Diabetes team consultation: impact on length of stay of diabetic patients admitted to a short-stay unit

OBJECTIVE: To assess the impact of endocrinology team consultation on hospital stay and clinical outcomes of diabetic patients admitted with a primary non-diabetes-related diagnosis in a short stay unit (SSU). METHODS: Patients admitted to the SSU between 2001 and 2005. Between 2001 and 2003 there was no endocrinology team consultation available and the management of hyperglycemia was handled by the SSU team alone. From 2003 until 2005 an endocrinology team was in charge of diabetes care. We compared in both periods: prevalence of diabetes, length of hospital stay, mortality, early readmissions and number of patients requiring conventional hospitalization. RESULTS: In period 2001-2003, 1023 patients were admitted, among which 212 were diabetic (20.7%). Over the years 2003-2005, 892 patients were hospitalized, 223 were diabetic (25%). Clinical characteristics of diabetic patients from both periods were comparable, but glycaemia at admission was higher on the second period (217 mg/dl versus 198 mg/dl). The length of stay of diabetic patients in the second period decreased from 5.49 to 4.90 days. There were no significant differences in mortality (1.4% versus 0.4%) or in early re-admissions among the two periods. CONCLUSIONS: The intervention of a diabetes team diminished the average length of stay of diabetic patients.     

在院发生与新入院急性心肌梗死的对比分析

目的 对比在院发生急性心肌梗死（AMI）与新入院AMI患者的发病、治疗及预后特点.方法 记录2013年1月至2014年1月中国人民解放军第422医院AMI患者的发病、治疗及预后信息,根据是否为住院期间发生的AMI,分为在院组和新入院组,对比两组基线资料、治疗和预后指标,分析其相关因素.结果 共纳入105例患者,新入院组90例,在院组15例,在院与新入院发生AMI患者的年龄、性别、高血压、糖尿病、高脂血症等比较,差异均无统计学意义（P＞0.05）.在院组患者重要脏器受累较新入院组多（P＜0.001）,其中基础呼吸系统疾病、脑疾病和运动功能不全比较,差异均有统计学意义（P＜0.05）.在院组患者严重电解质紊乱7例（46.7％）,新入院组21例（23.3％）,差异无统计学意义（P=0.058）.在院组患者死亡7例（46.7％）,新入院组死亡6例（6.7％）,差异有统计学意义（P＜0.001）.在院组行经皮冠状动脉介入治疗（PCI）的患者2例（13.3％）,新入院组42例（46.7％）,差异有统计学意义（P=0.027）,症状发作时间过长和家属拒绝为主要原因.结论 与新入院AMI比较,在院患者发生AMI预后差,死亡率高,可能与衰竭器官多、对介入治疗态度消极相关.     

Outcome predictors of cirrhosis patients admitted to the intensive care unit

OBJECTIVE: To evaluate outcome predictors of patients with cirrhosis admitted to an intensive care unit (ICU). METHODS: One hundred and twenty-nine consecutive patients with cirrhosis admitted to the ICU at a tertiary care transplant centre in Saudi Arabia between March 1999 and December 2000 were entered prospectively in an ICU database. Liver transplantation patients and readmissions to the ICU were excluded. The following data were documented: demographic features, severity of illness measures, parameters of organ failure, presence of gastrointestinal bleeding, and sepsis. The need for mechanical ventilation, renal replacement therapy and pulmonary artery catheter placement was recorded. The primary endpoint was hospital outcome. RESULTS: Cirrhotic patients admitted to the ICU had high hospital mortality (73.6%). However, the actual mortality was not significantly different from the predicted mortality using prediction systems. There was an association between the number of organs failing and mortality. Coma and acute renal failure emerged as independent predictors of mortality. All patients who were monitored with pulmonary artery catheterisation in this study died. Patients requiring mechanical ventilation and renal replacement therapy had very high mortalities (84% and 89%, respectively). All 13 cirrhotic patients admitted to ICU immediately post-cardiac arrest in this study died. CONCLUSIONS: Cirrhotic patients admitted to ICU have a poor prognosis, especially when admitted with coma, acute renal failure or post-cardiac arrest. The consistently poor prognosis associated with certain ICU interventions should raise new awareness regarding limitations of medical therapy. These mortality statistics compel a critical re-examination of uniformly aggressive life support for the critically ill cirrhotic patient, a percentage of whom will not benefit from invasive measures.     

