 95% CI: 0.98-1.09, p=0.20).

CONCLUSION

Duration of hypotension less than one hour and greater than one hour prior to norepinephrine initiation in MICU patients with septic shock is not associated with an increased risk for ICU mortality.

Healthcare-seeking behaviour of primary caregivers for acute otitis media in children aged 6 months to <30 months in Panama: results of a cross-sectional survey

BACKGROUND

Acute otitis media (AOM) is the most common bacterial childhood infection. However, caregivers with children having mild episodes often do not seek healthcare services, which may lead to an under-appreciation of the disease experienced by the community. The objectives of this survey were to estimate the proportion of primary caregivers who went to a healthcare facility when they suspected that their child aged 6 to <30 months was having an AOM episode during the past 6 months and to assess what factors influenced their decision.

METHODS

This observational, cross-sectional survey of primary caregivers (≥18 years), with at least one child aged 6 to <30 months was performed in 19 healthcare facilities in Panama (March to May 2013). A 28-item paper questionnaire was administered to assess demographic data, AOM symptoms, as well as potential healthcare-seeking behaviour and factors influencing this behaviour. Potential confounding effects were individually assessed using Chi-squared or Cochran-Mantel-Haenszel tests, and all together in logistic regression models.

RESULTS

The total number of eligible participants was 1330 (mean age 28.5 ± 8.0 years). Of these, 245 participants had at least one child whom they suspected had an AOM episode during the past 6 months. Of the 245 participants, 213 (86.9%) sought healthcare at a facility. Several factors were associated with healthcare usage: perceived severity of illness (p = 0.001), occupational status of the caregiver (p = 0.002), household income (p = 0.016) and length of time since the last suspected AOM episode (p = 0.032).

CONCLUSIONS

When confronted with a child with obvious symptoms of AOM, the majority of caregivers reported seeking healthcare. This behaviour appeared to be associated with factors related to the severity of the illness, the length of time since the last episode, as well as with the income and occupational status of the caregivers themselves. As many episodes of AOM present with non-specific respiratory symptoms, our results apply only to caregivers who were confronted with children with an obvious symptom.

Combining quick Sequential Organ Failure Assessment with plasma lactate concentration is comparable to standard Sequential Organ Failure Assessment score in predicting mortality of patients with and without suspected infection

PURPOSE

We sought to determine whether quick Sequential Organ Failure Assessment (qSOFA) score can be used to predict mortality of patients without suspected infection.

MATERIALS AND METHODS

Using prospectively collected data within the first hour of intensive care unit admission, the predictive ability of qSOFA was compared with the Simplified Acute Physiology Score III, Admission Mortality Prediction Model III, Acute Physiology and Chronic Health Evaluation II model, and standard (full-version) SOFA score using area under the receiver operating characteristic (AUROC) curve and Brier score.

RESULTS

Of the 2322 patients included, 279 (12.0%) died after intensive care unit admission. The qSOFA score had a modest ability to predict mortality of all critically ill patients (AUROC, 0.672; 95% confidence interval [CI], 0.638-0.707; Brier score 0.099) including the noninfected patients (AUROC, 0.685; 95% CI, 0.637-0.732; Brier score 0.081). The overall predictive ability and calibration of the qSOFA was comparable to other prognostic scores. Combining qSOFA score with lactate concentrations further enhanced its predictive ability (AUROC, 0.730; 95% CI, 0.694-0.765; Brier score 0.097), comparable to the standard SOFA score.

CONCLUSIONS

The qSOFA score had a modest ability to predict mortality of both septic and nonseptic patients; combining qSOFA with plasma lactate had a predictive ability comparable to the standard SOFA score.

The Multimorbidity Index: A Tool for Assessing the Prognosis of Patients from Their History of Illness

BACKGROUND

The Multimorbidity (MM) Index predicts the prognosis of patients from their diagnostic history. In contrast to existing approaches with broad diagnostic categories, it treats each diagnosis as a separate independent variable using individual International Classification of Disease, Revision 9 (ICD-9) codes.

OBJECTIVE

This paper describes the MM Index, reviews the published data on its accuracy, and provides procedures for implementing the Index within electronic health record (EHR) systems. Methods: The MM Index was tested on various patient populations by using data from the United States Department of Veterans Affairs data warehouse and claims data within the Healthcare Cost and Utilization Project of the Agency for Health Care Research and Quality.

