Outcomes of daytime nurse practitioner–staffed versus resident-staffed nonsurgical intensive care units: A retrospective observational study

BackgroundRapid developments in medical care—such as monitoring devices, medications, and working hours restrictions for intensive care personnel—have dramatically increased the demand for intensive care physicians. Therefore, nurse practitioner (NP)–staffed care is becoming increasingly important. This study was aimed to compare the outcomes of daytime NP-staffed and daytime resident-staffed nonsurgical intensive care units (ICU).MethodsWe retrospectively assessed patients admitted to a nonsurgical ICU from March 2017 to December 2017. We collected basic patient data, including age, sex, admission diagnosis, transferring unit, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Primary endpoints were ICU mortality, hospital mortality, and 30-day mortality. Secondary endpoints were 48-h readmission, discharge to nonhome locations, and lengths of ICU and hospital stay.ResultsA total of 838 subjects were analysed: 334 subjects in the NP-staffed group and 504 in the resident-staffed group. The NP-staffed group was more likely to come from inpatient units (38.3% vs 16.5% for resident-staffed group; p < 0.001) and had lower disease severity (APACHE II score, 13.9 ± 8.4 vs 15.1 ± 8.2 for resident-staffed group; p = 0.047). After adjusting for age, sex, location before ICU admission, APACHE II score, and significantly different basic characteristics, there were no differences in ICU mortality, hospital mortality, or 30-day mortality between the two groups. Secondary analysis showed the NP-staffed group had a lower discharge rate to nonhome locations (2.1% vs 6.3%; p = 0.023) and shorter hospital stay (12.1 ± 14.1 vs 14.2 ± 14.3 days; p = 0.015).ConclusionsWe observed no difference in mortality between daytime NP-staffed and resident-staffed nonsurgical ICUs. Daytime NP-staffed care is an effective, safe, feasible method for staffing nonsurgical ICUs.     

Effect of Enhanced Recovery After Surgery Protocol on Patients Who Underwent Off-Pump Coronary Artery Bypass Graft

PurposeEnhanced recovery after surgery (ERAS) is an evidence-based perioperative measure to improve outcomes. Although the benefits of ERAS are well proven for other surgeries, little is known about its effect on off-pump coronary artery bypass graft (OPCABG) surgery. Thus, this study aimed to explore the effect of an ERAS protocol in patients who underwent OPCABG surgery.MethodsThis quasi-experimental study included 94 participants (traditional care group = 47 vs ERAS group = 47). An ERAS protocol was established by a multidisciplinary team. Knowledge of coronary artery disease, fasting time, water deprivation time, extubation time of the tracheal tube and pericardial and mediastinal drainage tube, off-bed activity participation rate, length of hospital stay, hours of intensive care unit (ICU) stay, expenses in ICU, incidence rates of ICU delirium and postoperative nausea and vomiting, and the 6-Minute Walk Test on postoperative day 7 were recorded and calculated between the groups.ResultsDemographics, lifestyle, and disease severity showed no significant difference between the two groups (p > .05). The ERAS group patients had improved understanding of coronary artery disease (t = −3.89, p < .01), shorter fasting time (t = 7.98, p < .01), shorter water deprivation time (t = 9.29, p < .01), increased off-bed activity participation (t = 17.67, p < .01), and the improved 6-Minute Walk Test on postoperative day 7 (t = −3.23, p < .01).ConclusionsThe ERAS protocol is safe and effective for patients undergoing OPCABG surgery.     

