Serum magnesium level as a predictor of acute kidney injury in patients with acute pancreatitis

BACKGROUNDDecreased serum magnesium (Mg²⁺) is commonly seen in critically ill patients. Hypomagnesemia is significantly more frequent in patients with severe acute pancreatitis. Acute kidney injury (AKI) in patients with acute pancreatitis (AP) is associated with an extremely high mortality. The association underlying serum Mg²⁺ and AKI in AP has not been elucidated.AIMTo explore the association between serum Mg²⁺ on admission and AKI in patients with AP.METHODSA retrospective observational study was conducted in a cohort of patients (n = 233) with AP without any renal injury before admission to our center from August 2015 to February 2019. Demographic characteristics on admission, severity score, laboratory values and in-hospital mortality were compared between patients with and without AKI.RESULTSA total of 233 patients were included for analysis, including 85 with AKI. Compared to patients without AKI, serum Mg²⁺ level was significantly lower in patients with AKI at admission [OR = 6.070, 95%CI: 3.374-10.921, P < 0.001]. Multivariate logistic analysis showed that lower serum Mg²⁺ was an independent risk factor for AKI [OR = 8.47, 95%CI: 3.02-23.72, P < 0.001].CONCLUSIONOur analysis indicates that serum Mg²⁺ level at admission is independently associated with the development of AKI in patients with AP and may be a potential prognostic factor.     

ICU系统性红斑狼疮患者的临床特征与预后分析

目的探讨ICU系统性红斑狼疮（SLE）患者的临床特征和预后的影响因素。 方法回顾性分析2013年1月至2019年6月入住我院内科ICU的SLE患者的临床数据,主要包括：年龄、性别、患病年限、主要器官受累情况、SLE疾病活动指数（SLEDAI）、急性生理学与慢性健康状况（APACHEⅡ）评分、ICU住院时间及转归、入住ICU的直接原因、ICU住院期间治疗（包括糖皮质激素、免疫抑制剂、大剂量免疫球蛋白、有创机械通气、血液透析、血管活性药物）以及主要的实验室检查数据。 结果共纳入61例患者,以女性为主（68.85%）,APACHEⅡ评分（18.93±7.62）分。感染和急性心力衰竭是转入ICU最常见的原因。多因素Logistic回归分析提示APACHEⅡ评分≥20分、血管活性药物应用、脓毒症与预后相关（OR=23.326,95%CI：2.307~235.896,P=0.008;OR=26.218,95%CI：1.641~418.897,P=0.021;OR=17.194,95%CI：1.332~221.945,P=0.029）。 结论ICU的SLE患者预后较差,APACHEⅡ评分≥20分、血管活性药物应用、脓毒症是其死亡的危险因素。     

早期肌钙蛋白I对危重孕产妇重症监护病房住院时间的预测价值

目的评估入重症监护病房（ICU）早期出现肌钙蛋白I（TnI）升高对重症孕产妇ICU住院时间的预测价值。 方法对2014年1月1日至2019年7月1日入住北京大学人民医院ICU的危重孕产妇的临床资料进行回顾性分析。根据入住ICU住院时间是否大于72 h,分为ICU住院时间延长和ICU住院时间非延长2个组。采用多因素Logistic回归方法分析ICU住院时间延长的独立危险因素。采用受试者工作特征（ROC）曲线评价入ICU早期TnI水平及AKI对ICU住院时间延长的预测价值。 结果本研究纳入转入ICU的危重孕产妇119例;其中ICU住院时间延长组47例（39.5%）,非延长组72例（60.5%）。Logistic回归分析发现,早期TnI升高（优势比6.697,95%CI：1.27~35.332,P=0.025）和急性肾损伤（AKI,优势比6.054,95%CI：1.248~29.368,P=0.025）是危重孕产妇ICU住院时间延长的独立危险因素。ROC曲线分析显示,入ICU早期发生TnI升高及AKI对ICU住院时间延长预测的曲线下面积分别为0.741（95%CI 0.65~0.832,P<0.001）和0.729（95%CI 0.634~0.825,P<0.001）;二者联合对ICU住院时间延长预测的曲线下面积为0.806（95%CI 0.723~0.889,P<0.001）。 结论早期出现TnI升高和AKI是预测危重孕产妇ICU住院时间延长的独立危险因素,对ICU住院时间有预测价值。     

