Agreement between bedside blood and plasma glucose measurement in the ICU setting

STUDY OBJECTIVE: To assess the agreement between bedside glucose (bGlu) measurements and laboratory plasma glucose (pGlu) measurements in the ICU setting. DESIGN: Retrospective study. SETTING: ICU of a tertiary academic medical center. PATIENTS: One hundred ninety-seven patients admitted to the ICU from January through December 2002 who underwent 816 simultaneous bGlu and pGlu measurements. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: To calculate the agreement between the two methods of glucose measurement, the mean difference was obtained, and the limits of the agreement were calculated as the mean difference +/- 2 SDs. On 767 occasions, the mean bGlu was 159 mg/dL and the mean pGlu was 151 mg/dL (p < 0.001). The mean difference between the two techniques was 7.9 mg/dL (SD, 17.6 mg/dL), and the limits of agreement were + 43.1 and -27.2. On 31 occasions, the bGlu was reported as > 400 mg/dL, and in these cases the mean pGlu was 423 mg/dL (range, 300 to 900 mg/dL). On 18 occasions, the bGlu was reported as < 50 mg/dL, and in these cases the mean pGlu was 66.9 mg/dL (range, 13 to 198 mg/dL). CONCLUSIONS: On average, bGlu provides a reasonable estimate for pGlu. However, for the individual patient, bGlu gives an unreliable estimate for pGlu. All of those taking care of critically ill patients should be aware of the limitations of bedside glucometry.     

Obstructive sleep apnea syndrome is associated with some components of metabolic syndrome

BACKGROUND: Obesity, hypertension, dyslipidemia, and hyperglycemia are prevalent in obstructive sleep apnea syndrome (OSAS). Metabolic syndrome, however, is defined by visceral fat obesity plus at least two of these factors. However, whether OSAS contributes to the development of metabolic syndrome has not been defined. We investigated whether the components of metabolic syndrome were associated with OSAS in nonobese patients. METHODS: We investigated the occurrence of hypertension, dyslipidemia, and hyperglycemia in 42 men with OSAS and 52 men without OSAS matched for age, body mass index (BMI), and visceral fat accumulation. RESULTS: Although serum levels of triglycerides, high-density lipoprotein cholesterol, and diastolic BP did not differ significantly between the two groups, fasting blood glucose (111 +/- 6 mg/dL vs 93 +/- 3 mg/dL) [mean +/- SE] and the percentage of hypertensive patients (45% vs 15%) were significantly higher in the group with OSAS. In addition, a significantly higher percentage of patients with OSAS (19% vs 4%) had at least two of the following: hypertension, hyperglycemia, and dyslipidemia. Logistic regression analysis showed that the apnea-hypopnea index value was the predictor of number of metabolic syndrome parameters such as hypertension, hyperglycemia, and dyslipidemia, while BMI and lowest arterial oxygen saturation during sleep did not. CONCLUSION: Independent of visceral fat obesity, OSAS was associated with hypertension, dyslipidemia, and hyperglycemia. It is possible that OSAS may predispose even nonobese patients to the development of metabolic syndrome.     

Glycaemic control and hypoglycaemia with insulin glargine 300 U/mL versus insulin glargine 100 U/mL in insulin-naïve people with type 2 diabetes: 12-month results from the EDITION 3 trial

AimTo explore if efficacy and safety findings for insulin glargine 300 U/mL (Gla-300) versus insulin glargine 100 U/mL (Gla-100), observed over 6 months in insulin-naïve people with type 2 diabetes, are maintained after 12 months.MethodsEDITION 3 was a phase 3a, randomized, multicentre, open-label, parallel-group, treat-to-target study of once-daily Gla-300 versus Gla-100 (target fasting self-monitored plasma glucose, 4.4–5.6 mmol/L [80–100 mg/dL]). Participants completing the initial 6-month treatment phase continued their previously allocated basal insulin.ResultsOf 878 participants randomized, 337/439 (77%) and 314/439 (72%) assigned to Gla-300 and Gla-100, respectively, completed 12 months of treatment. Improved glycaemic control was sustained until 12 months in both treatment groups, with similar reductions in HbA_1c from baseline to month 12 (difference: −0.08 [95% confidence interval (CI): −0.23 to 0.07] % or −0.9 [−2.5 to 0.8] mmol/mol). Relative risk of experiencing ≥ 1 confirmed (≤ 3.9 mmol/L [≤ 70 mg/dL]) or severe hypoglycaemic event with Gla-300 versus Gla-100 was 0.86 (95% CI: 0.69 to 1.07) at night and 0.92 (0.82 to 1.03) at any time of day. For events with a glycaemic threshold of < 3.0 mmol/L (< 54 mg/dL) these numbers were 0.76 (0.49 to 1.19) and 0.66 (0.50 to 0.88). A similar pattern was seen for documented symptomatic events. No between-group differences in adverse events were identified.ConclusionOver 12 months, Gla-300 treatment was as effective as Gla-100 in reducing HbA_1c in insulin-naïve people with type 2 diabetes, with lower overall risk of hypoglycaemia at the < 3.0 mmol/L threshold.     