Prospective evaluation of bleeding risk among thrombocytopenic patients admitted in intensive care unit

PurposeBleeding risk evaluation of thrombocytopenic patients admitted in ICU has been poorly investigated.MethodsA prospective observational study conducted in an 18-bed medical ICU. Consecutive patients with thrombocytopenia (<150 Giga/L) and no bleeding at admission were included.ResultsOver one year, 91 patients were included, mainly men (63%), with an age of 61 [46–68] years and a SOFA score of 6 [3–8]. Twenty-three patients (25%) had an hemorrhagic event during ICU stay, mainly digestive (n = 9; 39%) and urological (n = 6; 26%). The time between ICU admission and bleeding was 8 [2–19] days. Almost half of bleeding events required vasopressor infusion and a hemostatic procedure. At admission, two variables were significantly different between the Bleeding and No-Bleeding groups: plasma urea level was significantly higher in the Bleeding group (9 [5.1; 13] vs. 13 [8.9; 31] mmol/L; p < 0.001) and the presence of skin purpura was associated with a 3-fold higher risk for bleeding during ICU stay (HR: 3.4 [1.3–8.3]; p < 0.05). In contrast, admission platelet count was not significantly different between the 2 groups (90 [32; 128] vs 62 [36; 103] G/L; p = 0.26).ConclusionPlasma urea levels and the presence of skin purpura are helpful in identifying thrombocytopenic patients at high-risk of bleeding during ICU stay.     

Clinical impact of lung ultrasound monitoring for diagnosis of ventilator associated pneumonia: A diagnostic randomized controlled trial

PurposeStudies have shown that lung-ultrasound may be superior to chest x-ray (CXR) in diagnosing ventilator-associated pneumonia (VAP). This study investigated whether the use of lung-ultrasound monitoring could detect VAP earlier and improve patient outcome.MethodsThis was a single-center diagnostic randomized controlled trial. In the control group, VAP was diagnosed using a combination of CXR and clinical findings. In the intervention group, VAP was diagnosed using a combination of lung-ultrasound and clinical findings. The primary outcome measured was ventilator free days (VFD). Secondary outcomes were ICU mortality, length of stay in ICU, change in Sequential Organ Failure Score at day 4 compared to day 0 (delta SOFA), antibiotic duration and ventilator days.ResultsWe randomized intubated patients until 44 VAP diagnosis was made in each group. VFD was higher in the intervention group than in the control group (7.80+/− 9.7 days versus 3.7+/− 6.4 days, p = .044). There were no differences between the groups in terms of ICU mortality (p=.104), ICU length of stay, (p = .058), ventilator days, (p = .081), delta SOFA (p = .10) and antibiotic duration (p = .70).ConclusionThe use of lung-ultrasound monitoring for diagnosis of VAP improves patient outcome when compared to the standard diagnostic strategy that relies on CXR.     

Short-term Effects of Alfacalcidol on Hospital Length of Stay in Patients Undergoing Valve Replacement Surgery: A Randomized Clinical Trial

PurposeVitamin D deficiency is highly prevalent in critically ill patients, and has been associated with more prolonged length of hospital stay and poor prognosis. Patients undergoing open-heart surgery are at higher risk due to the associated life-threatening postoperative complications. This study investigated the effect of alfacalcidol treatment on the length of hospital stay in patients undergoing valve-replacement surgery.MethodsThis single-center, randomized, open-label, controlled trial was conducted at El-Demerdash Cardiac Academy Hospital (Cairo, Egypt), from April 2017 to January 2018. This study included adult patients undergoing valve-replacement surgery who were randomized to the intervention group (n = 47; alfacalcidol 2 μg/d started 48 h before surgery and continued throughout the hospital stay) or to the control group (n = 42). The primary end points were lengths of stay (LOS) in the intensive care unit (ICU) and in the hospital. Secondary end points were the prevalence of postoperative hospital-acquired infections, cardiac complications, and in-hospital mortality.FindingsA total of 86 patients were included in the final analysis, with 51 (59.3%) being vitamin D deficient on hospital admission. Treatment with alfacalcidol was associated with a statistically significant decrease in ICU LOS (hazard ratio = 1.61; 95% CI, 1.77–2.81; P = 0.041) and hospital LOS (hazard ratio = 1.63; 95% CI, 1.04–2.55; P = 0.034). Treated patients had a significantly lower postoperative infection rate than did the control group (35.5% vs 56.1%; P = 0.017). The median epinephrine dose was lower in the intervention group compared to that in the control group (5.9 vs 8.2 mg; P = 0.019). The rate of in-hospital mortality was not significantly different between the 2 groups.ImplicationsEarly treatment with 2 μg of alfacalcidol in patients undergoing valve-replacement surgery is promising and well tolerated. This effect may be attributed to its immunomodulatory and cardioprotective mechanisms. ClinicalTrials.gov identifier: NCT04085770.     

