Factors associated with myocardial infarction after emergency endoscopy for upper gastrointestinal bleeding in high-risk patients: a prospective observational study

BACKGROUND: Because myocardial infarction (MI) after emergency endoscopy for upper gastrointestinal bleeding carries high mortality, we investigated factors associated with procedure-related MI in high-risk patients. METHODS: Consecutive patients with coronary artery disease or age-based risk for coronary artery disease (men, age >45 years; women, >55 years) who underwent emergency endoscopy were enrolled at a single ED. Demographic, laboratory, and outcome data were recorded. Patients fit 1 of 3 groups: MI before endoscopy (pre-panendoscopy [PES] MI), MI after endoscopy (post-PES MI), or non-MI. RESULTS: We enrolled 108 high-risk patients, including 5 (4.6%) with MI diagnosed preendoscopy. Five patients (4.6%) had MIs postendoscopy. Compared with non-MI patients, significantly more post-PES MI patients had heart disease (60.0% vs 12.2%; P = .021), lower systolic pressure on arrival (86.2 +/- 16.6 vs 128.0 +/- 27.2 mm Hg; P = .002), lower diastolic pressure on arrival (50.0 +/- 6.3 vs 69.5 +/- 15.8 mm Hg; P = .003), lower hemoglobin on arrival (6.7 +/- 1.1 vs 9.1 +/- 2.4 g/dL; P = .021), and more persistent shock status preendoscopy (80.0% vs 13.3%; P = .002). There was no significant difference in factors including duration of procedure and rates of recurrent bleeding, postprocedure complication, and mortality. CONCLUSIONS: Heart disease, lower blood pressure or hemoglobin level on arrival, and persistent shock before endoscopy are associated with increased risk for procedure-related MI.     

Type 2 diabetes and acute myocardial infarction. Angiographic findings and results of an invasive therapeutic approach in type 2 diabetic versus nondiabetic patients.

OBJECTIVE: Mortality in diabetic patients with acute myocardial infarction (MI) is high. The significance of the pretreatment coronary status in type 2 diabetic patients with acute MI, as well as the effect of mechanical revascularization using percutaneous transluminal coronary angioplasty (PTCA), has not been established. RESEARCH DESIGN AND METHODS: All patients with type 2 diabetes and acute MI (n = 54) were prospectively enrolled into a study of immediate coronary angiography to guide PTCA of the occluded infarct vessel. Hospital and long-term course were assessed and compared with an unselected control group of nondiabetic patients (n = 358) who were enrolled in the same study. RESULTS: Angiography showed that sites of occlusion and acute coronary flow were similar in both groups. Multivessel disease and shock were more common in type 2 diabetic versus nondiabetic patients: 69 vs. 51% and 21 vs. 10% (P < 0.02), respectively. Direct PTCA was successful in > 90% in both groups. Mortality after 30 days was 13% in type 2 diabetic patients versus 5% in patients without diabetes (P < 0.04). Left ventricular (LV) ejection fraction before discharge was lower in diabetic patients (48 +/- 17 vs. 55 +/- 15%, P < 0.05). Mortality 1 year after discharge was 11 vs. 4% in diabetic versus nondiabetic patients (P < 0.02). Multivariate analysis identified type 2 diabetes as an independent risk factor for acute, but not for late, mortality. CONCLUSIONS: Direct PTCA is safe and effective in type 2 diabetic patients with acute MI. Mortality after 30 days in unselected diabetic patients is < 15% with this approach. Advanced disease and shock contribute to an increased mortality in type 2 diabetic patients with acute MI versus nondiabetic patients.     