急诊危重患者急性肾损伤发生的危险因素分析

目的:调查急诊抢救室患者急性肾损伤（acute kindey injury,AKI）的发生率并探讨相关危险因素。方法:采用回顾性队列研究方法,纳入2018年9~12月经由本院抢救室收治的患者,根据患者入院后7 d内是否发生AKI,将患者分为AKI组和非AKI组。收集患者入抢救室时的人口学特征、APACHE Ⅱ评分、是否使用肾脏毒性药物、24 h液体出入量及院内生存时间等相关指标。使用多因素Logistic回归分析AKI发生的危险因素。使用COX回归研究AKI的发生对患者住院生存率的影响,并分析AKI严重程度对患者死亡风险的影响。结果:纳入急诊抢救室的患者238例,其中108例发生AKI（45.4%）,AKI 1期83例（34.9%）,AKI 2~3期25例（10.5%）。APACHE Ⅱ评分>13分[ OR=1.11,95% CI（1.07~1.16）, P<0.01],应用血管活性药[ OR=2.20,95% CI（1.08~4.49）, P=0.03],糖尿病（ OR=2.33,95% CI（1.23~4.42）, P=0.01）,24 h入量>3 L（ OR=3.10,95% CI（1.17~8.25）, P=0.02）是发生AKI的独立危险因素。多因素COX回归校正APACHE Ⅱ评分和年龄后,AKI仍是急诊抢救室患者死亡的独立危险因素,且AKI严重程度显著增加急诊患者死亡风险[AKI1期 HR=1.45,95% CI（1.08~2.03）, P=0.04; AKI2-3期 HR=3.15,95% CI（1.49~4.81）, P=0.03]。 结论:急诊抢救室患者中AKI的发生较常见。APACHE Ⅱ评分>13分,应用血管活性药,糖尿病,24 h入量>3 L是发生AKI的独立危险因素。随着AKI严重程度的增加,死亡风险增加。     

急诊危重患者急性肾损伤发生的危险因素分析

目的:调查急诊抢救室患者急性肾损伤（acute kindey injury,AKI）的发生率并探讨相关危险因素。方法:采用回顾性队列研究方法,纳入2018年9~12月经由本院抢救室收治的患者,根据患者入院后7 d内是否发生AKI,将患者分为AKI组和非AKI组。收集患者入抢救室时的人口学特征、APACHE Ⅱ评分、是否使用肾脏毒性药物、24 h液体出入量及院内生存时间等相关指标。使用多因素Logistic回归分析AKI发生的危险因素。使用COX回归研究AKI的发生对患者住院生存率的影响,并分析AKI严重程度对患者死亡风险的影响。结果:纳入急诊抢救室的患者238例,其中108例发生AKI（45.4%）,AKI 1期83例（34.9%）,AKI 2~3期25例（10.5%）。APACHE Ⅱ评分>13分[ OR=1.11,95% CI（1.07~1.16）, P<0.01],应用血管活性药[ OR=2.20,95% CI（1.08~4.49）, P=0.03],糖尿病（ OR=2.33,95% CI（1.23~4.42）, P=0.01）,24 h入量>3 L（ OR=3.10,95% CI（1.17~8.25）, P=0.02）是发生AKI的独立危险因素。多因素COX回归校正APACHE Ⅱ评分和年龄后,AKI仍是急诊抢救室患者死亡的独立危险因素,且AKI严重程度显著增加急诊患者死亡风险[AKI1期 HR=1.45,95% CI（1.08~2.03）, P=0.04; AKI2-3期 HR=3.15,95% CI（1.49~4.81）, P=0.03]。 结论:急诊抢救室患者中AKI的发生较常见。APACHE Ⅱ评分>13分,应用血管活性药,糖尿病,24 h入量>3 L是发生AKI的独立危险因素。随着AKI严重程度的增加,死亡风险增加。     

Common bile duct morphology is associated with recurrence of common bile duct stones in Billroth II anatomy patients

BACKGROUNDEndoscopic retrograde cholangiopancreatography (ERCP) is the primary choice for removing common bile duct (CBD) stones in Billroth II anatomy patients. The recurrence of CBD stones is still a challenging problem.AIMTo evaluate CBD morphology and other predictors affecting CBD stone recurrence.METHODSA retrospective case-control analysis was performed on 138 CBD stones patients with a history of Billroth II gastrectomy, who underwent therapeutic ERCP for stone extraction at our center from January 2011 to October 2020. CBD morphology and other predictors affecting CBD stone recurrence were examined by univariate analysis and multivariate logistic regression analysis.RESULTSCBD morphology (P < 0.01) and CBD diameter ≥ 1.5 cm (odds ratio [OR] = 6.15, 95% confidence interval [CI]: 1.87-20.24, P < 0.01) were the two independent risk factors. In multivariate analysis, the recurrence rate of patients with S type was 16.79 times that of patients with straight type (OR = 16.79, 95%CI: 4.26-66.09, P < 0.01), the recurrence rate of patients with polyline type was 4.97 times that of patients with straight type (OR = 4.97, 95%CI: 1.42-17.38, P = 0.01), and the recurrence rate of S type patients was 3.38 times that of patients with polyline type (OR = 3.38, 95%CI: 1.07-10.72, P = 0.04).CONCLUSIONCBD morphology, especially S type and polyline type, is associated with increased recurrence of CBD stones in Billroth II anatomy patients.     

