Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure

Introduction

Although diuretics are mainly used for the treatment of acute decompensated heart failure (ADHF), inadequate responses and complications have led to the use of extracorporeal ultrafiltration (UF) as an alternative strategy for reducing volume overloads in patients with ADHF.

Objective

The aim of our study is to perform meta-analysis of the results obtained from studies on extracorporeal venous ultrafiltration and compare them with those of standard diuretic treatment for overload volume reduction in acute decompensated heart failure.

Methods

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched using a pre‑specified criterion. Pooled estimates of outcomes after 48 h (weight change, serum creatinine level, and all-cause mortality) were computed using random effect models. Pooled weighted mean differences were calculated for weight loss and change in creatinine level, whereas a pooled risk ratio was used for the analysis of binary all-cause mortality outcome.

Results

A total of nine studies, involving 613 patients, met the eligibility criteria. The mean weight loss in patients who underwent UF therapy was 1.78 kg [95% Confidence Interval (CI): −2.65 to −0.91 kg; p < 0.001) more than those who received standard diuretic therapy. The post-intervention creatinine level, however, was not significantly different (mean change = −0.25 mg/dL; 95% CI: −0.56 to 0.06 mg/dL; p = 0.112). The risk of all-cause mortality persisted in patients treated with UF compared with patients treated with standard diuretics (Pooled RR = 1.00; 95% CI: 0.64–1.56; p = 0.993).

Conclusion

Compared with standard diuretic therapy, UF treatment for overload volume reduction in individuals suffering from ADHF, resulted in significant reduction of body weight within 48 h. However, no significant decrease of serum creatinine level or reduction of all-cause mortality was observed.     

Hydration with magnesium and mannitol without furosemide prevents the nephrotoxicity induced by cisplatin and pemetrexed in patients with advanced non-small cell lung cancer

Background

The aim of this study was to examine the effect of hydration with magnesium and mannitol without furosemide on the nephrotoxocity accompanying combination chemotherapy using cisplatin and pemetrexed in patients with advanced non-small cell lung cancer (NSCLC).

Methods

Fifty patients with NSCLC who received cisplatin plus pemetrexed, using either old hydration protocol including normal saline with mannitol and furosemide, or a new one including normal saline with magnesium and mannitol without furosemide were retrospectively analyzed. Nephrotoxicity was compared between patients treated using the old protocol and those treated with the new protocol. Univariate and multivariate analyses were performed to identify the independent factors associated with protection against nephrotoxicity in patients with NSCLC who received cisplatin plus pemetrexed.

Results

Thirty patients received the old hydration protocol, while 20 patients were treated using the new hydration protocol. The patients treated using the new hydration protocol showed a significantly greater increase in creatinine clearance (P=0.0004) and a decrease in the serum creatinine level (P=0.0148) after one course of chemotherapy compared with those treated using the old hydration protocol. There were no differences in the chemotherapeutic response or overall survival between the groups (P=0.572). The new hydration protocol with supplemented magnesium with mannitol without furosemide was an independent factor for the protection against nephrotoxicity induced by cisplatin and pemetrexed in patients with advanced NSCLC [HR 0.232 (95% CI: 0.055-0.986), P=0.039].

Conclusions

These results demonstrate that the new hydration protocol comprising supplementation with magnesium without furosemide could prevent the nephrotoxicity induced by cisplatin and pemetrexed without affecting the treatment outcome.KEY WORDS : Lung cancer, cisplatin, magnesium, nephrotoxicity, pemetrexed     

Tuberculosis in the intensive care unit: A retrospective descriptive cohort study with determination of a predictive fatality score

BACKGROUND:

Despite effective treatments, tuberculosis-related mortality remains high among patients requiring admission to the intensive care unit (ICU).

OBJECTIVE:

To determine prognostic factors of death in tuberculosis patients admitted to the ICU, and to develop a simple predictive scoring system.

METHODS:

A 10-year, retrospective study of 53 patients admitted consecutively to the Hôpitaux de Paris, Hôpital Lariboisière (Paris, France) ICU with confirmed tuberculosis, was conducted. A multivariate analysis was performed to identify risk factors for death. A predictive fatality score was determined.