Effect of peripheral arterial disease in patients undergoing percutaneous coronary intervention with intracoronary stents

OBJECTIVE: To compare the short-term and long-term outcomes of patients with coronary artery disease and peripheral arterial disease (PAD) who underwent intracoronary (IC) stent Implantation during percutaneous coronary intervention (PCI) with the outcomes of patients with isolated coronary artery disease but without PAD who underwent IC stent implantation. PATIENTS AND METHODS: We analyzed the outcomes of 7696 patients who underwent IC stent implantation during PCI at the Mayo Clinic in Rochester, Minn, between January 1996 and December 2002. Outcomes of 6299 patients (82%) with Isolated coronary artery disease and without PAD who underwent IC stent implantation (group 1) were compared with outcomes of 1397 patients (18%) with coronary artery disease and PAD (group 2) who underwent PCI with IC stent implantation. RESULTS: Patients in group 2 were older (71.1+/-10.2 years vs 65.0+/-12.0 years; P<.001) and had a higher prevalence of hypertension (79% vs 61%; P<.001), diabetes mellitus (33% vs 20%; P<.001), hyperlipidemia (76% vs 70%; P<.001), and history of smoking (70% vs 63%; P<.001) compared with group 1. Prevalence of multivessel disease was higher in group 2 (79% vs 68%; P<.001). Procedural success was significantly lower In group 2 (95% vs 97%; P<.001). In-hospital complications were higher in group 2: death (3% vs 1%; P<.001), any myocardial Infarction (MI) (8% vs 5%; P<.001), death/MI/coronary artery bypass grafting (CABG)/target vessel revascularization (11% vs 7%; P<.001), and blood loss requiring transfusion (11% vs 5.8%; P<.001). After adjustment for other risk factors, the odds ratio for in-hospital death was 1.84 (95% confidence interval [CI], 1.16-2.90; P=.009), and for death/MI/CABG/target vessel revascularization, the odds ratio was 1.25 (95% CI, 1.00-1.55; P=.048) in patients with PAD treated with IC stents. Median follow-up was 3.1 years. Six-month, 1-year, and 2-year Kaplan-Meier estimates of survival free of death/MI/CABG/target vessel revascularization were 84%, 77%, and 69%, respectively, for group 2 and were significantly worse compared with group 1 (89%, 85%, and 80%, respectively; P<.001). This effect remained after adjustment for other risk factors (hazard ratio, 1.36; 95% CI, 1.22-1.51). CONCLUSIONS: Compared with patients who had isolated coronary artery disease but no PAD, patients with coronary artery disease and PAD had lower procedural success and higher in-hospital major cardiovascular complications, including higher blood loss requiring transfusion, after PCI with stent Implantation. On follow-up, the short-term and long-term outcomes of patients with PAD were worse, with higher mortality, MI, and need for repeated target vessel revascularization.     

重症医学科严重大出血患者预后危险因素

  目的  探讨影响重症医学科病房(Intensive Care Unit, ICU)严重大出血患者预后的危险因素。  方法  回顾性分析北京协和医院2013年1月至2015年12月全部收住ICU 24 h内输注红细胞(red blood cell, RBC)超过20 U的大出血患者的临床资料, 比较生存组与死亡组的差异, 并采用Logistic回归分析影响这些患者预后的危险因素。  结果  研究共纳入严重大出血患者141例, 生存组和死亡组患者分别为78例和63例, 住院死亡率44.7%。其中非手术相关大出血78例, 手术相关大出血63例。全部严重大出血患者死亡组ICU输RBC量(P=0.002)、非手术相关大出血患者的比例(P=0.002)以及来自急诊的大出血患者的比例(P=0.010)均显著高于生存组, 而来自手术科室患者的比例低于生存组(P=0.001), 输RBC前凝血功能, 肝、肾功能明显较生存组差(P均 < 0.05)。在非手术相关大出血患者中, 死亡组感染造成大出血患者的比例显著高于生存组(P=0.009), 而应激性溃疡导致大出血患者的比例(P=0.048)、输RBC前血小板水平(P=0.003)和采用手术止血措施的患者比例(P=0.039)均显著低于生存组。在手术相关大出血患者中, 死亡组ICU输RBC量显著多于生存组(P=0.019), 输RBC前基线肝、肾功能受损的比例显著高于生存组(P均 < 0.05)。Logistic回归分析显示患者凝血功能紊乱(P=0.014, OR=3.594)及入ICU后仍存在活动性大出血(P=0.025, OR=2.680)为全部严重大出血患者死亡危险因素。  结论  患者凝血功能紊乱及入ICU后仍存在活动性大出血是严重大出血患者的死亡危险因素。     