Variation in ICU risk-adjusted mortality: impact of methods of assessment and potential confounders

BACKGROUND: Federal and state agencies are considering ICU performance assessment and public reporting; however, an accurate method for measuring performance must be selected. In this study, we determine whether a substantial variation in ICU mortality performance still exists in modern ICUs, and compare the predictive accuracy, reliability, and data burden of existing ICU risk-adjustment models. METHODS: A retrospective chart review of 11,300 ICU patients from 35 California hospitals from 2001 to 2004 was performed. We calculated standardized mortality ratios (SMRs) for each hospital using the mortality probability model III (MPM(0) III), the simplified acute physiology score (SAPS) II, and the acute physiology and chronic health evaluation (APACHE) IV risk-adjustment models. We compared discrimination, calibration, data reliability, and abstraction time for the models. RESULTS: Regardless of the model used, there was a large variation in SMRs among the ICUs studied. The discrimination and calibration were adequate for all risk-adjustment models. APACHE IV had the best discrimination (area under the receiver operating characteristic curve [AUC], 0.892) compared to MPM(0) III (AUC, 0.809), and SAPS II (AUC, 0.873; p < 0.001). The models differed substantially in data abstraction times, as follows: MPM(0)III, 11.1 min (95% confidence interval [CI], 8.7 to 13.4); SAPS II, 19.6 min (95% CI, 17.0 to 22.2); and APACHE IV, 37.3 min (95% CI, 28.0 to 46.6). CONCLUSIONS: We found substantial variation in the ICU risk-adjusted mortality rates that persisted regardless of the risk-adjustment model. With unlimited resources, the APACHE IV model offers the best predictive accuracy. If constrained by cost and manual data collection, the MPM(0) III model offers a viable alternative without a substantial loss in accuracy.     

Platelet count decline: an early prognostic marker in critically ill patients with prolonged ICU stays

BACKGROUND: Thrombocytopenia is common in ICU patients. The objective of this study was to evaluate possible links between declining platelet counts early in the ICU stay and survival. METHODS: All patients who were admitted to the ICU for at least 5 days and had no thrombocytopenia at the time of admission were included in the study. A multivariable logistic regression model, with hospital mortality as the outcome variable, was built. RESULTS: We included 1,077 patients in the study. At ICU admission, the median platelet count was not significantly different in survivors (256 x 10(9) cells/L; interquartile range [IQR], 206 to 330 x 10(9) cells/L) and nonsurvivors (262 x 10(9) cells/L; 211 to 351 x 10(9) cells/L). Median simplified acute physiology scores II (SAPS II) at ICU admission was worse in nonsurvivors than in survivors (50 [IQR, 37 to 63] vs 37 [IQR, 27 to 48], respectively; p < 0.0001), as was the mean (+/- SD) sequential organ failure assessment (SOFA) score on day 3 (6.3 +/- 3.24 vs 4 +/- 2.8, respectively; p < 0.0001). Absolute platelet counts were lowest on day 4, but differed significantly between survivors and nonsurvivors only on day 7. Conversely, any percentage decline in platelet counts from 10 to 60% on day 4 was significantly associated with mortality. By multivariable analysis, a 30% decline in platelet count independently predicted death (odds ratio, 1.54; 95% confidence interval, 1.12 to 2.14; p = 0.008), in addition to increasing or stable SOFA scores from ICU admission to day 4, older age, male gender, ICU admission for coma, worse SAPS II score at ICU admission, transfer from another ward, and comorbidity. CONCLUSION: In patients who spend > 5 days in the ICU and have normal platelet counts at ICU admission, a decline in platelet counts provides prognostic information. This parameter deserves to be included in new scoring systems.     