RESULTS:

Diagnoses included pulmonary tuberculosis (96%) and tuberculous encephalomeningitis (26%). Patients required mechanical ventilation (45%) and vasopressor infusion (28%) on admission. Twenty patients (38%) died, related to direct tuberculosis-induced organ failure (n=5), pulmonary bacterial coinfections (n=14) and pulmonary embolism (n=1). Using a multivariate analysis, three independent factors on ICU admission were predictive of fatality: miliary pulmonary tuberculosis (OR 9.04 [95% CI 1.25 to 65.30]), mechanical ventilation (OR 11.36 [95% CI 1.55 to 83.48]) and vasopressor requirement (OR 8.45 [95% CI 1.29 to 55.18]). A score generated by summing these three independent variables was effective at predicting fatality with an area under the ROC curve of 0.92 (95% CI 0.85 to 0.98).

CONCLUSIONS:

Fatalities remain high in patients admitted to the ICU with tuberculosis. Miliary pulmonary tuberculosis, mechanical ventilation and vasopressor requirement on admission were predictive of death.     

Risk factors and outcomes associated with chronic obstructive pulmonary disease exacerbations requiring hospitalization

BACKGROUND:

Acute respiratory exacerbations are the most frequent cause of medical visits, hospitalization and death for chronic obstructive pulmonary disease (COPD) patients and, thus, exert a significant social and economic burden on society.

OBJECTIVE:

To identify the risk factors associated with hospital readmission(s) for acute exacerbation(s) of COPD (AECOPD).

METHODS:

A review of admission records from three large urban hospitals in Vancouver, British Columbia, identified 310 consecutive patients admitted for an AECOPD between April 1, 2001, and December 31, 2002. Logistic regression analysis was performed to identify risk factors for readmissions following an AECOPD.

RESULTS:

During the study period, 38% of subjects were readmitted at least once. The mean (± SD) duration from the index admission to the first readmission was 5±4.08 months. Comparative analysis among the three hospitals identified a significant difference in readmission rates (54%, 36% and 18%, respectively). Logistic regression analysis revealed that preadmission home oxygen use (OR 2.55; 95%CI 1.45 to 4.42; P=0.001), history of a lung infection within the previous year (OR 1.73; 95% CI 1.01 to 2.97; P=0.048), other chronic respiratory disease (OR 1.78; 95% CI 1.06 to 2.99; P=0.03) and shorter length of hospital stay (OR 0.97; 95% CI 0.945 to 0.995; P=0.021) were independently associated with frequent readmissions for an AECOPD.

CONCLUSIONS:

Hospital readmission rates for AECOPD were high. Only four clinical factors were found to be independently associated with COPD readmission. There was significant variability in the readmission rate among hospitals. This variability may be a result of differences in the patient populations that each hospital serves or may reflect variability in health care delivery at different institutions.     

Predictors for contrast media-induced nephropathy and long-term survival: prospectively assessed data from the randomized controlled Dialysis-Versus-Diuresis (DVD) trial

BACKGROUND:

Among the numerous studies concerning contrast media-induced nephropathy (CIN), there was no prospective trial that provided data on the long-term outcomes.

OBJECTIVES:

To prospectively assess predictors of CIN and long-term outcomes of affected patients.

METHODS:

Four hundred twelve consecutive patients with serum creatinine levels of 115 μmol/L to 309 μmol/L (1.3 mg/dL to 3.5 mg/dL) undergoing elective coronary angiography were included. Patients were randomly assigned to periprocedural hydration alone, hydration plus onetime hemodialysis or hydration plus N-acetylcysteine.

RESULTS:

Multivariate logistic regression identified the following as predictors of CIN within 72 h (equivalent to an increase in creatinine 44.2 μmol/L [0.5 mg/dL] or more) : prophylactic postprocedural hemodialysis (OR 2.86, 95% CI 1.07 to 7.69), use of angiotensin-converting enzyme inhibitors (OR 6.16, 95% CI 2.01 to 18.93), baseline glomerular filtration rate (OR 0.94, 95% CI 0.90 to 0.98) and the amount of contrast media given (OR 1.01, 95% CI 1.00 to 1.01). With regard to long-term outcome (mean follow-up 649 days), multivariate Cox regression models found elevated creatinine levels at 30 days (hazard rate ratio [HRR] 5.48, 95% CI 2.85 to 10.53), but not CIN within 72 h (HRR 1.12, 95% CI 0.63 to 2.02), to be associated with increased mortality. In addition, independent predictors for death during follow-up included left ventricular ejection fraction lower than 35% (HRR 4.01, 95% CI 2.22 to 7.26), serum phosphate (HRR 1.64, 95% CI 1.10 to 2.43) and hemoglobin (HRR 0.80, 95% CI 0.67 to 0.96).