Sinus Mapping in Patients with Cardiac Arrest and Coronary Disease—Results and Correlation with Outcome

Electrophysiological testing and left ventricular endocardial mapping in sinus rhythm were performed in 61 patients with coronary artery disease who presented with cardiac arrest in an attempt to relate the results of these studies to clinical outcome. Forty-one patients (67%) had inducible sustained arrhythmias (18 uniform ventricular tachycardia, 23 polymorphic ventricular tachycardia/ventricular fibrillation) and 20 had no inducible arrhythmia. Patients with inducible arrhythmia had 45% abnormal and 6% fractionated electrograms versus 31% and 0% for those without inducible arrhythmia (P greater than 0.05 for both comparisons). Sixteen of 59 patients (27%) with adequate follow-up had arrhythmia recurrence (11/39 [31%] with inducible arrhythmia and 5/20 [25%] without inducible arrhythmia) over a mean follow-up period of 27 months. Of five patients without inducible arrhythmia who experienced recurrence, two did so despite the anti-ischemic therapy. In the 20 patients without inducible arrhythmia, the 15 who remained arrhythmia-free had a mean of 78 +/- 22% normal sites versus 46 +/- 24% normal sites in those with recurrence (P greater than 0.05). We conclude that in patients with coronary artery disease and cardiac arrest: 1) patients without inducible arrhythmia have less marked endocardial electrical abnormality than those with inducible arrhythmia, 2) those patients who have marked endocardial abnormality despite the lack of inducible arrhythmia are at risk for clinical recurrence which suggests that these abnormalities may represent an anatomic substrate for arrhythmia which cannot be identified by programmed stimulation. These patients are candidates for AICD implantation and 3) patients with relatively normal endocardial electrograms do well with anti-ischemic therapy alone.     

Left ventricular systolic and diastolic dyssynchrony in coronary artery disease with preserved ejection fraction

The present study aims to evaluate LV (left ventricular) mechanical dyssynchrony in CAD (coronary artery disease) with preserved and depressed EF (ejection fraction). Echocardiography with TDI (tissue Doppler imaging) was performed in 311 consecutive CAD patients (94 had preserved EF > or =50% and 217 had depressed EF <50%) and 117 healthy subjects to determine LV systolic and diastolic dyssynchrony by measuring Ts-SD (S.D. of time to peak myocardial systolic velocity during the ejection period) and Te-SD (S.D. of time to peak myocardial early diastolic velocity during the filling period) respectively, using a six-basal/six-mid-segmental model. In CAD patients with preserved EF, both Ts-SD (32.2+/-17.3 compared with 17.7+/-8.6 ms; P<0.05) and Te-SD (26.2+/-13.6 compared with 20.3+/-8.1 ms; P<0.05) were significantly prolonged when compared with controls, although they were less prolonged than CAD patients with depressed EF (Ts-SD, 37.8+/-16.5 ms; and Te-SD, 36.0+/-23.9 ms; both P<0.005). Patients with preserved EF who had no prior MI (myocardial infarction) had Ts-SD (32.9+/-17.5 ms) and Te-SD (28.6+/-14.8 ms) prolonged to a similar extent (P=not significant) to those with prior MI (Ts-SD, 28.4+/-16.8 ms; and Te-SD, 25.5+/-15.0 ms). Patients with class III/IV angina or multi-vessel disease were associated with more severe mechanical dyssynchrony (P<0.05). Furthermore, the majority of patients with mechanical dyssynchrony had narrow QRS complexes in those with preserved EF. This is in contrast with patients with depressed EF in whom systolic and diastolic dyssynchrony were more commonly associated with wide QRS complexes. In conclusion, LV mechanical dyssynchrony is evident in CAD patients with preserved EF, although it was less prevalent than those with depressed EF. In addition, mechanical dyssynchrony occurred in CAD patients without prior MI and narrow QRS complexes.     