Predictive accuracy of severity scoring system: a prospective cohort study using APACHE III in a Korean intensive care unit

AIM: To evaluate the discrimination, calibration, and uniformity of fit by age group, operative status, and location before ICU admission of APACHE III in a single-center ICU population. DESIGN AND SETTING: Prospective data collection in a 25 bed mixed (surgical and medical) ICU of 850-bed teaching hospital in Pusan, South Korea. SUBJECTS AND METHODS: The worst values on APACHE III variables during 24h following ICU admission were collected from the patient's charts and clinical flow sheets of 284 consecutively admitted subjects. RESULTS: The mortality rate was 31.0%, and showed a strong positive correlation between APACHE III score (r=0.97, p<0.0001 for entire population, r=0.97, p<0.0001 for medical patients, r=0.91, p<0.0001 for surgical patients). Hospital mortality was significantly higher for medical patients than surgical patients (OR=7.23, 95% CI=3.76-13.88), and for patients located in the operating room than at ward before admitting ICU (OR=0.09, 95% CI=0.04-0.23). At the predicted risk of 0.5 (66 of APACHE III score), sensitivity was 0.72, specificity 0.91, and correct classification rate 0.85. Area under the ROC curve was 0.905 (95% CI=0.867-0.943). Correlation coefficient (r) between observed and expected mortality rate was 0.99. The value (chi-square) of Lemeshow-Hosmer (L-H) goodness-of-fit statistic was 6.54 (p=0.59). In patients stratified according to age groups, operative status, and location in the hospital before ICU admission, discrimination was generally good in all subgroups (area under the ROC curve >0.85), and the chi-squared of L-H goodness-of -fit statistic showed a good fit for all subgroup, especially for operative status. CONCLUSIONS: The predictive accuracy of the APACHE III scoring system showed better discrimination, as well as uniformity of fit. So, it was thought that could be utilized for the subject hospital.     

白细胞介素-17水平对脓毒症患者发生急性肾损伤的预测价值

目的分析脓毒症患者发生急性肾损伤(acute kidney injury,AKI)的影响因素,探讨白细胞介素(interleukin,IL)-17对脓毒症患者并发AKI的预测价值。方法102例脓毒症患者,根据入住ICU 7 d内是否发生AKI分为AKI组和非AKI组。比较2组患者一般资料及序贯器官衰竭评分(sequential organ failure assessment,SOFA)和急性生理和慢性健康状况评分Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ);采用ELISA法检测血清IL-17、IL-23水平,采用免疫比浊法检测降钙素原水平,并进行2组间比较;采用多因素logistic回归分析脓毒症患者发生AKI的影响因素;绘制ROC曲线,评估IL-17早期预测脓毒症患者发生AKI的效能。结果入住ICU 7 d内102例患者共发生AKI 31例,发生率为30.39%。AKI组患者平均动脉压[(77.25±8.94)mm Hg]、氧合指数[(233.04±19.26)mm Hg]低于非AKI组[(88.17±9.38)、(254.88±18.57)mm Hg](P<0.05),SOFA评分[(8.81±1.35)分]、APACHEⅡ评分[(18.87±2.69)分]及血清降钙素原[(4.83±0.99)μg/L]、IL-23[(63.25±10.78)μg/L]、IL-17[(43.85±13.27)μg/L]水平均高于非AKI组[(6.94±1.52)分、(14.79±2.95)分、(3.91±1.13)μg/L、(56.88±11.75)μg/L、(31.99±7.13)μg/L](P<0.05)。平均动脉压(OR=0.877,95%CI:0.810~0.950,P=0.001)、SOFA评分(OR=2.096,95%CI:1.493~2.942,P<0.001)、降钙素原(OR=1.720,95%CI:1.052~2.812,P=0.030)、IL-17(OR=1.078,95%CI:1.014~1.145,P=0.015)是脓毒症患者发生AKI的影响因素。血清IL-17、平均动脉压、SOFA评分、降钙素原的最佳截断值分别为40.92μg/L、82.33 mm Hg、8.35分、4.22μg/L时,预测脓毒症患者发生AKI的AUC分别为0.848(95%CI:0.764~0.912,P<0.001)、0.677(95%CI:0.577~0.766,P<0.001)、0.689(95%CI:0.590~0.777,P<0.001)、0.638(95%CI:0.537~0.731,P<0.001),灵敏度分别为67.74%、93.55%、67.74%、70.97%,特异度分别为87.32%、39.55%、69.01%、50.93%。结论IL-17可对脓毒症患者是否发生AKI进行早期预警。     

Prognostic indicators of patients with acute kidney injury in intensive care unit

BACKGROUND:

Acute kidney injury (AKI) is associated with a high mortality. This study was undertaken to detect the factors associated with the prognosis of AKI.