RESULTS

In cross-validated studies, the MM Index outperformed prognostic indices based on physiological markers, such as CD4 cell counts in HIV/AIDS, HbAlc levels in diabetes, ejection fractions in heart failure, or the 13 physiological markers commonly used for patients in intensive care units. When predicting the prognosis of nursing home patients by using the cross-validated area under a receiver operating characteristic (ROC) curve, the MM Index was 15 percent outperformed the Quan variant of the Charlson Index, 27 percent more accurate than the Deyo variant of the Charlson Index, and 22 percent more accurate than the von Walraven variant of the Elixhauser Index. For patients in intensive care units, the MM Index was 13 percent outperformed the cross-validated area under ROC associated with Elixhauser's categories. The MM Index also demonstrated greater accuracy than a number of commercially available measures of illness severity; including a fivefold greater accuracy than the All Patient Refined Diagnosis-Related Groups and a threefold greater accuracy than All Payer Severity-Adjusted Diagnosis-Related Groups.

CONCLUSION

The MM Index is statistically more accurate than many existing measures of prognosis. The magnitude of improvement is large and may lead to a clinically meaningful difference in patient care. Given the large improvements in accuracy, the use of the MM Index for policy and comparative effectiveness analysis is recommended.

Association of severity of illness and intensive care unit readmission: A systematic review

OBJECTIVES

To determine whether ICU readmission is associated with higher severity of illness scores in adult patients.

BACKGROUND

Readmissions to the intensive care unit (ICU) are associated with increased costs, morbidity, and mortality.

METHODS

We performed searches of MEDLINE, EMBASE, and grey literature databases. We selected studies reporting data from adults who were hospitalized in an ICU, received severity of illness scores, and were discharged from the ICU. Characteristics of readmitted and non-readmitted patients were examined.

RESULTS

We screened 4766 publications and included 31 studies in our analysis. In most studies, severity of illness scores were higher in patients readmitted to the ICU. Readmission was also associated with higher mortality and longer ICU and hospital stays. Excessive heterogeneity precluded the reporting of results in the form of a meta-analysis.

CONCLUSIONS

ICU readmission is associated with higher severity of illness scores during the same hospitalization in adult patients.

Acid-base disturbances in acute poisoning and their association with survival

PURPOSE

The purpose was to investigate the association between acid-base disturbances and mortality in acute poisoning.

MATERIALS AND METHODS

We performed a retrospective cross-sectional exploratory study on all acutely poisoned patients older than 12 years who had been admitted to the main tertiary toxicology hospital in Tehran between March and August 2010.

RESULTS

Of a total of 1167 patients (median age=25 years, 50.9% male), 98 died (74.5% male). Psychotropic medications were the most common cause of poisoning (36.5%), whereas narcotics and psychodysleptics were the most common cause of death (23.5%). Mixed respiratory alkalosis and metabolic acidosis with normal pH were the most common acid-base status (333, 28.5%). However, patients with primary metabolic acidosis and respiratory compensation had significantly higher mortality (31 cases, 18.8%). Logistic regression analysis identified age (odds ratio [OR], 1.051; 95% confidence interval [CI], 1.031-1.070; P<.001), intensive care unit admission (OR, 12.405; 95% CI, 7.178-21.440; P<.001), consciousness level (OR, 1.752; 95% CI, 1.301-2.359; P<.001), hospitalization period (OR, 1.1361; 95% CI, 1.079-1.195; P<.001), severe metabolic acidosis (OR, 6.016; 95% CI, 1.647-21.968; P=.007), and primary respiratory alkalosis (OR, 5.579; 95% CI, 1.353-23.001; P=.017) as death predictors during hospitalization (P<.001).

CONCLUSION

On-arrival acid-base status predicts survival and can be used in prognostication of the poisoned patients.

Differences in severity at admission for heart failure between rural and urban patients: the value of adding laboratory results to administrative data

BACKGROUND

Rural/urban variations in admissions for heart failure may be influenced by severity at hospital presentation and local practice patterns. Laboratory data reflect clinical severity and guide hospital admission decisions and treatment for heart failure, a costly chronic illness and a leading cause of hospitalization among the elderly. Our main objective was to examine the role of laboratory test results in measuring disease severity at the time of admission for inpatients who reside in rural and urban areas.