Enteral alimentation and gastrointestinal bleeding in mechanically ventilated patients

The incidence of upper gastrointestinal (GI) bleeding in mechanically ventilated ICU patients receiving enteral alimentation was reviewed and compared to bleeding occurring in ventilated patients receiving prophylactic antacids or cimetidine. Of 250 patients admitted to our ICU during a 1-yr time period, 43 ventilated patients were studied. Patients in each group were comparable with respect to age, respiratory diagnosis, number of GI hemorrhage risk factors, and number of ventilator, ICU, and hospital days. Twenty-one patients had evidence of GI bleeding. Fourteen of 20 patients receiving antacids and 7 of 9 patients receiving cimetidine had evidence of GI bleeding. No bleeding occurred in 14 patients receiving enteral alimentation. Complications of enteral alimentation were few and none required discontinuation of enteral alimentation. Our preliminary data suggest the role of enteral alimentation in critically ill patients may include not only protection against malnutrition but also protection against GI bleeding.     

Spatial distribution of repolarization times in patients with coronary artery disease

The potential clinical value of QT dispersion (QTd), a measure of the interlead range of QT interval duration in the surface 12-lead ECG, remains ambiguous. The aim of the study was the temporal and spatial analysis of the QT interval in healthy subjects and in patients with coronary artery disease (CAD) using magnetocardiography (MCG) and surface ECG. Standard 12-lead ECG and 37-channel MCG were performed in 20 healthy subjects, 23 patients with CAD without prior myocardial infarction (MI), 31 MI patients and 11 MI patients with ventricular tachycardia (VT). QTd was increased in CAD without MI compared to normals (ECG 46.1 +/- 6.0 vs 42.8 +/- 5.0, P < 0.05; MCG 66.8 +/- 20.3 vs 49.7 +/- 10.8, P < 0.01) and in VT compared to MI (ECG 66.8 +/- 16.5 vs 51.9 +/- 16.6, P < 0.05; MCG 93.6 +/- 29.6 vs 66.8 +/- 20.8, P < 0.005). In MCG, spatial distribution of QT intervals in patient groups differed from those in healthy subjects in three ways: (1) greater dispersion, (2) greater local variability, and (3) a change in overall pattern. This was quantified on the basis of smoothness indexes (SI). Normalized SI was higher in CAD without MI compared to normals (3.8 +/- 1.1 vs 2.7 +/- 0.6, P < 0.001) and in VT compared to MI (6.4 +/- 1.6 vs 4.2 +/- 1.4, P < 0.0005). For the normal-CAD comparison a sensitivity of 74% and a specificity of 80% was obtained, for MI-VT, 100% and 77%, respectively. The results suggest that examining the spatial interlead variability in multichannel MCG may aid in the initial identification of CAD patients with unimpaired left ventricular function and the identification of post-MI patients with augmented risk for VT.     

Primary and secondary intra-abdominal hypertension—different impact on ICU outcome

OBJECTIVE: To investigate the differences in incidence, time course and outcome of primary versus secondary intra-abdominal hypertension (IAH), and to evaluate IAH as an independent risk factor of mortality in a presumable risk population of critically ill patients. DESIGN: Prospective observational study. SETTING: General intensive care unit of a university hospital. PATIENTS: A total of 257 mechanically ventilated patients at presumable risk for the development of IAH were studied during their ICU stay and followed up for 90-day survival. INTERVENTIONS: Repeated measurements of intra-abdominal pressure (IAP). MEASUREMENTS AND RESULTS: IAP was measured intermittently, via bladder. IAH (sustained or repeated IAP >/= 12 mmHg) developed in 95 patients (37.0%). Primary IAH was observed in 60 and secondary IAH in 35 patients. Patients with secondary IAH demonstrated a significant increase of mean IAP during the first three days (mean DeltaIAP was 2.2 +/- 4.7 mmHg), whilst IAP decreased (mean DeltaIAP -1.1 +/- 3.7 mmHg) in the patients with primary IAH. The patients with IAH had a significantly higher ICU- (37.9 vs. 19.1%; P = 0.001), 28-day (48.4 vs. 27.8%, P = 0.001), and 90-day mortality (53.7 vs. 35.8%, P = 0.004) compared to the patients without the syndrome. Patients with secondary IAH had a significantly higher ICU mortality than patients with primary IAH (P = 0.032). Development of IAH was identified as an independent risk factor for death (OR 2.52; 95% CI 1.23-5.14). CONCLUSIONS: Secondary IAH is less frequent, has a different time course and worse outcome than primary IAH. Development of IAH during ICU period is an independent risk factor for death.     