METHODS:

We retrospectively reviewed 98 patients with AKI treated from March 2008 to August 2009 at this hospital. In these patients, 60 were male and 38 female. Their age ranged from 19 to 89 years (mean 52.4±16.1 years). The excluded patients were those who died within 24 hours after admission to ICU or those who had a history of chronic kidney disease or incomplete data. After 60 days of treatment, the patients were divided into a survival group and a death group. Clinical data including gender, age, history of chronic diseases, the worst laboratory values within 24 hours after diagnosis (values of routine blood tests, blood gas analysis, liver and renal function, levels of serum cystatin C, and blood electrolytes) were analyzed. Acute physiology, chronic health evaluation (APACHE) II scores and 60-day mortality were calculated. Univariate analysis was performed to find variables relevant to prognosis, odds ratio (OR) and 95% confidence interval (CI). Multiple-factor analysis with logistic regression analysis was made to analyze the correlation between risk factors and mortality.

RESULTS:

The 60-day mortality was 34.7% (34/98). The APACHE II score of the death group was higher than that of the survival group (17.4±4.3 vs. 14.2±4.8, P<0.05). The mortality of the patients with a high level of cystatin C>1.3 mg/L was higher than that of the patients with a low level of cystatin C (<1.3 mg/L) (50% vs. 20%, P<0.05). The univariate analysis indicated that organ failures≥2, oliguria, APACHE II>15 scores, cystatin C>1.3 mg/L, cystatin C>1.3 mg/L+APACHE II>15 scores were the risk factors of AKI. Logistic regression analysis, however, showed that organ failures≥2, oliguria, cystatin C>1.3 mg/L +APACHE II>15 scores were the independent risk factors of AKI.

CONCLUSION:

Cystatin C>1.3 mg/L+APACHE II>15 scores is useful in predicting adverse clinical outcomes in patients with AKI.KEY WORDS: Intensive care unit, Acute kidney injury, Serum cystatin C, APACHE II, Oliguria, Retrospective studies, Prognosis     

Prognostic factors associated with hospital survival in comatose survivors of cardiac arrest

AIM: To identify patient, cardiac arrest and management factors associated with hospital survival in comatose survivors of cardiac arrest.METHODS: A retrospective, single centre study of comatose patients admitted to our intensive care unit (ICU) following cardiac arrest during the twenty year period between 1993 and 2012. This study was deemed by the Human Research Ethics Committee (HREC) of Monash Health to be a quality assurance exercise, and thus did not require submission to the Monash Health HREC (Research Project Application, No. 13290Q). The study population included all patients admitted to our ICU between 1993 and 2012, with a discharge diagnosis including “cardiac arrest”. Patients were excluded if they did not have a cardiac arrest prior to ICU admission (i.e., if their primary arrest was during their admission to ICU), or were not comatose on arrival to ICU. Our primary outcome measure was survival to hospital discharge. Secondary outcome measures were ICU and hospital length of stay (LOS), and factors associated with survival to hospital discharge.RESULTS: Five hundred and eighty-two comatose patients were admitted to our ICU following cardiac arrest, with 35% surviving to hospital discharge. The median ICU and hospital LOS was 3 and 5 d respectively. There was no survival difference between in-hospital and out-of-hospital cardiac arrests. Males made up 62% of our cardiac arrest population, were more likely to have a shockable rhythm (56% vs 37%, P < 0.001), and were more likely to survive to hospital discharge (40% vs 28%, P = 0.006). On univariate analysis, therapeutic hypothermia, regardless of method used (e.g., rapid infusion of ice cold fluids, topical ice, “Arctic Sun”, passive rewarming, “Bair Hugger”) and location initiated (e.g., pre-hospital, emergency department, intensive care) was associated with increased survival. There was however no difference in survival associated with target temperature, time at target temperature, location of initial cooling, method of initiating cooling, method of maintaining cooling or method of rewarming. Patients that survived were more likely to have a shockable rhythm (P < 0.001), shorter time to return of spontaneous circulation (P < 0.001), receive therapeutic hypothermia (P = 0.03), be of male gender (P = 0.006) and have a lower APACHE II score (P < 0.001). After multivariate analysis, only a shockable initial rhythm (OR = 6.4, 95%CI: 3.95-10.4; P < 0.01) and a shorter time to return of spontaneous circulation (OR = 0.95, 95%CI: 0.93-0.97; P < 0.01) was found to be independently associated with survival to hospital discharge.CONCLUSION: In comatose survivors of cardiac arrest, shockable rhythm and shorter time to return of spontaneous circulation were independently associated with increased survival to hospital discharge.     

Can admission serum cystatin C level be an early marker subclinical acute kidney injury in critical care patients?