CONCLUSION:

From the present prospective trial, performance of post-procedural hemodialysis, use of angiotensin-converting enzyme inhibitors, reduced baseline glomerular filtration rate and amount of contrast media were independent predictors of CIN within 72 h after catheterization. Assessing renal function after 30 days, rather than within 72 h, seemed to be more predictive for patients’ long-term survival.     

Association of Proton Pump Inhibitor Therapy with Hepatic Encephalopathy in Hepatitis B Virus-related Acute-on-Chronic Liver Failure

Background:

Hepatic encephalopathy (HE) is an important neuropsychiatry complication of acute-on-chronic liver failure (ACLF). PPI therapy may increase the intestinal bacterial overgrowth and infections.

Objectives:

The aim of this study was to assess whether PPI use in ACLF is associated with HE.

Patients and Methods:

A retrospective case-control study was performed. Fifty five admitted patients with hepatitis B virus (HBV)-related ACLF complicated by Stage II-IV HE developed after admission between January 2008 and December 2012 were matched (by sex, age, and MELD score) with comparable HBV-related ACLF patients (n = 110) who did not develop this complication during hospitalization. We excluded combined HE upon admission and other neurological disorders in patients with ACLF. Univariate and multivariate analyses of 30 variables (laboratory examination, predisposition, treatment, etc.) before the occurrence of HE were carried out to identify the factors predictive of HE.

Results:

In univariate analysis, patients with HE in ACLF had a significantly higher rate of PPI use (89.1%) compared with non-HE (63.6%, P = 0.001). In addition, clinical and standard laboratory variables were significantly different between the two groups regarding the infection rate, hyponatremia, alpha-fetoprotein (AFP), Arginine Hydrochloride use and Lactulose use. Logistic regression analysis was used to examine the combined effects of the variables with HE as the outcome. HE in ACLF was associated with hyponatremia (odds ratio (OR) = 6. 318, 95% confidence interval (CI) = 2. 803-14.241; P = 0. 000), PPI use was independently associated with HE (OR = 4. 392, CI = 1. 604-12.031; P = 0. 004), and lactulose use was protective (OR = 0. 294, CI = 0. 136-0.675; P = 0. 003).

Conclusions:

The occurrence of HE is associated with hyponatremia and PPI use in patients with ACLF.     

Prevalence and incidence of antimicrobial-resistant organisms among hospitalized inflammatory bowel disease patients

BACKGROUND:

Patients with inflammatory bowel disease (IBD) experience frequent hospitalizations and use of immunosuppressive medications, which may predispose them to colonization with antimicrobial-resistant organisms (ARO).

OBJECTIVE:

To determine the prevalence of ARO colonization on admission to hospital and the incidence of infection during hospitalization among hospitalized IBD patients.

METHODS:

A chart review comparing the prevalence of colonization and incidence of infection with methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL) in hospitalized IBD patients with those of non-IBD controls was performed.

RESULTS:

On admission, there were no significant differences between IBD inpatients and controls in the prevalence of colonization of methicillin-resistant S aureus (1.0% versus 1.2%; P=0.74), vancomycin-resistant enterococci (0.2% versus 0%; P=1.0) or ESBL (4.1% versus 5.5%; P=0.33). Pooling data from historical clinic-based cohorts, IBD patients were more likely than controls to have ESBL colonization (19% versus 6.6%; P<0.05). Antibiotic use on admission was associated with ESBL colonization among IBD inpatients (OR 4.2 [95% CI 1.4 to 12.6]). The incidence of ARO infections during hospitalization was not significantly different between IBD patients and controls. Among IBD patients who acquired ARO infections during hospitalizations, the mean time interval from admission to infection was shorter for those who were already colonized with ARO on admission.