METHODS

We retrospectively analyzed discharge data on 13,998 hospital discharges for heart failure from three states, Hawai'i, Minnesota, and Virginia. Hospital discharge records from 2008 to 2012 were derived from the State Inpatient Databases of the Healthcare Cost and Utilization Project, and were merged with results of laboratory tests performed on the admission day or up to two days before admission. Regression models evaluated the relationship between clinical severity at admission and patient urban/rural residence. Models were estimated with and without use of laboratory data.

RESULTS

Patients residing in rural areas were more likely to have missing laboratory data on admission and less likely to have abnormal or severely abnormal tests. Rural patients were also less likely to be admitted with high levels of severity as measured by the All Patient Refined Diagnosis Related Groups (APR-DRG) severity subclass, derivable from discharge data. Adding laboratory data to discharge data improved model fit. Also, in models without laboratory data, the association between urban compared to rural residence and APR-DRG severity subclass was significant for major and extreme levels of severity (OR 1.22, 95% CI 1.03-1.43 and 1.55, 95% CI 1.26-1.92, respectively). After adding laboratory data, this association became non-significant for major severity and was attenuated for extreme severity (OR 1.12, 95% CI 0.94-1.32 and 1.43, 95% CI 1.15-1.78, respectively).

CONCLUSION

Heart failure patients from rural areas are hospitalized at lower severity levels than their urban counterparts. Laboratory test data provide insight on clinical severity and practice patterns beyond what is available in administrative discharge data.

Coronavirus and Other Respiratory Illnesses Comparing Older with Young Adults

BACKGROUND

Study of human coronavirus and other virus-associated respiratory illnesses is needed to describe their clinical effects on chronically ill, older adults.

METHODS

A prospective study during 2009 to 2013 clinically assessed acute respiratory illnesses soon after onset and 3 to 4 weeks later in patients aged ≥60 years with chronic lung and heart diseases (group 1, 100 subjects) and healthy adults aged 18 to 40 years (group 2, 101 subjects). Respiratory secretions were tested for nucleic acids of a panel of respiratory viruses. An increase in antibody titer was assessed for 4 coronavirus strains.

RESULTS

Virus-associated illnesses (29 [39.1%] of 74 illnesses in group 1 and 59 [48.7%] of 121 illnesses in group 2) occurred in all calendar quarters, most commonly in the first and fourth quarters. Coronaviruses (group 1: 14 [18.9%] illnesses; group 2: 26 [21.5%] illnesses) and enteroviruses/rhinoviruses (group 1: 14 [18.9%] illnesses; group 2: 37 [30.6%] illnesses) were most common. Virus co-infections occurred in 10 illnesses. Illnesses with 9 to 11 symptoms were more common in group 1 (17 [23.0%]) than in group 2 (15 [12.4%]) (P < .05). Compared with group 2, more group 1 subjects reported dyspnea, more severe disease of longer duration, and treatment for acute illness with prednisone and antibiotics. Coronavirus-associated illnesses (percent of illnesses, group 1 vs group 2) were characterized by myalgias (21% vs 68%, P < .01), chills (50% vs 52%), dyspnea (71% vs 24%, P < .01), headache (64% vs 72%), malaise (64% vs 84%), cough (86% vs 68%), sputum production (86% vs 60%), sore throat (64% vs 80%), and nasal congestion (93% vs 96%).

CONCLUSIONS

Respiratory illnesses were commonly associated with coronaviruses and enteroviruses/rhinoviruses affecting chronically ill, older patients more than healthy, young adults.

Pediatric Early Warning Score and unplanned readmission to the pediatric intensive care unit

BACKGROUND AND OBJECTIVES

Early unplanned Pediatric Intensive Care Unit (PICU) readmission is associated with greater length of stay and mortality. No tools exist to identify children at risk for PICU readmission. The Pediatric Early Warning Score (PEWS) currently identify children at risk for deterioration on the ward. Our primary objective was to evaluate the ability of PEWS to identify children at risk for unplanned PICU readmission.

METHODS

A single-center case-control study of 189 children (38 cases and 151 age-matched controls) 18years or younger transferred from the PICU to the pediatric ward from January 1, 2010-March 30, 2013, at an urban tertiary care children's hospital was conducted.