Background In critical care patients, the diagnosis of subclinical acute kidney injury (AKI) might be difficult with measurements of serum creatinine and estimated glomerular filtration rate (eGFR). Their ‘sensitive kidneys’ can easily be affected from sepsis, underlying diseases, medications and volume status and if they can be detected earlier, some preventive measures might be taken. In this study we aimed to determine whether admission serum cystatin C (sCys-C) and other clinical parameters can identify subclinical AKI in medical intensive care unit (ICU) patients with normal creatinine-based eGFR at admission. Methods A prospective cohort study, performed in an adult ICU of a university hospital between January 2008 and March 2013. The blood samples were obtained within the first 24-48 hours of admission and sCys-C levels were analyzed with particle-enhanced immunonephelometric assay. AKI development was assessed according to RIFLE criteria. The cutoff value of sCys-C for the prediction of AKI was determined with receiver operating characteristic (ROC) curve analysis. Results A total of 72 patients were included in the study and 19 (26%) of them developed AKI. Among the patients with AKI admission sCys-C levels were significantly higher when compared with non-AKI patients (1.06?±?0.29 vs. 0.89?±?0.28 respectively, p?=?0.026). With ROC curve analysis, the threshold level for sCys-C was 0.94?mg/L with 63% sensitivity and 66% specificity [AUC: 0.67, p?=?0.026]. With logistic regression analysis ‘high sCys-C levels at admission’ (OR?=?4.73; 95%CI 1.03–21.5, p?=?0.044) was found as one of the independent variables for the prediction of AKI development, in addition to ‘being intubated before ICU admission’ (OR?=?10.2; 95%CI 1.72–60.4, p?=?0.01) and ‘hypotension during ICU follow-up’ (OR?=?12.3; 95%CI 2.5–60.1, p?=?0.002). Conclusion In this cohort of patients, a high sCys-C level at admission was found to be a predictor of subclinical AKI arising during their ICU stay. If supported with further studies, it might be used to provide more accurate and earlier knowledge about renal dysfunction and to take appropriate preventive measures.     

Prognostic factors in critically ill cancer patients admitted to the intensive care unit

Objective

The objective of this study is to identify factors predicting intensive care unit (ICU) mortality in cancer patients admitted to a medical ICU.

Patients and methods

We conducted a retrospective study in 162 consecutive cancer patients admitted to the medical ICU of a 1000-bed university hospital between January 2009 and June 2012. Medical history, physical and laboratory findings on admission, and therapeutic interventions during ICU stay were recorded. The study end point was ICU mortality. Logistic regression analysis was performed to identify independent risk factors for ICU mortality.

Results

The study cohort consisted of 104 (64.2%) patients with solid tumors and 58 patients (35.8%) with hematological malignancies. The major causes of ICU admission were sepsis/septic shock (66.7%) and respiratory failure (63.6%), respectively. Overall ICU mortality rate was 55 % (n = 89). The ICU mortality rates were similar in patients with hematological malignancies and solid tumors (57% vs 53.8%; P = .744). Four variables were independent predictors for ICU mortality in cancer patients: the remission status of the underlying cancer on ICU admission (odds ratio [OR], 0.113; 95% confidence interval [CI], 0.027-0.48; P = .003), Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.032-1.215; P = .007), sepsis/septic shock during ICU stay (OR, 8.94; 95% CI, 2.28-35; P = .002), and vasopressor requirement (OR 16.84; 95% CI, 3.98-71.24; P = .0001). Although Acute Physiology and Chronic Health Evaluation II score (OR, 1.30; 95% CI, 1.054-1.61; P = .014), admission through emergency service (OR, 0.005; 95% CI, 0.00-0.69; P = .035), and vasopressor requirement during ICU stay (OR, 140.64; 95% CI, 3.59-5505.5; P = .008) were independent predictors for ICU mortality in patients with hematological malignancies, Sequential Organ Failure Assessment score (OR, 1.83; 95% CI, 1.29-2.6; P = .001), lactate dehydrogenase level on admission (OR, 1.002; 95% CI, 1-1.005; P = .028), sepsis/septic shock during ICU stay (OR, 138.4; 95% CI, 12.54-1528.4; P = .0001), and complete or partial remission of the underlying cancer (OR, 0.026; 95% CI, 0.002-0.3; P = .004) were the independent risk factors in patients with solid tumors.

Conclusion

Intensive care unit mortality rate was 55% in our cancer patients, which suggests that patients with cancer can benefit from ICU admission. We also found that ICU mortality rates of patients with hematological malignancies and solid tumors were similar.     

Impact of type 2 diabetes on adenoma detection in screening colonoscopies performed in disparate populations