Outcome of patients having dermatomyositis admitted to the intensive care unit

Patients having systemic rheumatic diseases constitute a small percentage of admissions to the medical intensive care units (ICUs). Dermatomyositis (DM) is one of the rheumatic diseases that have secondary complications that may lead to a critical illness requiring hospitalization in the ICU. Herein, we present the features, clinical course, and outcome of critically ill patients having DM who were admitted to the ICU. The medical records of six DM patients admitted to the ICU in a large tertiary hospital in a 12-year period were reviewed. The mean age of patients at time of admission to the ICU was 38 (range 16–37). Mean disease duration from diagnosis to admission to the ICU was 1.6 years (range 1 month–8 years), while the main reason for admission to the ICU was acute respiratory failure. Two of six patients died during the hospitalization. The main causes of death were respiratory complications and sepsis. The outcome of DM patients admitted to the ICU was generally not different from the outcome of other patients hospitalized in the ICU. The main reason for hospitalization was acute respiratory failure. As there are many reasons for respiratory failure in DM, an early diagnosis and aggressive appropriate treatment may help to further reduce the mortality in these patients.     

Prognosis of patients with acute myocardial infarction admitted to a coronary care unit. I: Survival in hospital

On a basis of history, clinical examination, and the electrocardiogram it was possible to identify groups of patients with acute myocardial infarction with good and bad prognoses as regards hospital survival. Individual adverse factors were age, prevous history of ischaemic heart disease, anterior infarction, persistent sinus tachycardia, pulmonary crepitations, hypotension, and raised venous pressure. Multivariate analysis showed four factors remaining significant--age, tachycardia, hypotension, and pulmonary crepitations. As a result of treatment of cardiac arrest, hospital mortality, which would otherwise have been 20 percent, was 17 percent. Preceding unstable angina did not worsen the immediate prognosis.     

Outcome of patients with acute myocardial infarction who are ineligible for thrombolytic therapy

OBJECTIVE: To determine what proportion of patients with acute myocardial infarction are not eligible for thrombolytic therapy and to assess their natural history. DESIGN: Retrospective chart review. SETTING: A large community-based hospital. PATIENTS: All patients with acute myocardial infarction hospitalized during a 27-month period. MEASUREMENTS: Of 1471 patients with acute myocardial infarction, 230 (16%) received thrombolytic therapy according to the protocol and an additional 97 (7%) received nonprotocol thrombolytic therapy, primary coronary balloon angioplasty, or both because of contraindications. The other 1144 patients (78%) did not receive reperfusion therapy. MAIN RESULTS: The patients who did not receive thrombolytic therapy were older, more likely to be women, and more likely to have a history of hypertension, previous myocardial infarction, or chronic angina (all comparisons, P less than 0.002). An average of 1.9 reasons for exclusion were identified per patient among the ineligible patients. Mortality was fivefold higher among ineligible patients (19%; Cl, 16% to 21%) than among protocol-treated patients (4%; Cl, 1% to 6%) (P less than 0.001). In-hospital mortality rates for excluded patients were 28% (Cl, 23% to 32%) in elderly patients (age, greater than 76 years; n = 396); 29% (Cl, 23% to 35%) in patients with stroke or bleeding risk (n = 209); 17% (Cl, 14% to 20%) in patients with delayed presentation (greater than 4 hours after the onset of chest pain; [n = 599]); 14% (Cl, 11% to 16%) in patients with an ineligible electrocardiogram (ECG) (n = 673); and 26% (Cl, 21% to 32%) in patients with a miscellaneous reason for exclusion (n = 243). Independent predictors of increased mortality were: age greater than 76 years, stroke or other bleeding risk, ineligible ECG, or the presence of two or more exclusion criteria. CONCLUSIONS: Thrombolytic therapy is currently used in the United States for only a minority of patients with acute myocardial infarction: those who have low-risk prognostic characteristics.     

Outcome of adult umbilical cord blood transplant patients admitted to a medical intensive care unit

Umbilical cord blood transplant (UCBT) has emerged as an alternate source of stem cells for transplantation in patients with hematologic malignancies. However, outcomes of adult UCBT patients requiring ICU admission remain unknown. In order to identify predictors of ICU transfer and mortality in UCBT patients, the course and outcome of all adult (> or = 16 years old) patients who underwent UCBT between 1 January 1998 and 31 December 2003 at University Hospitals of Cleveland were analyzed. Forty-four patients underwent UCBT during the study period and 25 (57%) required ICU transfer. Use of a myeloablative preparative regimen was a significant predictor of ICU transfer (P = 0.03). An infusion of higher numbers of nucleated cells was protective from ICU transfer (P = 0.05). For those patients transferred to the ICU, mortality was 72%. The univariate predictors of mortality, at the time of ICU admission were a high APACHE III score (P = 0.0004), use of vasopressors (P = 0.03), and a low platelet count (P = 0.03). We conclude that transfer of UCBT patients to an ICU may be predicted by their preparative regimen, while ICU mortality may be predicted by physiologic parameters upon admission.     