Nonhemorrhagic gastrointestinal complications in acute respiratory failure

While GI hemorrhage is a recognized complication of critical illness, nonhemorrhagic GI complications are less well described. We studied prospectively the incidence and predisposing factors of nonhemorrhagic GI complications in 124 acute respiratory failure (ARF) patients over a 13-month period. Diarrhea occurred in 51% (63/124), decreased bowel sounds in 50% (62/124), and abdominal distention in 46% (57/124). Patients with pneumonia as the etiology of respirator failure had the highest number of different complications (five per ICU stay). Ileus was found more frequently in patients with a past history of liver disease (p less than .03). Antacid administration was associated with a significant increase in diarrhea (p less than .01), as were the combined treatments of antacids and cimetidine (p less than .02). Patients with ARF have a high incidence of nonhemorrhagic GI complications. Diarrhea is the most common complication and occurs more frequently in patients who receive antacids.     

Clinical features and prognostic implications of severe corticosteroid-treated cryptogenic chronic active hepatitis

To assess the nature and prognosis of severe chronic active hepatitis of unknown cause, we compared 26 patients who had been fully screened for etiologic factors with 112 patients who had autoimmune chronic active hepatitis after similar durations of corticosteroid therapy (17(+)/- 2 versus 23 (+)/- 2 months), and follow-up versus 103 +/- 7 months). Patients with cryptogenic disease could not be distinguished from those with autoimmune disease on the basis of age, sex distribution, duration of illness, immunoglobulin levels, frequency of concurrent immunologic disorders, or histologic findings. Serum gamma-globulin levels were higher (3.4 +/- 0.1 versus 2.5 +/- 0.2 g/dl, P = 0.007) and albumin levels were lower (2.9 +/- 0.1 versus 3.3 +/- 0.1 g/dl, P = 0.003) in patients with autoimmune disease than in those with cryptogenic disease, but individual findings did not differentiate the patients. Remission (69 versus 75%), treatment failure (23 versus 13%), relapse after drug withdrawal (67 versus 68%), progression to cirrhosis (57 versus 36%), and death from hepatic failure (12 versus 11%) occurred as commonly in patients with cryptogenic as in those with autoimmune disease. Patients with different constellations of immunoserologic findings were similar clinically. We conclude that patients with severe chronic active hepatitis who have been fully screened for etiologic factors cannot be distinguished from patients with autoimmune disease of comparable severity. These two groups of patients have a similar prognosis after corticosteroid therapy, and such treatment should be considered in these highly selected patients.     

Gastrointestinal dysfunction among intensive care unit patients

This study used the Acute Physiological and Chronic Health Evaluation (APACHE II) system to select two groups of ICU patients with comparable risk of hospital death to evaluate the importance of GI dysfunction, defined as failure to tolerate enteral nutrition (EN), as a prognostic factor. In our ICU, patients who have not undergone recent bowel surgery are treated by EN. Those patients who cannot tolerate EN are treated by total parenteral nutrition (TPN). One hundred and eleven patients who tolerated EN (functioning gut) and 97 TPN patients who failed to tolerate EN (GI dysfunction) were studied. The mean APACHE II scores of the two groups were 17.7 +/- 6.5 (SD) and 17.7 +/- 5.1, respectively. The observed mortality of patients with GI dysfunction (51%) was significantly higher (p less than .0005) than that of patients with a functioning gut (25%). This was associated with significantly poorer APACHE II mean BP, oxygenation, and creatinine scores among the GI dysfunction patients. Our results suggest that shock, ischemia, and hypoxemia, in addition to causing impairment of renal function, may bring about changes in the GI tract, evident clinically only as a failure to tolerate EN, which have an adverse effect on the prognosis of ICU patients so affected.     