Characteristics of pleural effusion due to paradoxical response in patients with pulmonary tuberculosis

BackgroundPatients with pulmonary tuberculosis may present with deterioration of pleural effusion during anti-tuberculosis therapy, referred to as a paradoxical response (PR), with some patients requiring additional intervention. However, PR may be confused with other differential diagnoses, and the predictive factors for recommending additional therapies are unknown. Therefore, this study aimed to reveal useful information for the diagnosis and intervention of PR.MethodsData from human immunodeficiency virus-negative patients with tuberculous pleurisy (n = 210), including 184 patients with pre-existing pleural effusion and 26 patients with PR at Fukujuji Hospital, were retrospectively collected from January 2012 to December 2022 and compared. Furthermore, patients with PR were divided into the intervention group (n = 9) and the no intervention group (n = 17) and were compared.ResultsPatients in the PR group had lower pleural lactate dehydrogenase (LDH) (median 177 IU/L vs. 383 IU/L, p < 0.001) and higher pleural glucose (median 122 mg/dL vs. 93 mg/dL, p < 0.001) levels than those in the preexisting pleural effusion group. Other pleural fluid data were not significantly different. Patients in the intervention group had a shorter duration from the initiation of anti-tuberculosis therapy to the development of PR than patients in the no intervention group (median 19.0 days [interquartile range (IQR): 18.0–22.0] vs. median 37.0 days [IQR: 28.0–58.0], p = 0.012).ConclusionThis study demonstrates that, apart from lower pleural LDH and elevated pleural glucose levels, PR presents with similar features to preexisting pleural effusion and that patients who develop PR faster tend to require intervention.     

One-year survival in patients with solid tumours discharged alive from the intensive care unit after unplanned admission: A retrospective study

PurposeOutcomes in cancer patients after unplanned ICU admission was reassessed.Methodsretrospective cohort of patients with solid tumours admitted to ICU over a 10 years period.Results622 patients (age 62 [53–70]) were analysed. The most common primary sites of cancer were lung (n = 133; 21.4%) and digestive tract (n = 126; 20.2%) The ICU mortality rate was 22.2% (n = 138). Among 470 ICU survivors, the 1-year mortality was 41.3% (95% CI, 36–45.9) (n = 167). Factors independently associated with 1-year mortality were ICU admission after 2010 (HR 0.53 (0.37–0.76), p < .001), disease status (respectively, HR = 1.88 (1.0.2–3.45), p = .002) for locally advanced cancer and HR = 2.23 (1.35–3.67), p = .003) for metastatic cancer), poor performance status (HR = 1.58 (1.08–2.31), p = .019), newly diagnosed cancer at ICU admission (HR = 2.02 (1.28–3.20), p = .003), inability to receive oncologic treatment after ICU discharge (HR = 5.34 (3.49–8.18), p < .001) and decision to withhold life-sustaining treatment during ICU stay (HR = 2.34 (1.50–3.65), p < .001).ConclusionsAmong the factors associated with one-year mortality after ICU discharge, the possibility of receiving oncologic treatment after ICU discharge seems crucial.     