Prognosis of patients with acute myocardial infarction admitted to a coronary care unit. II. Survival after hospital discharge

The factors adversely affecting long-term prognosis differed from those affecting outcome of acute infarction. Individual factors were previous history of infarction or hypertension, tachycardia, cardiac arrest, ventricular arrhythmia, atrial fibrillation, 3rd heart sound, raised venous pressure, and pulmonary crepitations. Multivariate analysis reduced these to 6--previous infarct or hypertension, sinus tachycardia, cardiac arrest, ventricular arrhythmia, and artial fibrillation. Of those who survived 5 years, approximately half had angina. Two-thirds of the under 60 survivors were at their normal work.     

Prognosis of patients with acute myocardial infarction admitted to a coronary care unit. I: Survival in hospital.

On a basis of history, clinical examination, and the electrocardiogram it was possible to identify groups of patients with acute myocardial infarction with good and bad prognoses as regards hospital survival. Individual adverse factors were age, prevous history of ischaemic heart disease, anterior infarction, persistent sinus tachycardia, pulmonary crepitations, hypotension, and raised venous pressure. Multivariate analysis showed four factors remaining significant--age, tachycardia, hypotension, and pulmonary crepitations. As a result of treatment of cardiac arrest, hospital mortality, which would otherwise have been 20 percent, was 17 percent. Preceding unstable angina did not worsen the immediate prognosis.     

Outcome of patients with idiopathic pulmonary fibrosis admitted to the intensive care unit

This retrospective study describes the clinical course of 38 patients with idiopathic pulmonary fibrosis (IPF) admitted to the intensive care unit (ICU). There were 25 males and 13 females who were the mean age of 68.3 +/- 11.5 years. Twenty patients were on corticosteroids at the time of admission to the hospital, and 24 had been on home oxygen therapy. The most common reason for ICU admission was respiratory failure. The Acute Physiology and Chronic Health Evaluation III-predicted ICU and hospital mortality rates were 12% and 26%, whereas the actual ICU and hospital mortality rates were 45% and 61%, respectively. We did not find significant differences in pulmonary function or echocardiogram findings between survivors and nonsurvivors. Mechanical ventilation was used in 19 patients (50%). Sepsis developed in nine patients. Multiple organ failure developed in 14% of the survivors and in 43% of the nonsurvivors (p = 0.14). Ninety-two percent of the hospital survivors died at a median of 2 months after discharge. These findings suggest that patients with IPF admitted to the ICU have poor short- and long-term prognosis. Patients with IPF and their families should be informed about the overall outlook when they make decisions about life support and ICU care.     

2001年至2011年台州医院急性心肌梗死数据的回顾性分析

目的回顾性评价2001~2011年台州医院急性心肌梗死(AMI)患者的特征、诊疗模式和院内结局方面的变化趋势。方法冠心病医疗结果评价和临床转化研究是一项多中心临床研究,为AMI回顾性研究,台州医院为162家协作医院之一。本研究采用两阶段随机抽样数据设计。选取台州医院有效合格AMI患者197例,其中2001年25例、2006年59例、2011年113例,对3个特定年份患者临床特征、诊疗模式和院内不良心血管事件进行比较。结果 AMI患者以老年、男性(69.5%)、ST段抬高型心肌梗死(89.3%)为特点。直接PCI从2001年的0上升到2011年的50.4%(P<0.05)。入院24h内应用阿司匹林2001年96.0%,2006年96.6%,2011年97.3%,入院24h内应用氯吡格雷2001年4.0%,2006年96.6%,2011年97.3%、他汀类药物2001年60.0%,2006年96.6%,2011年97.3%(P<0.05,P<0.01)。2006年与2011年主要不良心血管事件发生率有统计学差异(50.8%vs31.1%,P<0.05)。多元logistic回归分析显示,吸烟(OR=0.036,P<0.05)、Killip分级(OR=2.682,P<0.05)和院内死亡(OR=177.970,P<0.05)是AMI患者院内心源性休克的独立危险因素。结论台州地区AMI的发展趋势为,尽管某些治疗措施在过去的10年改善明显,仍需进一步提高医疗质量,改善AMI患者预后。     

Prognosis of patients with acute myocardial infarction admitted to a coronary care unit. II. Survival after hospital discharge.