RESULTS

Thirty-eight cases had unplanned PICU readmission within 48hours of transfer to pediatric ward, whereas 151 controls were not readmitted. The PEWS assigned prior to PICU discharge and first PEWS assigned on the ward were collected for cases and controls. Each 1-point increase in the PEWS score significantly increased risk of PICU readmission (odds ratios [95% confidence intervals], 1.6 [1.12-2.27; P = .009] and 1.89 [1.33-2.69; P < .001], respectively). Discrimination ability of PEWS for PICU readmission improved when chronic diagnoses were included.

CONCLUSIONS

Higher PEWS scores were associated with increased risk of unplanned PICU readmission. However, cutoff scores are not sensitive or specific enough to be clinically useful. Adding chronic disease variables may improve the clinical utility of cutoff PEWS scores.

Indicators for childhood asthma in Spain, using the Rand method

OBJECTIVE

To develop quality indicators to measure asthma care in primary health care.

METHOD

A modified RAND was used, which included the systematic review of the literature in Embase, Cochrane and Pubmed Quality Agencies and Database. The work group identified the indicators, translated them into Spanish and resolved any duplicates. Each indicator is composed of several dimensions (access to care, clinical effectiveness, patient-centred quality and patient safety). A multidisciplinary panel of 98 professionals from all over Spain were invited to score each indicator using a Likert scale. After calculating the average and median of each indicator, this information was sent to those who responded (n=38) for a second round and further scoring. The agreement percentage for the group was obtained for each indicator.

RESULTS

Of the 105 asthma indicators reviewed, we selected 46 that were presented to the panel of experts. In both Delphi phases, 37.1% of the members of the initial panel of experts responded. Of these, 26 were primary care paediatricians, six were pulmonologists, three were nurses, two were pharmacists and one was an allergist. For 32 indicators, agreement exceeded 70% and seven of those scored highest for the various care aspects for asthmatic children.

CONCLUSION

Quality indicators are presented for the follow-up of asthma and their implementation in primary care, which have undergone a strict selection and agreement process by a multidisciplinary work group.

[Relationship between previous severity of illness and outcome of in-hospital cardiac arrest]

OBJECTIVES

To analyze the relationship between previous severity of illness, lactic acid, creatinine and inotropic index with mortality of in-hospital cardiac arrest (CA) in children, and the value of a prognostic index designed for adults.

METHODS

The study included total of 44 children aged from 1 month to 18 years old who suffered a cardiac arrest while in hospital. The relationship between previous severity of illness scores (PRIMS and PELOD), lactic acid, creatinine, treatment with vasoactive drugs, inotropic index with return of spontaneous circulation and survival at hospital discharge was analyzed.

RESULTS

The large majority (90.3%) of patients had a return of spontaneous circulation, and 59% survived at hospital discharge. More than two-thirds (68.2%) were treated with inotropic drugs at the time of the CA. The patients who died had a higher lactic acid before the CA (3.4 mmol/L) than survivors (1.4 mmol/L), P=.04. There were no significant differences in PRIMS, PELOD, creatinine, inotropic drugs, and inotropic index before CA between patients who died and survivors.

CONCLUSION

A high lactic acid previous to cardiac arrest could be a prognostic factor of in-hospital cardiac arrest in children.

Performance of the SAPS 3 admission score as a predictor of ICU mortality in a Philippine private tertiary medical center intensive care unit

Background

This study aimed to assess the performance of the Simplified Acute Physiology Score 3 (SAPS 3) as a predictor of ICU mortality in critically ill patients of different case mixes admitted to an intensive care unit.

Methods

This retrospective cohort study was performed from January 2011 to August 2013 in the intensive care unit of a private tertiary referral center in the Philippines. Predicted ICU mortality was calculated using the SAPS 3 global model. Observed versus predicted mortality rates were compared, and the standardized mortality ratio (SMR) was calculated. The discrimination and calibration characteristics of the SAPS 3 system to predict ICU mortality were assessed.

Results

A total of 2,426 patients were included. The observed ICU mortality was 277 (11.42%). The SAPS 3 global model had fair to good discrimination with an area under the receiver operating characteristic curve of 0.80 (CI 0.78–0.81). Good calibration was seen with the Hosmer-Lemeshow goodness of fit at Ĉ = 11.51 (p = 0.175). Standardized mortality ratio was 0.36 (0.26–0.81).