CONCLUSIONS:

This particular population of hospitalized IBD patients was not shown to have a higher prevalence or incidence of ARO colonization or infection compared with non-IBD inpatients.     

Risk factors and complications following percutaneous endoscopic gastrostomy: a case series of 1041 patients

BACKGROUND:

Most studies exclude patients with severe coagulation disorders or those taking anticoagulants when evaluating the outcomes of percutaneous endoscopic gastrostomy (PEG).

OBJECTIVE:

To investigate complications and risk factors of PEG in a large clinical series including patients undergoing antiplatelet and anticoagulant therapy.

METHODS:

During a six-year period, 1057 patients referred for PEG placement were prospectively audited for clinical outcome. Exclusion criteria and follow-up care were defined. Complications were defined as minor or severe. Uni- and multivariate analyses were used to evaluate 14 risk factors. No standardized antibiotic prophylaxis was given.

RESULTS:

A total of 1041 patients (66% male, 34% female) with the following conditions underwent PEG: neurogenic dysphagia (n=450), cancer (n=385) and others (n=206). No anticoagulants were administered to 351 patients, thrombosis prophylaxis was given to 348 while full therapeutic anticoagulation was received by 313. No increased bleeding risk was associated with patients who had above-normal international normalized ratio values (OR 0.79 [95% CI 0.08 to 7.64]; P=1.00). The total infection rate was 20.5% in patients with malignant disease, and 5.5% in those with nonmalignant disease. Severe complications occurred in 19 patients (bleeding 0.5%, peritonitis 1.3%). Cirrhosis (OR 2.91 [95% CI 1.31 to 6.54]; P=0.008), cancer (OR 2.34 [95% CI 1.33 to 4.12]; P=0.003) and radiation therapy (OR 2.34 [95% CI 1.35 to 4.05]; P=0.002) were significant predictors of post-PEG infection. The 30-day mortality rate was 5.8%. There were no procedure-related deaths.

CONCLUSIONS:

Cancer, cirrhosis and radiation therapy were predictors of infection. Post-PEG bleeding and other complications were rare events. Collectively, the data suggested that patients taking concurrent anticoagulants had no elevated risk of post-PEG bleeding.     

Very Long-Term Prognostic Role of Admission BNP in Non-ST Segment Elevation Acute Coronary Syndrome

Background

BNP has been extensively evaluated to determine short- and intermediate-term prognosis in patients with acute coronary syndrome, but its role in long-term mortality is not known.

Objective

To determine the very long-term prognostic role of B-type natriuretic peptide (BNP) for all-cause mortality in patients with non-ST segment elevation acute coronary syndrome (NSTEACS).

Methods

A cohort of 224 consecutive patients with NSTEACS, prospectively seen in the Emergency Department, had BNP measured on arrival to establish prognosis, and underwent a median 9.34-year follow-up for all-cause mortality.

Results

Unstable angina was diagnosed in 52.2%, and non-ST segment elevation myocardial infarction, in 47.8%. Median admission BNP was 81.9 pg/mL (IQ range = 22.2; 225) and mortality rate was correlated with increasing BNP quartiles: 14.3; 16.1; 48.2; and 73.2% (p < 0.0001). ROC curve disclosed 100 pg/mL as the best BNP cut-off value for mortality prediction (area under the curve = 0.789, 95% CI= 0.723-0.854), being a strong predictor of late mortality: BNP < 100 = 17.3% vs. BNP ≥ 100 = 65.0%, RR = 3.76 (95% CI = 2.49-5.63, p < 0.001). On logistic regression analysis, age >72 years (OR = 3.79, 95% CI = 1.62-8.86, p = 0.002), BNP ≥ 100 pg/mL (OR = 6.24, 95% CI = 2.95-13.23, p < 0.001) and estimated glomerular filtration rate (OR = 0.98, 95% CI = 0.97-0.99, p = 0.049) were independent late-mortality predictors.

Conclusions

BNP measured at hospital admission in patients with NSTEACS is a strong, independent predictor of very long-term all-cause mortality. This study allows raising the hypothesis that BNP should be measured in all patients with NSTEACS at the index event for long-term risk stratification.     