Effectiveness of daily interruption of sedation in sedated patients with mechanical ventilation in ICU: A systematic review

PurposeTo evaluate the effectiveness of daily sedation interruption in patients with mechanical ventilation in intensive care unit (ICU).MethodsThe randomized controlled trials (RCTs) on the application of daily interruption of sedation in sedated patients with mechanical ventilation in ICU were collected through databases including Cochrane library, MEDLINE, Web of Knowledge, Embase, CNKI, CBM and VIP Data. Two reviewers independently assessed the quality of studies and extracted the data. Meta-analysis was conducted on the included studies.ResultsEight RCTs involving 757 patients were included. The daily sedation interruptions could shorten the duration of mechanical ventilation (Z = 5.36, p < 0.0001), length of stay (Z = 2.93, p = 0.003 < 0.05) and reduce the rate of tracheotomy (Z = 3.97, p < 0.00001) in these patients. Additionally, daily sedation interruption was not associated with increased rate of unplanned extubation by the patients (Z = 0.53, p = 0.6 < 0.05).ConclusionThe application of daily interruption of sedation in patients with mechanical ventilation in ICU is safe and effective.     

Mechanical ventilation and mortality among 223 critically ill patients with coronavirus disease 2019: A multicentric study in Germany

BackgroundThere are large uncertainties with regard to the outcome of patients with coronavirus disease 2019 (COVID-19) and mechanical ventilation (MV). High mortality (50–97%) was proposed by some groups, leading to considerable uncertainties with regard to outcomes of critically ill patients with COVID-19.ObjectivesThe aim was to investigate the characteristics and outcomes of critically ill patients with COVID-19 requiring intensive care unit (ICU) admission and MV.MethodsA multicentre retrospective observational cohort study at 15 hospitals in Hamburg, Germany, was performed. Critically ill adult patients with COVID-19 who completed their ICU stay between February and June 2020 were included. Patient demographics, severity of illness, and ICU course were retrospectively evaluated.ResultsA total of 223 critically ill patients with COVID-19 were included. The majority, 73% (n = 163), were men; the median age was 69 (interquartile range = 58–77.5) years, with 68% (n = 151) patients having at least one chronic medical condition. Their Sequential Organ Failure Assessment score was a median of 5 (3–9) points on admission. Overall, 167 (75%) patients needed MV. Noninvasive ventilation and high-flow nasal cannula were used in 31 (14%) and 26 (12%) patients, respectively. Subsequent MV, due to noninvasive ventilation/high-flow nasal cannula therapy failure, was necessary in 46 (81%) patients. Renal replacement therapy was initiated in 33% (n = 72) of patients, and owing to severe respiratory failure, extracorporeal membrane oxygenation was necessary in 9% (n = 20) of patients. Experimental antiviral therapy was used in 9% (n = 21) of patients. Complications during the ICU stay were as follows: septic shock (40%, n = 90), heart failure (8%, n = 17), and pulmonary embolism (6%, n = 14). The length of ICU stay was a median of 13 days (5–24), and the duration of MV was 15 days (8–25). The ICU mortality was 35% (n = 78) and 44% (n = 74) among mechanically ventilated patients.ConclusionIn this multicentre observational study of 223 critically ill patients with COVID-19, the survival to ICU discharge was 65%, and it was 56% among patients requiring MV. Patients showed high rate of septic complications during their ICU stay.     

Completely Reversed Flow in the Vertebral Artery Does Not Always Indicate Subclavian Steal Phenomenon

We evaluated the causes, differential diagnosis and clinical significance of completely reversed flow (CRF) in the vertebral artery (VA). Twenty-three patients diagnosed with CRF in the VA by Doppler ultrasound were studied retrospectively. CRF was divided into intermittent CRF and continuous CRF. The peak reversed velocity (PRV) and ratio of time in intermittent CRF to one cardiac cycle (t_ICRF/CC) were calculated. Causes of CRF were determined on the basis of previous angiography results. The results indicated that subclavian steal phenomenon (SSP) caused all cases of continuous CRF (n = 8). Intermittent CRF was caused by SSP (n = 6) or proximal VA occlusion (n = 9). PRV and t_ICRF/CC were increased in SSP as compared with VA occlusion (p < 0.05). Using a cutoff of t_ICRF/CC = 0.30, we achieved excellent accuracy in predicting the cause of intermittent CRF (100%) and posterior circulatory infarction (91%). Thus, analysis of CRF patterns and measurements of VA parameters can be used in differential diagnosis of the causes of CRF and in prediction of posterior circulatory infarction.     