Usefulness of the plasma glucose concentration-to-HbA1c ratio in predicting clinical outcomes during acute illness with extreme hyperglycaemia

AimsTo evaluate the correlation between the plasma glucose-to-glycated haemoglobin ratio (GAR) and clinical outcome during acute illness.MethodsThis retrospective observational cohort study enrolled 661 patients who visited the emergency department of our hospital between 1 July 2008 and 30 September 2010 with plasma glucose concentrations > 500 mg/dL. Systolic blood pressure, heart rate, white blood cells, neutrophils, haematocrit, blood urea nitrogen, serum creatinine, liver function and plasma glucose concentration were recorded at the initial presentation to the emergency department. Data on glycated haemoglobin over the preceding 6 months were reviewed from our hospital database. The glucose-to-HbA_1c ratio (GAR) was calculated as the plasma glucose concentration divided by glycated haemoglobin.ResultsThe GAR of those who died was significantly higher than that of the survivors (81.0 ± 25.9 vs 67.6 ± 25.0; P < 0.001). There was a trend towards a higher 90-day mortality rate in patients with higher GARs (log-rank test P < 0.0001 for trend). On multivariate Cox regression analysis, the GAR was significantly related to 90-day mortality (hazard ratio [HR] for 1 standard deviation [SD] change: 1.41, 95% confidence interval [CI]: 1.22–1.63; P < 0.001), but not to plasma glucose (HR: 0.89, 95% CI: 0.70–1.13; P = 0.328). Rates of intensive care unit (ICU) admission and mechanical ventilator use were also higher in those with higher GARs.ConclusionGAR independently predicted 90-day mortality, ICU admission and use of mechanical ventilation. It was also a better predictor of patient outcomes than plasma glucose alone in patients with extremely high glucose levels.     

Plasma aldosterone is related to severity of obstructive sleep apnea in subjects with resistant hypertension

OBJECTIVE: Obstructive sleep apnea (OSA) and primary aldosteronism are common in subjects with resistant hypertension; it is unknown, however, if the two disorders are causally related. This study relates plasma aldosterone and renin levels to OSA severity in subjects with resistant hypertension, and in those with equally severe OSA but without resistant hypertension serving as control subjects. METHODS: Seventy-one consecutive subjects referred to the University of Alabama at Birmingham (UAB) for resistant hypertension (BP uncontrolled on three medications) and 29 control subjects referred to UAB Sleep Disorders Center for suspected OSA were prospectively evaluated by an early morning plasma aldosterone concentration (PAC) and renin level, and by overnight, attended polysomnography. RESULTS: OSA (apnea-hypopnea index [AHI] > or = 5/h) was present in 85% of subjects with resistant hypertension. In these subjects, PAC correlated with AHI (rho = 0.44, p = 0.0002) but not renin concentration. Median PAC was significantly lower in control subjects compared to subjects with resistant hypertension (5.5 ng/dL vs 11.0 ng/dL, p < 0.05) and not related to AHI. In male subjects compared to female subjects with resistant hypertension, OSA was more common (90% vs 77%) and more severe (median AHI, 20.8/h vs 10.8/h; p = 0.01), and median PAC was significantly higher (12.0 ng/dL vs 8.8 ng/dL, p = 0.006). CONCLUSION: OSA is extremely common in subjects with resistant hypertension. A significant correlation between PAC and OSA severity is observed in subjects with resistant hypertension but not in control subjects. While cause and effect cannot be inferred, the data suggest that aldosterone excess may contribute to OSA severity.     