BACKGROUNDThe Black/African Ancestry (AA) population has a higher prevalence of type 2 diabetes mellitus (T2DM) and a higher incidence and mortality rate for colorectal cancer (CRC) than all other races in the United States. T2DM has been shown to increase adenoma risk in predominantly white/European ancestry (EA) populations, but the effect of T2DM on adenoma risk in Black/AA individuals is less clear. We hypothesize that T2DM has a significant effect on adenoma risk in a predominantly Black/AA population.AIMTo investigate the effect of T2DM and race on the adenoma detection rate (ADR) in screening colonoscopies in two disparate populations.METHODSA retrospective cohort study was conducted on ADR during index screening colonoscopies (age 45-75) performed at an urban public hospital serving a predominantly Black/AA population (92%) (2017-2018, n = 1606). Clinical metadata collected included basic demographics, insurance, body mass index (BMI), family history of CRC, smoking, diabetes diagnosis, and aspirin use. This dataset was combined with a recently reported parallel retrospective cohort data set collected at a suburban university hospital serving a predominantly White/EA population (87%) (2012-2015, n = 2882).RESULTSThe ADR was higher in T2DM patients than in patients without T2DM or prediabetes (35.2% vs 27.9%, P = 0.0166, n = 981) at the urban public hospital. Multivariable analysis of the combined datasets showed that T2DM [odds ratio (OR) = 1.29, 95% confidence interval (CI): 1.08-1.55, P = 0.0049], smoking (current vs never OR = 1.47, 95%CI: 1.18-1.82, current vs past OR = 1.32, 95%CI: 1.02-1.70, P = 0.0026), older age (OR = 1.05 per year, 95%CI: 1.04-1.06, P < 0.0001), higher BMI (OR = 1.02 per unit, 95%CI: 1.01-1.03, P = 0.0003), and male sex (OR = 1.87, 95%CI: 1.62-2.15, P < 0.0001) were associated with increased ADR in the combined datasets, but race, aspirin use and insurance were not.CONCLUSIONT2DM, but not race, is significantly associated with increased ADR on index screening colonoscopy while controlling for other factors.     

Adequate antibiotic therapy prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality

IntroductionIn patients with severe sepsis and septic shock as cause of Intensive Care Unit (ICU) admission, we analyze the impact on mortality of adequate antimicrobial therapy initiated before ICU admission.MethodsWe conducted a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock from January 2008 to September 2013. The primary end-point was in-hospital mortality. We considered two groups for comparisons: patients who received adequate antibiotic treatment before or after the admission to the ICU.ResultsA total of 926 septic patients were admitted to ICU, and 638 (68.8%) had available microbiological isolation: 444 (69.6%) received adequate empirical antimicrobial treatment prior to ICU and 194 (30.4%) after admission. Global hospital mortality in patients that received treatment before ICU admission, between 0-6h ICU, 6–12h ICU, 12–24h ICU and after 24 hours since ICU admission were 31.3, 53.2, 57.1, 50 and 50.8% (p<0.001). The multivariate analysis showed that urinary focus (odds ratio (OR) 0.20; 0.09–0.42; p<0.001) and adequate treatment prior to ICU admission (OR 0.37; 0.24–0.56; p<0.001) were protective factors whereas APACHE II score (OR 1.10; 1.07–1.14; p<0.001), septic shock (OR 2.47; 1.57–3.87; p<0.001), respiratory source (OR 1.91; 1.12–3.21; p=0.016), cirrhosis (OR 3.74; 1.60–8.76; p=0.002) and malignancy (OR 1.65; 1.02–2.70; p=0.042) were variables independently associated with in-hospital mortality. Adequate treatment prior to ICU was a protective factor for mortality in patients with severe sepsis (n=236) or in septic shock (n=402).ConclusionsThe administration of adequate antimicrobial therapy before ICU admission is decisive for the survival of patients with severe sepsis and septic shock. Our efforts should be directed to assure the correct administration antibiotics before ICU admission in patients with sepsis.     

行肠外营养治疗的ICU重症患者发生抗生素相关性腹泻的影响因素分析

目的分析行肠外营养治疗的ICU重症患者的临床资料,探讨其发生抗生素相关性腹泻(antibiotic-associated diarrhea,AAD)的影响因素。方法行肠外营养治疗的ICU重症患者177例,发生AAD者50例为AAD组,未发生AAD者127例为非AAD组。比较2组年龄,性别比例,合并高血压、糖尿病比率,ICU住院时间,入住ICU时白蛋白水平,急性生理与慢性健康评分Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)及益生菌、质子泵抑制剂、抗生素使用情况;多因素logistic回归分析行肠外营养治疗的ICU重症患者发生AAD的影响因素。结果177例患者AAD发生率为28.25%。AAD组年龄[(56.80±20.41)岁]大于非AAD组[(47.12±19.30)岁](P<0.05),ICU住院时间[(17.82±12.15)d]、抗生素使用时间[(13.08±8.84)d]长于非AAD组[(9.83±7.11)、(7.92±4.83)d](P<0.05),联合使用抗生素(72.00%)及联合使用3种抗生素比率(46.00%),加酶抑制剂类、抗真菌类、恶唑烷酮类及喹诺酮类抗生素使用比率(80.00%、58.00%、26.00%、28.00%)均高于非AAD组(43.31%、19.69%、62.99%、24.41%、12.60%、11.02%)(P<0.05)。多因素logistic回归分析结果显示,年龄(OR=1.020,95%CI:1.000~1.041,P=0.048)、ICU住院时间(OR=1.058,95%CI:1.007~1.113,P=0.026)、抗生素使用时间(OR=1.124,95%CI:1.062~1.189,P<0.001)、联合使用3种抗生素(OR=3.366,95%CI:1.655~6.848,P=0.001)、使用加酶抑制剂类抗生素(OR=2.350,95%CI:1.076~5.131,P=0.032)是行肠外营养治疗的重症患者发生AAD的影响因素。结论年龄、ICU住院时间、抗生素使用时间、联合使用3种抗生素与行肠外营养治疗的ICU重症患者发生AAD有关。     