The metabolic syndrome is associated with complicated gallstone disease

BACKGROUND:

Gallstone disease (GD) is a common condition worldwide. Several studies demonstrated that the presence of gallstones is strongly associated with cardiovascular disease. The metabolic syndrome is a highly prevalent cardiovascular condition.

OBJECTIVE:

To examine the relationship between complicated GD (CGD) and the metabolic syndrome or its components.

METHODS:

Two hundred seventeen patients with gallstones were examined. All patients underwent biliary ultrasonography after a complete medical history and laboratory examination. Data collection for the diagnosis of metabolic syndrome included measurements of waist circumference, blood pressure and lipids, and biochemical tests.

RESULTS:

Of the 217 patients examined, 115 patients (53%) had CGD and 102 patients (47%) had uncomplicated GD (UCGD). There was a significant difference between the number of patients with large gallstones in the CGD and UCGD groups (n=14 [12%] versus n=2 [2%], respectively; P=0.004). Metabolic syndrome, diabetes mellitus and large waist circumference were more prevalent in the CGD group than in the UCGD group. Homeostatic model assessment of insulin resistance scores were higher in the CGD group than in UCGD group (2.51 [95% CI 0.57 to 23.90] versus 2.20 [95% CI 0.09 to 8.87], respectively; P=0.032). Logistic regression analysis revealed that the presence of metabolic syndrome (OR 1.434; 95% CI 1.222 to 1.846, P=0.014), diabetes mellitus (OR 1.493; 95% CI 1.255 to 1.953; P=0.035) and large gallstones (OR 1.153; 95% CI 1.033 to 1.714; P=0.017) were independent predictors of CGD.

CONCLUSION:

Results of the present study demonstrated that metabolic syndrome, diabetes and gallstone size were associated with CGD. Further prospective studies are needed to understand the clinical importance of this association.     

Initial thrombolysis treatment compared with anticoagulation for acute intermediate-risk pulmonary embolism: a meta-analysis

Background

The use of thrombolysis in patients with acute, intermediate-risk pulmonary embolism (PE) remains controversial. This meta-analysis compared the efficacy and safety of thrombolysis and anticoagulation treatments for intermediate-risk PE patients.

Methods

Two investigators independently reviewed the literature and collected data from randomized controlled trials (RCTs) of thrombolysis for intermediate-risk PE in the PubMed, MEDLINE, EMBASE, the Cochrane Library, and Chinese Biomedical Literature Databases (CBM).

Results

A total of 1,631 intermediate-risk PE patients from seven studies were included. Significant differences were not found regarding the 30-day, all-cause mortality rates between the thrombolytic and anticoagulant groups [odds ratio (OR), 0.60; 95% confident interval (CI), 0.34-1.06; P=0.08]. The rate of clinical deterioration in the thrombolytic group was lower than that in the anticoagulant group (OR, 0.27; 95% CI, 0.18-0.41; P<0.01). Recurrent PE in the thrombolytic group was also significantly lower than that in the anticoagulant group (OR, 0.34; 95% CI, 0.15-0.77; P=0.01). Comparing the thrombolytic and anticoagulation groups, the incidence of minor bleeding was significantly higher in the thrombolytic group (OR, 5.33; 95% CI, 2.85-9.97; P<0.00001), but there were no difference in the incidences of major bleeding events (OR, 2.07; 95% CI, 0.60-7.16; P=0.25).

Conclusions

Thrombolytic treatment for intermediate-risk PE patients, if not contraindicated, could reduce clinical deterioration and recurrence of PE, and trends towards a decrease in all-cause, 30-day mortality. Despite thrombolytic treatment having an increased total bleeding risk, there was no difference in the incidence of major bleeding events, compared with patients receiving anticoagulation treatment.     

Influence of Spironolactone on Matrix Metalloproteinase-2 in Acute Decompensated Heart Failure

Background

Matrix metalloproteinases (MMPs) are a family of enzymes important for the resorption of extracellular matrices, control of vascular remodeling and repair. Increased activity of MMP2 has been demonstrated in heart failure, and in acutely decompensated heart failure (ADHF) a decrease in circulating MMPs has been demonstrated along with successful treatment.