Prognosis of lung cancer patients with life-threatening complications

BACKGROUND: The management of patients with lung cancer has improved recently, and many of them will require admission to the ICU. The aims of this study were to determine hospital mortality and to identify risk factors for death in a large cohort of critically ill patients. METHODS: Cohort study in two ICUs specialized in the management of patients with cancer, in France and Brazil. RESULTS: Of the 143 patients (mean age, 61.6 +/- 9.9 years [+/- SD]), 25 patients (17%) had small cell lung cancer and 118 patients (83%) had non-small cell lung cancer. The main reasons for ICU admission were sepsis (44%) and acute respiratory failure (31%). Mechanical ventilation (MV) was used in 100 patients (70%), including 38 patients in whom lung cancer was considered a reason for MV. Hospital mortality was 59% overall and 69% in patients receiving MV. By multivariate logistic regression, airway infiltration or obstruction by cancer, number of organ failures, cancer recurrence or progression, and severity of comorbidities were associated with increased mortality. CONCLUSIONS: The improved survival previously reported in patients with cancer admitted to the ICU seems to extend to patients with lung cancer, including those who need MV. Mortality increased with the number of organ failures, severity of comorbidities, and presence of respiratory failure due to cancer progression. The type of the cancer per se was not associated with mortality and, therefore, should not be factored into ICU triage decisions.     

Transferring critically ill patients out of hospital improves the standardized mortality ratio: a simulation study

BACKGROUND: Transferring critically ill patients to other acute care hospitals may artificially impact benchmarking measures. We sought to quantify the effect of out-of-hospital transfers on the standardized mortality ratio (SMR), an outcome-based measure of ICU performance. METHODS: We performed a cohort study and Monte Carlo simulation using data from 85 ICUs participating in the acute physiology and chronic health evaluation (APACHE) clinical information system from 2002 to 2003. The SMR (observed divided by expected hospital mortality) was calculated for each ICU using APACHE IV risk adjustment. A set number of patients was randomly assigned to be transferred out alive rather than experience their original outcome. The SMR was recalculated, and the mean simulated SMR was compared to the original. RESULTS: The mean (+/- SD) baseline SMR was 1.06 +/- 0.19. In the simulation, increasing the number of transfers by 2% and 6% over baseline decreased the SMR by 0.10 +/- 0.03 and 0.14 +/- 0.03, respectively. At a 2% increase, 27 ICUs had a decrease in SMR of > 0.10, and two ICUs had a decrease in SMR of > 0.20. Transferring only one additional patient per month was enough to create a bias of > 0.1 in 27 ICUs. CONCLUSIONS: Increasing the number of acute care transfers by a small amount can significantly bias the SMR, leading to incorrect inference about ICU quality. Sensitivity to the variation in hospital discharge practices greatly limits the use of the SMR as a quality measure.     

Improving the ICU: part 1

ICUs are a vital component of modern health care. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasizes the need to assess and improve ICU systems and processes. This is the first part of a two-part treatise. It discusses existing problems in ICU care, and the methods for defining and measuring ICU performance.     

Effects of hypercapnia on BP in hypoalbuminemic and Nagase analbuminemic rats

STUDY OBJECTIVE: To determine if animals with abnormally low albumin levels are more susceptible to the effects of hypercapnia on BP compared to normal animals. DESIGN: Prospective, controlled laboratory experiment. SETTING: University research laboratory. Animals: Eighteen male Sprague-Dawley rats: 6 rats 10 to 12 weeks old (young Sprague-Dawley [YSD]), 6 rats 6 to 9 months old (old Sprague-Dawley [OSD]), and 6 rats 10 to 12 weeks old (Nagase analbuminemic mutant Sprague-Dawley [NAR]). METHODS: Under general anesthesia and paralysis, we varied the Paco(2) by changing the respiratory rate on mechanical ventilation. Mean arterial pressure (MAP) was monitored in a continuous fashion. We obtained arterial blood for blood gas and electrolyte analysis, and nitric oxide (NO) production. RESULTS: OSD rats had reduced serum albumin, while NAR rats were analbuminemic. Although NAR animals had a decreased buffer capacity compared to age-matched control animals (0.010 vs 0.013, p < 0.05), the MAP decreased in an identical fashion in all three groups. NO production increased with hypercapnia but was similar in all three groups. However, NAR rats had consistently higher plasma strong ion gap (2.8 to 4.1 mEq/L greater) compared to either YSD or OSD rats (p < 0.01), and baseline strong ion difference (mean +/- SD) was significantly lower in NAR rats (28.7 +/- 2.1 mEq/L) compared to either YSD rats (33.0 +/- 5.1 mEq/L) or OSD rats (31.2 +/- 5.1 mEq/L) [p < 0.05]. CONCLUSIONS: These findings suggest that analbuminemic or hypoalbuminemic rats are not more susceptible to hypercapnia-induced hemodynamic instability. Baseline values for apparent strong ion difference are lower in NA rats consistent with a reduced buffer base resulting from analbuminemia.     