血浆N末端B型钠尿肽前体对重症患者预后的预测价值研究

目的 探讨入重症监护病房(ICU)时血浆N末端B型钠尿肽前体(NT-pro-BNP)水平是否是预测重症患者预后的独立因子.方法 采用前瞻性、单中心、观察性研究方法.选择6个月内入本院ICU＞18岁的120例患者,最终有88例患者符合试验要求.血浆NT-pro-BNP样本在进入ICU时收集;计算进入ICU后24 h内急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)的最差值;入ICU后28 d患者生存状态为预测终点.结果 入ICU 28 d死亡35例,病死率为39.8%.88例患者血浆NT-pro-BNP水平(ng/L)为1221.7(78.7～5 500.0),生存组明显低于死亡组[781.8(78.7～5 066.6)比2 774.5(166.8～5 500.0),P＜0.01].男性NT-pro-BNP水平(ng/L)高于女性[1 585.5(103.7～5 100.0)比794.5(78.7～5 500.0),P＜0.05];性别与NT-pro-BNP水平有相关性(r=-0.224,P＜0.05).进入ICU时重度感染患者NT-pro-BNP水平(ng/L)较其他患者更高[3 416.1(103.7～5 100.0)比883.4(78.7～5 500.0),P＜0.01];入ICU时是否存在重度感染与NT-pro-BNP水平有相关性(r=0.285,P＜0.01).NT-pro-BNP和APACHE Ⅱ评分的受试者工作特征曲线(ROC曲线)下面积分别为0.734[95%可信区间(95%CI)0.628～0.840]和0.747(95%CI0.637～0.858).Logistic回归分析显示:入ICU时NT-pro-BNP水平＞1 418 ng/L和APACHE Ⅱ评分均可作为28 d生存状态预测的独立因子[相对比值比(OR)5.235,95%CI 1.819～15.071;OR 1.105,95%CI1.819～15.071].以入ICU时NT-pro-BNP最佳临界值1 418 ng/L为分界点进行生存分析,高于此值者生存率比低于此值者低(x2=16.9,P＜0.01).结论 入ICU时血浆NT-pro-BNP＞1 418 ng/L和APACHE Ⅱ评分可作为重症患者短期生存状态的预测因子;NT-pro-BNP值可能用来诊断或者鉴别重度感染患者.

Abstract：

Objective To investigate whether plasma N-terminal pro-B-type natriuretic peptide (NT-pro-BNP)as measured at admission to intensive care unit(ICU)is an independent predictor of mortality in critically ill patients. Methods A prospective observational study of patients in ICU was conducted. One hundred and twenty patients aged＞18 years were included during a 6-month period. Among them 88 patients were enrolled for the study. Plasma NT-pro-BNP samples were obtained at admission to ICU. The acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)score was calculated within 24hours after admission based on the worst values up to that point. The final evaluation was 28-day mortality.Results Thirty-five patients died within 28 days of ICU admission, the mortality was 39. 8%. In 88 patients, the mean plasma NT-pro-BNP levels(ng/L)were 1 221.7(78.7- 5 500.0), and that in survivor group was significantly lower than non-survivor group[781.8(78. 7 - 5 066. 6)vs. 2 774. 5(166.8 - 5 500.0), P＜0.01]. The mean NT-pro-BNP level(ng/L)in male patients was higher than that in females[1 585. 5(103.7 - 5 100. 0)vs. 794. 5(78. 7 - 5 500. 0), P＜0. 05]. There was correlation between gender and NT-pro-BNP levels(r=-0. 224, P＜0. 05). Patients admitted to the ICU because of a severe infection had higher levels of NT-pro-BNP(ng/L)compared with the rest of the cohorts[3 416.1(103. 7 -5 100.0)vs. 883. 4(78. 7 - 5 500. 0), P＜0.01]. There was correlation between severe infection at admission to ICU and NT-pro-BNP levels(r=0. 285, P＜0. 01). Areas under the receiver operating characteristic curves(ROC curves)of NT-pro-BNP and APACHE I score were 0. 734[95% confidence interval(95%CI)0. 628 - 0. 840]and 0. 747(95%CI 0. 637 - 0. 858), respectively. Logistic regression analysis showed that the NT-pro-BNP level ＞ 1 418 ng/L and the APACHE I score were independently associated with 28-day mortality[odds ratio(OR)5.235, 95%CI 1.819- 15.071; OR 1.105, 95%CI 1.819- 15.071]. WithI 418 ng/L of NT-pro-BNP as the cutoff value, survival rate was significantly lower in the patients with higher NT-pro-BNP level as compared with those with lower values at admission(x2= 16.9, P＜0. 01).Conclusion The ICU NT-pro-BNP level higher than 1 418 ng/L and APACHE Ⅱ score at admission are independent prognosis markers of early mortality. NT-pro-BNP might serve as a potent early diagnostic and prognostic marker in critically ill patients.     