Objective

Our aim was to test the influence of spironolactone in MMP2 levels.

Methods

Secondary analysis of a prospective, interventional study including 100 patients with ADHF. Fifty patients were non-randomly assigned to spironolactone (100 mg/day) plus standard ADHF therapy (spironolactone group) or standard ADHF therapy alone (control group).

Results

Spironolactone group patients were younger and had lower creatinine and urea levels (all p < 0.05). Baseline MMP2, NT-pro BNP and weight did not differ between spironolactone and control groups. A trend towards a more pronounced decrease in MMP2 from baseline to day 3 was observed in the spironolactone group (-21 [-50 to 19] vs 1.5 [-26 to 38] ng/mL, p = 0.06). NT-pro BNP and weight also had a greater decrease in the spironolactone group. The proportion of patients with a decrease in MMP2 levels from baseline to day 3 was also likely to be greater in the spironolactone group (50% vs 66.7%), but without statistical significance. Correlations between MMP2, NT-pro BNP and weight variation were not statistically significant.

Conclusion

MMP2 levels are increased in ADHF. Patients treated with spironolactone may have a greater reduction in MMP2 levels.     

A prospective,randomized study to evaluate the efficacy of various diuretic strategies in acute decompensated heart failure

Aim

To evaluate the safety and efficacy of various initial strategies of loop diuretic administration in patients with acute decompensated heart failure (ADHF) on diuresis, renal function, electrolyte balance and clinical outcomes.

Methods

Consecutive patients admitted with ADHF were randomized into three groups - intravenous furosemide infusion + intravenous dopamine, intravenous furosemide bolus in two divided doses and intravenous furosemide continuous infusion alone. At 48 h, the treating physician could adjust the diuretic strategy. Primary endpoint was negative fluid balance at 24 h after admission. Secondary end points were duration of hospital stay, negative fluid balance at 48, 72, 96 h, the trend of serum electrolytes, and renal function and 30 day clinical outcome (death and emergency department visits).

Results

Overall ninety patients (thirty in each group) were included in the study. There was a greater diuresis in first 24 h (p = 0.002) and a shorter hospital stay (p = 0.023) with the bolus group. There was no significant difference in renal function and serum sodium and serum potassium levels. There was no difference in the number of emergency department visits among the three groups.

Conclusion

All three modes of diuretic therapies can be practiced with no difference in worsening of renal function and electrolyte levels. Bolus dose administration with its rapid volume loss and shorter hospital stay might be a more effective diuretic strategy.     

Delayed tuberculosis treatment in urban and suburban Ontario

BACKGROUND:

Delay in the treatment of patients with tuberculosis (TB) increases the risk of poor clinical outcomes – including death and transmission of disease – and may be reducible.

OBJECTIVE:

To estimate delays in TB treatment in a Canadian, multicultural population and to examine factors associated with longer time to treatment.

METHODS:

Adult cases of active TB from January 1998 to December 2001 from the Ontario Reportable Disease Information System were included. Time to treatment was defined as the number of days between symptom onset and treatment.

RESULTS:

Data from 1753 TB patients (76% of eligible patients) were analyzed. Median time to treatment was 62 days (interquartile range 31 to 114 days). Time periods longer than the median time to treatment were independently associated with middle-aged patients (OR 1.54, 95% CI 1.21 to 1.98), foreign-born patients who had lived in Canada for more than 10 years (OR 1.47, 95% CI 1.02 to 2.12), patients with nonpulmonary disease (OR 1.57, 95% CI 1.28 to 1.92) and patients managed within certain health districts.

CONCLUSION:

A time to TB treatment of two months or more is common in Ontario, and associated with several factors. Future studies are needed to build on these findings to decrease delay and improve individual and public health outcomes.     

Patient characteristics and outcomes of a provincial prolonged-ventilation weaning centre: A retrospective cohort study

BACKGROUND:

Growing numbers of critically ill patients require prolonged mechanical ventilation and experience difficulty with weaning. Specialized centres may facilitate weaning through focused interprofessional expertise with an emphasis on rehabilitation.