Ventilator settings and outcome of respiratory failure in chronic interstitial lung disease

BACKGROUND: While patients with interstitial lung disease (ILD) may be particularly susceptible to ventilator-induced lung injury, ventilator strategies have not been studied in this group of patients. PURPOSES: To describe the clinical course and outcome of patients with ILD and acute respiratory failure in relation to ventilatory parameters. METHODS: We retrospectively identified a cohort of ventilated patients with ILD who had been admitted to five ICUs at a single institution. We analyzed demographic data, pulmonary function test results, severity of illness, and the parameters of continuous ventilation for the initial 24 h after admission to the ICU. Primary outcomes were survival to hospital discharge and 1-year survival. Main results: Of 94 patients with ILD, 44 (47%) survived to hospital discharge and 39 (41%) were alive at 1 year. Nonsurvivors were less likely to be postoperative, had higher severity of illness, and were ventilated at higher airway pressures and lower tidal volumes. Step changes in positive end-expiratory pressure (PEEP) of > 10 cm H(2)O were attempted in 20 patients and resulted in an increase in plateau pressure (median difference, + 16 cm H(2)O; interquartile range [IQR], 9 to 24 cm H(2)O) and a decrease in respiratory system compliance (median difference, - 0.28 mL/kg/cm H(2)O; IQR, - 0.43 to - 0.13 mL/kg/cm H(2)O). The Cox proportional hazards model revealed that high PEEP (hazard ratio, 4.72; 95% confidence interval [CI], 2.06 to 11.15), acute physiology and chronic health evaluation (APACHE) III score predicted mortality (hazard ratio 1.33; 95% CI, 1.18 to 1.50), age (hazard ratio, 1.03; 95% CI, 1 to 1.05), and low Pao(2)/fraction of inspired oxygen ratio (hazard ratio, 0.96; 95% CI, 0.92 to 0.99) to be independent determinants of survival. CONCLUSION: Both severity of illness and high PEEP settings are associated with the decreased survival of patients with ILD who are receiving mechanical ventilation.     

Effect of decisions to withhold life support on prolonged survival

BACKGROUND: The effect on long-term mortality of decisions made to withhold life-supporting therapies (LST) for critically ill patients is unclear. We hypothesized that mortality 60 days after ICU admission is not influenced by a decision to withhold use of LST in the context of otherwise providing all indicated care. METHODS: We studied 2,211 consecutive, initial admissions to the adult, medical ICU of a university-affiliated teaching hospital. To achieve balanced groups for comparing outcomes, we created a multivariable regression model for the probability (propensity score [PS]) of having an order initiated in the ICU to withhold LST. Each of the 201 patients with such an order was matched to the patient without such an order having the closest PS; mortality rates were compared between the matched pairs. Cox survival analysis was performed to extend the main analysis. RESULTS: The matched pairs were well balanced with respect to all of the potentially confounding variables. Sixty days after ICU admission, 50.5% of patients who had an order initiated in the ICU to withhold life support had died, compared to 25.8% of those lacking such orders (risk ratio, 2.0; 95% confidence interval, 1.5 to 2.6). Survival analysis indicated that the difference in mortality between the two groups continued to increase for approximately 1 year. CONCLUSION: Contrary to our hypothesis, decisions made in the ICU to withhold LST were associated with increased mortality rate to at least 60 days after ICU admission.     