Intensive Care Unit prioritization: The impact of ICU bed availability on mortality in critically ill patients who requested ICU admission in court in a Brazilian cohort

PurposeTo assess hospital mortality in patients who requested ICU admission in court due to the scarcity of ICU beds in the Brazilian public health system and the consequences of these judicial litigations.Material and methodsRetrospective cohort study that included adult patients from the public health system of the Federal District, Brazil, who claimed ICU admission in court from January 2017 to December 2019.ResultsOf the 1752 patients, 1031 were admitted to ICU (58.8%). Hospital mortality was 61.1% (1071/1752). Of the requests, 768 (43.8%) were made by patients with priority levels III or IV, resulting in the ICU admission of 33.9% of these patients. Denial of ICU admission (p < 0.001) increased mortality. ICU admission reduced hospital mortality in patients classified as priority level I (p < 0.001), priority level II (p < 0.001), and priority level III (p < 0.001), but not as priority level IV (p = 0.619).ConclusionA large proportion of patients was denied ICU admission and it was associated with an increased mortality. A considerable portion of the ICU-admitted patients were classified as priority level III and IV, impairing the ICU admission of patients with priority level I which are the ones with the greatest benefit from it.     

Wearing a N95 mask increases rescuer's fatigue and decreases chest compression quality in simulated cardiopulmonary resuscitation

ObjectivesN95 mask is essential for healthcare workers dealing with the coronavirus disease 2019 (COVID-19). However, N95 mask causes discomfort breathing with marked reduction in air exchange. This study was designed to investigate whether the use of N95 mask affects rescuer's fatigue and chest compression quality during cardiopulmonary resuscitation (CPR).MethodsAfter a brief review of CPR, each participant performed a 2-minute continuous chest compression on a manikin wearing N95 (N95 group, n = 40) or surgical mask (SM group, n = 40). Compression rate and depth, the proportions of correct compression rate, depth, complete chest recoil and hand position were documented. Participants' fatigue was assessed using Borg score.ResultsSignificantly lower mean chest compression rate and depth were both achieved in the N95 group than in the SM group (p < 0.05, respectively). In addition, the proportion of correct compression rate (61 ± 19 vs. 75 ± 195, p = 0.0067), depth (67 ± 16 vs. 90 ± 14, p < 0.0001) and complete recoil (91 ± 16 vs. 98 ± 5%, p = 0.0248) were significantly decreased in the N95 group as compared to the SM group. At the end of compression, the Borg score in the N95 group was significantly higher than that in the SM group (p = 0.027).ConclusionWearing a N95 mask increases rescuer's fatigue and decreases chest compression quality during CPR. Therefore, the exchange of rescuers during CPR should be more frequent than that recommended in current guidelines when N95 masks are applied.     

Nursing implementation of a validated agitation and sedation scale: An evaluation of its outcomes on ventilator days and ICU length of stay

BackgroundIntensive Care Units (ICU) often initiate mechanical ventilation (MV) in conjunction with sedation for patients who cannot maintain adequate oxygenation or ventilation on their own. Continuous use of sedation increases the likelihood of negative events associated with ventilators such as ventilator-associated pneumonia while, at the same time, continuing to increase the length of MV. OBJECTIVES: This study sought to analyze the effects of implementing a mandated Richmond Agitation and Sedation Scale (RASS) entry with each sedative scan on a unit where no parameters were in place to monitor sedation levels.MethodsThis was a retrospective cross-sectional study which included chart-review of a Medical ICU. The data was gathered on ventilator days and sedation use for patients prior to and after the implementation of the RASS.ResultsA median weighted analysis and Mann-Whitney U test of 138 pre-RASS ventilator patients and 86 post-RASS ventilator patients appears to indicate that implementation of the RASS resulted in a 31% decrease of ventilator days (p = .0002). The pulmonary diagnosis subgroup showed a significant 39% reduction in ICU length of stay (U = 324, p = .042).ConclusionsThe results of this study lead to the conclusion that the implementation of the mandated RASS score entry limits over-sedation of ventilated patients, thereby reducing the number of MV days in the ICU. Sufficient evidence suggests that the mandated RASS entry also reduces the length of stay in the ICU.     