OBJECTIVE:

To characterize the population of a specialized prolonged-ventilation weaning centre (PWC) in Ontario, and to report weaning, mobility, discharge and survival outcomes.

METHODS:

Data from consecutively admitted patients were retrospectively extracted from electronic and paper medical records by research staff and verified by the primary investigator.

RESULTS:

From January 2004 to March 2011, 144 patients were admitted: 115 (80%) required ventilator weaning, and 29 (20%) required tracheostomy weaning or noninvasive ventilation. Intensive care unit length of stay before admission was a median 51 days (interquartile range [IQR] 35 to 86 days). Of the patients admitted for ventilator weaning, 76 of 115 (66% [95% CI 55% to 75%]) achieved a 24 h tracheostomy mask trial in a median of 15 days (IQR eight to 25 days). Weaning success, defined as no further ventilation for seven consecutive days, was achieved by 61 patients (53% [95% CI 44% to 62%]) in a median duration of 62 days (IQR 46 to 95 days) of ventilation, and 14 days (IQR nine to 29 days) after PWC admission. Seventeen patients died during admission. Of the 91 patients discharged from the PWC for one year, 43 (47.3% [95% CI 37.3% to 57.4%]) survived; of the 78 discharged for two years, 27 (34.6% [95% CI 25.0% to 45.7%]) were alive; of the 53 discharged for three years, 19 (35.9% [95% CI 24.3% to 49.3%]) were alive; and seven of 22 (31.8% [95% CI 16.4% to 52.7%]) survived to five years.

CONCLUSIONS:

Weaning success was moderate despite a prolonged intensive care unit stay before admission, but was comparable with studies reporting weaning outcomes from centres in other countries. Few patients survived to five years.     

Did Duty Hour Reform Lead to Better Outcomes Among the Highest Risk Patients?

Background

Earlier work demonstrated that ACGME duty hour reform did not adversely affect mortality, with slight improvement noted among specific subgroups.

Objective

To determine whether resident duty hour reform differentially affected the mortality risk of high severity patients or patients who experienced post-operative complications (failure-to-rescue).

Design

Observational study using interrupted time series analysis with data from July 1, 2000 - June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of mortality or failure-to-rescue (FTR) in more versus less teaching-intensive hospitals before and after duty hour reform.

Participants

All unique Medicare patients (n = 8,529,595) admitted to short-term acute care non-federal hospitals and all unique VA patients (n = 318,636 patients) with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, stroke or a DRG classification of general, orthopedic or vascular surgery.

Measurements and Main Results

We measured mortality within 30 days of hospital admission and FTR, measured by death among patients who experienced a surgical complication. The odds of mortality and FTR generally changed at similar rates for higher and lower risk patients in more vs. less teaching intensive hospitals. For example, comparing the mortality risk for the 10% of Medicare patients with highest risk to the other 90% of patients in post-reform year 1 for combined medical an OR of 1.01 [95% CI 0.90, 1.13], for combined surgical an OR of 0.91 [95% CI 0.80, 1.04], and for FTR an OR of 0.94 [95% CI 0.80, 1.09]. Findings were similar in year 2 for both Medicare and VA. The two exceptions were a relative increase in mortality for the highest risk medical (OR 1.63 [95% CI 1.08, 2.46]) and a relative decrease in the high risk surgical patients within VA in post-reform year 1 (OR 0.52 [95% CI 0.29, 0.96]).

Conclusions

ACGME duty hour reform was not associated with any consistent improvements or worsening in mortality or failure-to-rescue rates for high risk medical or surgical patients.KEY WORDS: medical errors internship and residency, education, medical, graduate, personnel staffing and scheduling, continuity of patient care     

Tuberculosis in hospitalized patients: clinical characteristics of patients receiving treatment within the first 24 h after admission

Objective:

To evaluate clinical characteristics and outcomes in patients hospitalized for tuberculosis, comparing those in whom tuberculosis treatment was started within the first 24 h after admission with those who did not.

Methods:

This was a retrospective cohort study involving new tuberculosis cases in patients aged ≥ 18 years who were hospitalized after seeking treatment in the emergency room.