The factors adversely affecting long-term prognosis differed from those affecting outcome of acute infarction. Individual factors were previous history of infarction or hypertension, tachycardia, cardiac arrest, ventricular arrhythmia, atrial fibrillation, 3rd heart sound, raised venous pressure, and pulmonary crepitations. Multivariate analysis reduced these to 6--previous infarct or hypertension, sinus tachycardia, cardiac arrest, ventricular arrhythmia, and artial fibrillation. Of those who survived 5 years, approximately half had angina. Two-thirds of the under 60 survivors were at their normal work.     

Outcome of patients with acute myocardial infarction who are ineligible for primary angioplasty trials.

We determined acute outcome in 148 consecutive patients with ST segment elevation myocardial infarction undergoing angioplasty including 72 patients (48.7%) considered ineligible for primary angioplasty trials. Overall, in-hospital mortality for acute infarct angioplasty was 12%, with fivefold higher mortality in the trial-ineligible group (21% vs. 4%, P = 0.003). Thus, primary angioplasty trials continue to exclude nearly 50% of acute infarction patients and reported mortality rates of primary angioplasty trials are likely to be significantly lower than the unselected in-hospital mortality rates. Cathet. Cardiovasc. Intervent. 49:237-243, 2000.     

Outcomes in patients with myocardial infarction who are initially admitted to stepdown units: data from the Multicenter Chest Pain Study

PURPOSE: To assess whether the admission of patients with chest pain to a stepdown unit would jeopardize the outcome of those patients who ultimately "ruled in" for a myocardial infarction. PATIENTS AND METHODS: We compared the risk of an adverse outcome in initially uncomplicated, "rule-out myocardial infarction" patients who were admitted directly to a stepdown unit (n = 58) or to a coronary care unit (n = 409) at 6 hospitals and who then ultimately "ruled in" for a myocardial infarction. RESULTS: An adverse outcome (death, serious complication, or invasive intervention) occurred in 16 (28%) stepdown unit patients compared with 159 (39%) coronary care unit patients. Among patients eligible for initial care in either location, the risk of an adverse outcome after controlling for clinical characteristics was similar in the two groups using each of two different multivariate approaches. CONCLUSION: Although our study was not of sufficient size to exclude the possibility of a small benefit from initial triage to a coronary care unit, our data suggest that (1) admission of initially uncomplicated chest pain patients with a relatively low probability of acute myocardial infarction to a stepdown unit does not seriously jeopardize those who eventually "rule in" for myocardial infarction; and (2) larger observational or randomized studies, which could reduce the residual possibility of somewhat higher risk in the stepdown unit, would be ethical to perform.     

Outcome of patients with scleroderma admitted to intensive care unit. A report of nine cases

OBJECTIVE: Patients with systemic rheumatic disease constitute a small percentage of admissions to the medical intensive care units (ICUs). Systemic sclerosis (SSc) is one of the rheumatic diseases that together with secondary complications may lead to a critical illness requiring hospitalization in the ICU. We present the features, clinical course and outcome of critically ill patients with scleroderma that were admitted to the ICU. METHODS: The medical records of nine patients with diagnosis of scleroderma (8 female, 1 male), admitted to the intensive care unit of Sheba Medical Center during the 11-year interval between 1991 and 2002, were reviewed. RESULTS: The mean age of the patients at the time of admission to the ICU was 48 +/- 13 [SD] years.The mean duration of SSc from diagnosis to the ICU admission was 8 +/- 8 years. Six patients had diffuse SSc, two patients had limited SSc and one patient had juvenile diffuse morphea. The main reasons for admission to the ICU were: infection/ septic syndrome (n = 4), scleroderma renal crisis (SRC) with pulmonary congestion (n = 2), acute renal failure associated with diffuse alveolar hemorrhage namely scleroderma- pulmonary - renal syndrome (SPRS) (n = 1), iatrogenic pericardial tamponade (n = 1), mesenteric ischemia (n = 1). The patients had high severity illness score (mean APACHE II 25 +/- 3). Eight out of nine patients (89%) that were admitted to the ICU died during the hospitalization, six (66.6%) of them died in the ICU. Septic complications as the main cause of death were determined in five patients (62.5%), while four of them had pneumonia and acute respiratory failure along with underlying severe pulmonary fibrosis. Lungs and kidneys were the most common severely affected organs by SSc in our patients. CONCLUSION: The outcome of scleroderma patients admitted to the ICU was extremely poor. Infectious complication was the most common cause of death in our patients. Although infections are treatable, the high mortality rate for this group of patients was dependent on the severity of the underlying visceral organ involvement, particularly severe pulmonary fibrosis. The severity of this involvement is a poor outcome predictor. An early diagnosis and an appropriate treatment of such complications may help to reduce the mortality in scleroderma patients.     

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.