Muscle degradation,vitamin D and systemic inflammation in hospitalized septic patients

PurposeTo date, the relationship between systemic inflammation and muscle changes observed by ultrasonography in septic patients in clinical studies is not known. Furthermore, the role of vitamin D on muscle changes in these patients needs to be investigated.Materials and methodsForty-five patients admitted to the ICU due to severe sepsis or septic shock. Blood samples were collected to evaluate systemic inflammation (interleukin (IL)-10, IL-1β, IL-1α, IL-6, IL-8 and tumor necrosis factor–α(TNF-α)) and vitamin D. Muscle mass was evaluated by ultrasound during hospitalization. Clinical tests of muscle strength (Medical Research Council (MRC) scale and handgrip) were performed after the awakening of patients.ResultsThere was a reduction in day 2 values to hospital discharge on TNF-alpha, IL-8, IL-6 and IL-10 (p < .05). The muscle mass showed a significant decline from day 6 of the ICU. After awakening, the patients had a significant increase in muscle strength (p < .05). There was a positive association between muscle mass variation (day 2 - ICU) with absolute values of IL-8 (r = 0.38 p = .05). For muscle strength, there was a negative association between handgrip strength with IL-8 (r = −0.36 p < .05) on ICU discharge. The vitamin D showed a positive association with the handgrip strength of the day 1 of the awakening (r = 0.51 p < .05).ConclusionsIn septic patients, there is an association between inflammation and changes in muscle mass and strength during ICU stay, which is similar to those observed in experimental studies. In addition, there was an association of vitamin D with recovery of muscle strength during hospitalization.     

Macrolide-based regimens in absence of bacterial co-infection in critically ill H1N1 patients with primary viral pneumonia

Purpose

To determine whether macrolide-based treatment is associated with mortality in critically ill H1N1 patients with primary viral pneumonia.

Methods

Secondary analysis of a prospective, observational, multicenter study conducted across 148 Intensive Care Units (ICU) in Spain.

Results

Primary viral pneumonia was present in 733 ICU patients with pandemic influenza A (H1N1) virus infection with severe respiratory failure. Macrolide-based treatment was administered to 190 (25.9 %) patients. Patients who received macrolides had chronic obstructive pulmonary disease more often, lower severity on admission (APACHE II score on ICU admission (13.1 ± 6.8 vs. 14.4 ± 7.4 points, p < 0.05), and multiple organ dysfunction syndrome less often (23.4 vs. 30.1 %, p < 0.05). Length of ICU stay in survivors was not significantly different in patients who received macrolides compared to patients who did not (10 (IQR 4–20) vs. 10 (IQR 5–20), p = 0.9). ICU mortality was 24.1 % (n = 177). Patients with macrolide-based treatment had lower ICU mortality in the univariate analysis (19.2 vs. 28.1 %, p = 0.02); however, a propensity score analysis showed no effect of macrolide-based treatment on ICU mortality (OR = 0.87; 95 % CI 0.55–1.37, p = 0.5). Moreover, the sensitivity analysis revealed very similar results (OR = 0.91; 95 % CI 0.58–1.44, p = 0.7). A separate analysis of patients under mechanical ventilation yielded similar results (OR = 0.77; 95 % CI 0.44–1.35, p = 0.4).

Conclusion

Our results suggest that macrolide-based treatment was not associated with improved survival in critically ill H1N1 patients with primary viral pneumonia.     