Quality of dying and death in two medical ICUs: perceptions of family and clinicians

OBJECTIVE: We compared perceptions of the quality of dying and death in the ICU across nurses, resident physicians, attending physicians, and family members. The aim was to obtain a surrogate assessment of the quality of the dying process and examine differences in the perceptions of different types of raters. DESIGN: Cross-sectional survey of family members and ICU clinicians conducted following the death of enrolled patients. SETTING: Two medical ICUs at academic tertiary care medical centers. PATIENTS: Patients dying in the ICU (n = 68). MEASUREMENTS AND RESULTS: The previously validated Quality of Dying and Death (QODD) instrument was modified for use in the ICU. Within 48 h of the time of death, the nurse, resident, and attending physician caring for the patient were asked to complete the QODD. One month following the death, a designated family member was contacted and the QODD was administered on the telephone. Family members and attending physicians gave the most favorable ratings of death, while nurses and residents provided less favorable ratings. Significant differences between these groups were notable (p < 0.01) on items related to patient autonomy: maintaining dignity, being touched by loved ones, and the overall quality of death. CONCLUSIONS: The perception of dying and death in the ICU varies considerably between nurses, attending physicians, resident physicians, and family members. Further studies are needed to explain these differences and determine the utility of the ICU QODD instrument for assessing and improving the quality of end-of-life care in the ICU.     

Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial

OBJECTIVE: To determine the effects of low-dose prolonged methylprednisolone infusion on lung function in patients with early severe ARDS. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: ICUs of five hospitals in Memphis. PARTICIPANTS: Ninety-one patients with severe early ARDS (相似文献   

Trends in end-of-life ICU use among older adults with advanced lung cancer

BACKGROUND: There is increasing concern about the appropriateness of intensive medical care near the end of life in ICUs throughout the United States. As a result of hospice expansion in the 1990s, we hypothesized that ICU use decreased over time in older adults with advanced lung cancer. METHODS: Retrospective analysis using the linked Surveillance, Epidemiology and End Results Medicare database. There were 45,627 Medicare beneficiaries > or = 66 years of age with confirmed stage IIIB or IV lung cancer between January 1, 1992, and December 31, 2002, who died within a year of their cancer diagnosis from 1993 through 2002. RESULTS: ICU use in the last 6 months of life increased from 17.5% in 1993 to 24.7% in 2002 (p < 0.001). After adjusting for patient characteristics, there was a 6.6% annual increase in ICU use from 1993 to 2002. During the same period, hospice use had risen from 28.8 to 49.9% (p < 0.001). A total of 6.2% of patients received both end-of-life ICU care and hospice care, a percentage that increased over time. The total health-care cost for Medicare fee-for-service patients during last 6 months was $40,929 for ICU users and $27,160 for non-ICU users (p < 0.001). CONCLUSION: Despite increasing hospice use, ICU utilization among older adults dying with advanced lung cancer continued to rise in the United States during the 1990s.     

Use of B-type natriuretic peptide in the risk stratification of acute exacerbations of COPD

BACKGROUND: In patients with COPD, prognosis might be determined at least in part by the extent of cardiac stress induced by hypoxia and pulmonary arterial hypertension. METHODS: B-type natriuretic peptide (BNP), a quantitative marker of cardiac stress, was determined in 208 consecutive patients presenting to the emergency department with an acute exacerbation of COPD (AECOPD). The accuracy of BNP to predict death at a 2-year follow-up was evaluated as the primary end point. The need for intensive care and in-hospital mortality were determined as secondary end points. RESULTS: BNP levels were significantly elevated during the acute exacerbation compared to recovery (65 pg/mL; interquartile range [IQR], 34 to 189 pg/mL; vs 45 pg/mL; IQR, 25 to 85 pg/mL; p < 0.001), particularly in those patients requiring ICU treatment (105 pg/mL; IQR, 66 to 553 pg/mL; vs 60 pg/mL; IQR, 31 to 169 pg/mL; p = 0.007). In multivariate Cox regression analysis, BNP accurately predicted the need for ICU care (hazard ratio, 1.13; 95% confidence interval [CI], 1.03 to 1.24 for an increase in BNP of 100 pg/mL; p = 0.008). In a receiver operating characteristic analysis to evaluate the potential of BNP levels to predict short-term and long-term mortality rates, areas under the curve were 0.55 (SD, 0.71; 95% CI, 0.41 to 0.68) and 0.56 (SD, 0.53; 95% CI, 0.45 to 0.66, respectively). CONCLUSIONS: In patients with AECOPD, BNP levels independently predict the need for intensive care. However, BNP levels failed to adequately predict short-term and long-term mortality rates in AECOPD patients.     