危重孕产妇住重症监护病房时间延长的危险因素分析——北京市3家医院5年回顾性研究

目的 评估危重孕产妇重症监护病房(ICU)住院时间延长的危险因素.方法 回顾性分析2006年1月1日至2010年12月31日北京市3家医院ICU危重孕产妇的临床资料,包括患者的基本特征、转入ICU的疾病种类、急性生理学与慢性健康状况评分系统I(APACHE I)评分、发病至转入ICU时间、各种检查结果、治疗措施、ICU住院时间以及孕产妇病死率.采用单因素比较和多因素Logistic回归分析危重孕产妇ICU住院时间延长的危险因素.结果 5年内共有207例危重孕产妇收入ICU,占所有孕产妇的0.42%;平均年龄(31.74±2.32)岁,平均孕龄(34.86+4.72)周.其中4例孕产妇死亡,病死率1.93%.207例危重孕产妇中,138例为产科重症,69例并发严重内科疾病.转入ICU最常见的产科病因为产后大出血(42例,20.29%)和妊娠相关性高血压(36例,17.39%),其次为妊娠急性脂肪肝(AFLP,27例,13.04%)和产科弥散性血管内凝血(DIC,23例,11.11%);最常见的内科病因为急性心功能衰竭(26例,12.56%)和急性呼吸衰竭(22例,10.63%),其次为重症急性胰腺炎(SAP,11例,5.31%).109例患者(占52.66%)ICU住院时间延长(ICU滞留时间＞3 d).单因素分析显示,未行规律产前检查、血肌酐、凝血酶原时间国际标准化比值(INR)、氧合指数(PaO2/FiO2)、AFLP、产科DIC、SAP、机械通气、血管活性药物、血液净化治疗和发病至转入ICU时间＞24 h与ICU住院时间延长有关.多因素Logistic回归分析显示,未行规律产前检查[优势比(OR)1.68,95%可信区间(95%CI)1.14～2.69,P=0.011]、PaO2/FiO2(OR 4.73,95%CI 1.46～11.37,P=0.013)、AFLP(OR 3.21,95%CI 1.13～4.76,P=0.026)、产科DIC(OR 2.73,95%CI 1.28～4.02,P=0.018)、SAP(OR 4.78,95%CI 1.83～7.42,P=0.021)、血管活性药物(OR 1.96,95%CI 1.24～3.15,P=0.001)、血液净化治疗(OR 11.02,95%CI 3.04～58.02,P=0.015)和发病至转入ICU时间＞24 h(OR 2.04,95%CI 1.21～4.25,P＜0.001)是ICU住院时间延长的独立危险因素.结论 危重孕产妇ICU住院时间延长的发生率较高.临床上可以根据危险因素预测危重孕产妇ICU住院时间延长,加强规律产前检查、避免产科及内科严重并发症;发病后尽快转入ICU并在ICU内加强各器官功能支持可能有助于缩短ICU住院时间.     

Outcomes of critically ill cancer patients with Acinetobacter baumannii infection

AIM: To describe the intensive care unit(ICU) outcomes of critically ill cancer patients with Acinetobacter baumannii(AB) infection.METHODS: This was an observational study that included 23 consecutive cancer patients who acquired AB infections during their stay at ICU of the National Cancer Institute of Mexico(INCan), located in Mexico City. Data collection took place between January 2011, and December 2012. Patients who had AB infections before ICU admission, and infections that occurred during the first 2 d of ICU stay were excluded. Data were obtained by reviewing the electronic health record of each patient. This investigation was approved by the Scientific and Ethics Committees at INCan. Because of its observational nature, informed consent of the patients was not required.RESULTS: Throughout the study period, a total of 494 critically ill patients with cancer were admitted to the ICU of the INCan, 23(4.6%) of whom developed AB infections. Sixteen(60.9%) of these patients had hematologic malignancies. Most frequent reasons for ICU admission were severe sepsis or septic shock(56.2%) and postoperative care(21.7%). The respiratory tract was the most frequent site of AB infection(91.3%). The most common organ dysfunction observed in our group of patients were the respiratory(100%), cardiovascular(100%), hepatic(73.9%) and renal dysfunction(65.2%). The ICU mortality of patients with 3 or less organ system dysfunctions was 11.7%(2/17) compared with 66.6%(4/6) for the group of patients with 4 or more organ system dysfunctions(P = 0.021). Multivariate analysis identified blood lactate levels(BLL) as the only variable independently associated with inICU death(OR = 2.59, 95%CI: 1.04-6.43, P = 0.040). ICU and hospital mortality rates were 26.1% and 43.5%, respectively.CONCLUSION: The mortality rate in critically ill patients with both HM, and AB infections who are admitted to the ICU is high. The variable most associated with increased mortality was a BLL ≥ 2.6 mmol/L in the first day of stay in the ICU.