Hepatic dysfunction impairs prognosis in critically ill patients with hematological malignancies: A post-hoc analysis of a prospective multicenter multinational dataset

PurposeHyperbilirubinemia is frequent in patients with hematological malignancies admitted to the intensive care unit (ICU). Literature about hepatic dysfunction (HD) in this context is scarce.MethodsWe investigated the prognostic impact of HD analyzing a prospective multicenter cohort of 893 critically ill hematology patients. Two groups were defined: patients with HD (total bilirubin ≥33 μmol/L at ICU admission) and patients without HD.ResultsTwenty one percent of patients were found to have HD at ICU admission. Cyclosporine, antimicrobials before ICU admission, abdominal symptoms, ascites, history of liver disease, neutropenia, increased serum creatinine and myeloma were independently associated with HD. Etiology remained undetermined in 73% of patients. Hospital mortality was 56.3% and 36.3% respectively in patients with and without HD (p < 0.0001). Prognostic factors independently associated with hospital mortality in HD group were, performance status >1 (OR = 2.07, 95% CI = 1.49–2.87, p < 0.0001), invasive mechanical ventilation (OR = 3.92, 95% CI = 2.69–5.71, p < 0.0001), renal replacement therapy (OR = 1.74, 95% CI = 1.22–2.47, p = 0.002), vasoactive drug (OR = 1.81, 95% CI = 1.21–2.71, p = 0.004) and SOFA score without bilirubin level at ICU admission (OR = 1.09, 95% CI = 1.04–1.14, p < 0.0001).ConclusionsHD is common, underestimated, infrequently investigated, and is associated with impaired outcome in critically ill hematology patients. HD should be considered upon ICU admission and managed as other organ dysfunctions.     

Are there different gait profiles in patients with advanced knee osteoarthritis? A machine learning approach

BackgroundDetermine whether knee kinematics features analyzed using machine-learning algorithms can identify different gait profiles in knee OA patients.Methods3D gait kinematic data were recorded from 42 patients (Kellgren-Lawrence stages III and IV) walking barefoot at individual maximal gait speed (0.98 ± 0.34 m/s). Principal component analysis, self-organizing maps, and k-means were applied to the data to identify the most relevant and discriminative knee kinematic features and to identify gait profiles.FindingsFour different gait profiles were identified and clinically characterized as type 1: gait with the knee in excessive varus and flexion (n = 6, 14%, increased knee adduction and increased maximum and minimum knee flexion, p < 0.01); type 2: gait with knee external rotation, either in varus or valgus (n = 11, 26%, excessive maximum and minimum external rotation, p < 0.001); type 3: gait with a stiff knee (n = 17, 40%, decreased knee flexion range of motion, p < 0.001); and type 4: gait with knee varus ‘thrust’ and decreased rotation (n = 8, 19%, increased and reduced range of motion in the coronal and transverse plane, respectively, p < 0.05).InterpretationIn a group of patients with homogeneous Kellgren-Lawrence classification of knee OA, gait kinematics data permitted to identify four different gait profiles. These gait profiles can be a valuable tool for helping surgical decisions and treatment. To allow generalization, further studies should be carried with a larger and heterogeneous population.     

Physiotherapy screening of patients referred for orthopaedic consultation in primary healthcare – A randomised controlled trial