Improving the ICU: part 2

ICUs are a vital but troubled component of modern health-care systems. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance, to a systems-oriented approach that emphasizes the need to assess and improve the ICU systems and processes that hinder the ability of individuals to perform their jobs well. This second part of a two-part treatise establishes a practical framework for performance improvement and examines specific strategies to improve ICU performance, including the use of information systems.     

Glycaemic control and hypoglycaemia with insulin glargine 300 U/mL compared with glargine 100 U/mL in Japanese adults with type 2 diabetes using basal insulin plus oral anti-hyperglycaemic drugs (EDITION JP 2 randomised 12-month trial including 6-month extension)

AimsTo compare insulin glargine 300 U/mL (Gla-300) with glargine 100 U/mL (Gla-100) in Japanese adults with uncontrolled type 2 diabetes on basal insulin and oral anti-hyperglycaemic drugs over 12 months.MethodsEDITION JP 2 was a randomised, open-label, phase 3 study. Following a 6-month treatment period, participants continued receiving previously assigned once daily Gla-300 or Gla-100, plus oral anti-hyperglycaemic drugs, in a 6-month extension period. Glycaemic control, hypoglycaemia and adverse events were assessed.ResultsThe 12-month completion rate was 88% for Gla-300 and 96% for Gla-100, with comparable reasons for discontinuation. Mean HbA_1c decrease from baseline to month 12 was 0.3% in both groups. Annualised rates of confirmed (≤ 3.9 mmol/L [≤ 70 mg/dL]) or severe hypoglycaemia were lower with Gla-300 than Gla-100 (nocturnal [00:00–05:59 h]: rate ratio 0.41; 95% confidence interval: 0.18 to 0.92; anytime [24 h]: rate ratio 0.64; 95% confidence interval: 0.44 to 0.94). Cumulative number of hypoglycaemic events was lower with Gla-300 than Gla-100. Adverse event profiles were comparable between treatments.ConclusionOver 12 months, Gla-300-treated participants achieved sustained glycaemic control and experienced less hypoglycaemia, particularly at night, versus Gla-100, supporting 6-month results.     

Outcome of patients with small-vessel vasculitis admitted to a medical ICU

PURPOSES: This study aims to describe the clinical course and prognostic factors of patients with small-vessel vasculitis admitted to a medical ICU. METHODS: We reviewed the clinical records of 38 patients with small-vessel vasculitis admitted consecutively to the ICU between January 1997 and May 2004. The APACHE (acute physiology and chronic health evaluation) III prognostic system was used to determine the severity of illness on the first ICU day; the sequential organ failure assessment (SOFA) score was used to measure organ dysfunction, and the Birmingham vasculitis activity score for Wegener granulomatosis (BVAS/WG) was used to assess vasculitis activity. Outcome measures were the 28-day mortality and ICU length of stay. RESULTS: Nineteen patients (50%) had Wegener granulomatosis, 16 patients (42%) had microscopic polyangiitis, 2 patients had CNS vasculitis, and 1 patient had Churg-Strauss syndrome. Reasons for ICU admission included alveolar hemorrhage in 14 patients (37%), sepsis in 5 patients (13%), seizures in 3 patients (8%), and pneumonia in 2 patients (5%). The median ICU length of stay was 4.0 days (interquartile range, 2.0 to 6.0 days). The APACHE III score was lower in survivors than nonsurvivors (p = 0.010). The predicted hospital mortality was 54% for nonsurvivors and 21% for survivors (p = 0.0038). The mean SOFA score was 11.6 (SD, 2.6) in nonsurvivors, compared to 6.9 (SD, 2.4) in survivors (p = 0.0004). Mean BVAS/WG scores were 8.6 (SD, 3.6) in nonsurvivors and 4.7 (SD, 4.6) in survivors (p = 0.0889). Twenty-six percent of the patients received invasive mechanical ventilation, and 33% underwent dialysis. The 28-day and 1-year mortality rates were 11% and 29%, respectively. CONCLUSIONS: The mortality of patients with small-vessel vasculitis admitted to the ICU is lower than predicted, and alveolar hemorrhage is the most common reason for ICU admission.