Results:

We included 305 hospitalized patients, of whom 67 (22.0%) received tuberculosis treatment within the first 24 h after admission ( ≤24h group) and 238 (88.0%) did not (>24h group). Initiation of tuberculosis treatment within the first 24 h after admission was associated with being female (OR = 1.99; 95% CI: 1.06-3.74; p = 0.032) and with an AFB-positive spontaneous sputum smear (OR = 4.19; 95% CI: 1.94-9.00; p < 0.001). In the ≤24h and >24h groups, respectively, the ICU admission rate was 22.4% and 15.5% (p = 0.258); mechanical ventilation was used in 22.4% and 13.9% (p = 0.133); in-hospital mortality was 22.4% and 14.7% (p = 0.189); and a cure was achieved in 44.8% and 52.5% (p = 0.326).

Conclusions:

Although tuberculosis treatment was initiated promptly in a considerable proportion of the inpatients evaluated, the rates of in-hospital mortality, ICU admission, and mechanical ventilation use remained high. Strategies for the control of tuberculosis in primary care should consider that patients who seek medical attention at hospitals arrive too late and with advanced disease. It is therefore necessary to implement active surveillance measures in the community for earlier diagnosis and treatment.     

Risk factors of ventilator-associated pneumonia in pediatric intensive care unit: a systematic review and meta-analysis

Objective

To identify risk factors of ventilator-associated pneumonia (VAP) in pediatric intensive care unit (PICU).

Methods

PubMed, Ovid, Web of Science, the Cochrane Library and references of retrieved articles were searched without language limitation. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by using both the Mantel-Haenszel fixed-effect and the DerSimonian-Laird random-effects models.

Results

Out of the 205 initially retrieved articles, 9 papers were included. All 4,564 patients were enrolled, including 213 patients with VAP and 4,351 patients without VAP. Among fourteen risk factors, six factors had statistical significances. Risk factors of VAP and its value of OR were as follows: genetic syndrome (OR =2.04; 95% CI: 1.08-3.86), steroids (OR =1.87; 95% CI: 1.07-3.27), reintubation or self-extubation (OR =3.16; 95% CI: 2.10-4.74), bloodstream infection (OR =4.42; 95% CI: 2.12-9.22), prior antibiotic therapy (OR =2.89; 95% CI: 1.41-5.94), bronchoscopy (OR =4.48; 95% CI: 2.31-8.71).

Conclusions

Special methods of preventions should be taken in the light of risk factors of VAP in PICU so as to decrease the rate.KEY WORDS : Risk factors, ventilator-associated pneumonia (VAP), pediatric intensive care unit (PICU), meta-analysis     

Association between proton pump inhibitor use and spontaneous bacterial peritonitis in cirrhotic patients with ascites

BACKGROUND:

There are data suggesting a link between proton pump inhibitor (PPI) use and the development of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites; however, these data are controversial.

OBJECTIVE:

To assess whether the use of PPIs in cirrhotic patients with ascites is associated with an increased risk for SBP.

METHODS:

A retrospective case-control study (June 2004 to June 2010) was conducted at the Centre Hospitalier de l’Université de Montréal in Montreal, Quebec. Fifty-one cirrhotic patients admitted with paracentesis-proven SBP (≥250 neutrophils/mm³), occurring within seven days of hospital admission, met the inclusion criteria. These patients were matched 1:2 (for age, Child-Pugh class and year of admission) with 102 comparable cirrhotic patients with ascites who were admitted for conditions other than SBP.

RESULTS:

Patients with SBP had a significantly higher rate of pre-hospital PPI use (60.8%) compared with cirrhotic patients without SBP (42.2%; P=0.03). On multivariate analysis, PPI use was the only factor independently associated with SBP (OR 2.09 [95% CI 1.04 to 4.23]; P=0.04). Thirty-five (35%) patients in both groups had no documented indication for PPI use in their charts. Forty-five percent of the remaining cirrhotic patients with SBP had an inappropriate indication, as defined in the protocol, for PPI use compared with 25% of controls.

CONCLUSIONS:

Cirrhotic patients with SBP were twice as likely to have taken PPIs than patients without SBP. These findings reinforce the association between PPI use and SBP observed in other studies. A high percentage of cirrhotic patients were taking a PPI without any documented indication.