A large proportion of patients who consult primary healthcare for musculoskeletal pain are referred for orthopaedic consultation, but only a small number of these patients are appropriate for orthopaedic intervention. Experienced physiotherapists have the appropriate knowledge to manage musculoskeletal disorders. The primary aim of this randomised study was therefore to evaluate a screening by a physiotherapist of patients referred for orthopaedic consultation compared to standard practice in primary care.Patients referred for orthopaedic consultation (n = 203) were randomised to physiotherapy screening or standard practice. Selection accuracy for orthopaedic intervention and other referrals were analysed with proportion analysis. Patient views of the quality of care were analysed with Mann–Whitney U-test, waiting time with Independent t-test.There was higher selection accuracy for orthopaedic intervention in the physiotherapy screening group (p = 0.002). A smaller proportion of patients in the screening group were referred back to their general practitioner (GP) (p < 0.001) and a larger proportion to the physiotherapy clinic (p < 0.001) compared to standard practice. The proportion of patients referred for further investigations was significantly lower in the physiotherapy screening group (p < 0.039). Waiting time was shorter in the screening group (p < 0.001). A large proportion of the patients reported no hesitation to attend the clinic for future care, no difference between the groups (p < 0.95).The findings in this study suggest that an experienced physiotherapist effectively can screen patients referred for orthopaedic consultation in primary healthcare.     

Impact of obstructive sleep apnea on the obesity paradox in critically ill patients

ObjectivePatients admitted to an intensive care unit (ICU) frequently suffer from multiple chronic diseases, including obstructive sleep apnea (OSA). Until recently OSA was not considered as a key determinant in an ICU patient's prognosis. The objective of this study was to document the impact of OSA on the prognosis of ICU patients.MethodsData were retrospectively collected concerning adult patients admitted to ICU at two university hospitals. In a nested study OSA status was checked using the hospital electronic medical records to identify exposed and unexposed cases. The following outcomes were considered: length of stay in the ICU, ICU mortality, in-hospital mortality, ventilator-associated pneumonia (VAP).ResultsOut of 5146 patients included in the study, 289 had OSA at ICU admission (5.6%). After matching, the overall impact of OSA on length of ICU stay was not significant (p = .24). In a predefined subgroup analysis, there was a significant impact of OSA on the length of ICU stay for patients with BMI over 40 kg/m² (IRR: 1.56 [1.05; 2.32], p = .03). OSA status had no impact on ICU or hospital mortality and VAP.ConclusionIn general, known OSA did not increase the ICU stay except for patients with both OSA and morbid obesity.     

Loop-mediated isothermal amplification method for diagnosing Pneumocystis pneumonia in HIV-uninfected immunocompromised patients with pulmonary infiltrates

Loop-mediated isothermal amplification (LAMP) is becoming an established nucleic acid amplification method offering rapid, accurate, and cost-effective diagnosis of infectious diseases. We retrospectively evaluated 78 consecutive HIV-uninfected patients who underwent LAMP method for diagnosing Pneumocystis pneumonia (PCP). Diagnosis of PCP was made by the detection of Pneumocystis jirovecii (P. jirovecii) with positive LAMP or conventional staining (CS) (Grocott methenamine silver staining or Diff-Quick™) on the basis of compatible clinical symptoms and radiologic findings. Additionally, we reviewed HIV-uninfected immunocompromised patients who underwent subcontract PCR as a historical control. LAMP was positive in 10 (90.9%) of 11 positive-CS patients. Among 13 negative-CS patients with positive LAMP, 11 (84.6%) had PCP, and the remaining 2 were categorized as having P. jirovecii colonization. LDH levels in negative-CS PCP were higher than in positive-CS PCP (p = 0.026). (1 → 3)-β-D-glucan levels in negative-CS PCP were lower than in positive-CS PCP (p = 0.011). The interval from symptom onset to diagnosis as PCP in LAMP group (3.45 ± 1.77 days; n = 22) was shorter than in subcontract PCR group (6.90 ± 2.28 days; n = 10; p < 0.001). As for patients without PCP, duration of unnecessary PCP treatment in LAMP group (2; 2–3 days; n = 10) was shorter than in subcontract PCR group (7; 7–12.25 days; n = 6; p = 0.003). LAMP showed higher sensitivity (95.4%) and positive predictive value (91.3%) than subcontract PCR did. Pneumocystis LAMP method is a sensitive and cost-effective diagnostic method and is easy to administer in general hospitals. In-house LAMP method would realize early diagnosis of PCP, resulting in improving PCP prognosis and reducing unnecessary PCP-specific treatment.