Conclusion

The global SAPS 3 prediction model showed fair to good discrimination and good calibration in predicting mortality in our intensive care unit. Different levels of discrimination and calibration across the different subgroups analyzed suggest that overall ICU performance seemed to be affected by case mix variations.

Electronic supplementary material

The online version of this article (doi:10.1186/2052-0492-2-29) contains supplementary material, which is available to authorized users.

A Disrupted-in-Schizophrenia 1 Gene Variant is Associated with Clinical Symptomatology in Patients with First-Episode Psychosis

OBJECTIVE

DISC1 gene is one of the main candidate genes for schizophrenia since it has been associated to the illness in several populations. Moreover, variations in several DISC1 polymorphisms, and in particular Ser704Cys SNP, have been associated in schizophrenic patients to structural and functional modifications in two brain areas (pre-frontal cortex and hippocampus) that play a central role in the genesis of psychotic symptoms. This study tested the association between Ser704Cys DISC1 polymorphism and the clinical onset of psychosis.

METHODS

Two hundred and thirteen Caucasian drug-naive patients experiencing a first episode of non-affective psychosis were genotyped for rs821616 (Ser704Cys) SNP of the DISC1 gene. The clinical severity of the illness was assessed using SAPS and SANS scales. Other clinical and socio-demographic variables were recorded to rule out possible confounding effects.

RESULTS

Patients homozygous for the Ser allele of the Ser704Cys DISC1 SNP had significantly (p<0.05) higher rates at the positive symptoms dimension (SAPS-SANS scales) and hallucinations item, compared to Cys carriers.

CONCLUSION

DISC1 gene variations may modulate the clinical severity of the psychosis at the onset of the disorder.

Obsessive-compulsive disorder; chronic versus non-chronic symptoms

OBJECTIVE

Understanding chronicity in OCD is hampered by contradictory findings arising from dissimilar definitions of chronic OCD. The purpose of this study was to investigate the magnitude of chronicity in OCD and to examine if chronic OCD is critically different from non-chronic OCD, using a chronicity definition that reflects empirical findings.

METHOD

Baseline data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, in which 379 OCD patients participated, were analyzed. Chronic OCD was defined as "continuous presence of at least moderately severe OCD symptoms during at least two years", and was assessed retrospectively using a Life-Chart Interview.

RESULTS

Application of the chronicity criterion resulted in two groups with highly distinguishable course patterns. The majority of the sample (61.7%) reported a chronic course. Patients with a chronic course reported significantly more severe OCD symptoms, more illness burden, more comorbidity, an earlier OCD onset and more contamination and washing - and symmetry and ordering symptoms. Multivariable logistic regression analysis revealed that chronic OCD was independently associated with more OCD-subtypes (p<0.001), contamination and washing symptoms (p<0.001), earlier OCD onset (p=0.05) and higher severity of compulsions (p<.01).

LIMITATIONS

The findings are based on a cross-sectional survey. Furthermore course was assessed retrospectively, implying the possibility of overestimation of persistence and severity of symptoms.

CONCLUSION

Chronicity is the rule rather than the exception in OCD in clinical samples. Chronic OCD is critically different from non-chronic OCD. Further attempts to break down the heterogeneity of OCD in homogeneous course subtypes should be made to allow for a more precise determination of the pathogenesis of OCD and better treatment.

An analysis of medicine costs of adult patients on a critical care unit

PURPOSE

To evaluate the costs of medicines used to treat critically ill patients in an intensive care environment and to correlate this with severity of illness and mortality.

MATERIALS AND METHODS

The study was conducted at a London Teaching Hospital Critical Care Unit. Data were collected for patients who were either discharged or died during September 2011 and stayed longer than 48 hours. The drug cost was related to 150 drugs that were then related to patient's acuity and outcome.

RESULTS

The median daily drug cost of the 85 patients was £26. The highest cost patients in the 85th percentile had significantly higher daily drug costs (median, £403) and higher scores for patient acuity. Patients with hematologic malignancy had a median daily drug cost (£561) more than 20 times higher than those without. A regression analysis based on patient's diversity explained 93% of the variance in the daily drug cost.

CONCLUSIONS

Although the median daily drug cost for an adult critically ill patient was low, this cost significantly escalated with patient acuity and hematologic malignancy. A reference method has been designed for an in-depth evaluation of daily drug cost that could be used to compare expenditure in other units.