综合重症监护治疗病房患者发生腹泻的相关因素分析

目的 分析综合重症监护治疗病房(ICU)患者发生腹泻的相关因素,以指导临床制订最佳治疗方案。方法对2001年1月-2002年12月入住山东省聊城市人民医院综合ICU的危重患者共735例进行回顾性分析,结合文献,综合评价ICU内腹泻发生的原因。结果 735例中,入住ICU前无腹泻,入住24 h后发生腹泻者为86例,发生率为11.70％。引起腹泻的原因主要为:不适当肠内营养51例次(占59.30％),肠道感染18例次(占20.93％),滥用广谱抗生素15例次(占17.44％),大量使用胃肠动力药物11例次(占12.79％),与饥械通气有关者5例次(占5.81％)。而且综合ICU内发生腹泻患者的年龄[平均(57.71±13.40)岁]、急性生理学与慢性健康状况Ⅱ评分[平均(21.51±4.90)分]及住ICU时间[平均(8.0±1.2)d]均明显高于同期入住综合ICU未发生腹泻患者[分别为(51.20±11.31)岁,(12.01±1.20)分和(4.0±1.0)d,P均<0.05],并且发生腹泻的原因不同于普通病房患者引起腹泻的病因。结论 综合ICU患者发生腹泻有其特点和原因,应予以高度重视。     

High-sensitivity C-reactive protein and coronary heart disease mortality in patients with type 2 diabetes: a 7-year follow-up study

OBJECTIVE: To investigate in a follow-up study whether high-sensitivity C-reactive protein (hs-CRP) predicts coronary heart disease (CHD) events in subjects with type 2 diabetes. RESEARCH DESIGN AND METHODS: The original study population consisted of 1,059 patients with type 2 diabetes (age 45-64 years). Mean duration of diabetes was 8 years. CRP values were available from 1,045 subjects, of whom 878 were free of myocardial infarction (MI) at baseline. CHD mortality and the incidence of nonfatal MI were assessed in a 7-year follow-up. RESULTS: Altogether, 157 patients died from CHD and 254 had a nonfatal or fatal CHD event. Patients with hs-CRP >3 mg/l had a higher risk for CHD death than patients with hs-CRP < or =3 mg/l (19.8 and 12.9%, respectively, P = 0.004). In Cox regression analysis, patients with high hs-CRP had a relative risk of 1.72 for CHD death even after the adjustment for confounding factors (P = 0.002). Among subjects who were free from MI at baseline, those with a high hs-CRP level had relative risks of 1.83 (P = 0.003) and 1.84 (P = 0.004) for CHD death in univariate and multivariate analyses, respectively. CONCLUSIONS: In this large cohort of type 2 diabetic patients, hs-CRP was an independent risk factor for CHD deaths.     

Early postoperative complications and prevention of them in ischemic heart disease patients after direct myocardial revascularization

AIM: To specify risk factors affecting development and frequency of complications early after the bypass operation in direct myocardial revascularization. MATERIAL AND METHODS: 455 patients with ischemic heart disease (IHD) of whom 392 (86.2%) had stable angina pectoris class III-IV, 25 (5.5%) had unstable angina pectoris (UAP) and 38 (8.5%) had survived myocardial infarction (MI) underwent autovenous coronary artery bypass operation. IHD combined with arterial hypertension in 103 (22.6%), diabetes mellitus type II in 67 (14.7%), cardiac failure (CF) stage IIa in 97 (21.3%) patients. The ejection fraction (EF) was 37.8 +/- 3.3% in 113 (24.8) patients, in the others it was 46.7 +/- 2.7%. RESULTS: Early postoperative complications arose more frequently in patients with UAP, MI, CF and low EF. Postoperative acute cardiovascular failure was registered in 132 (29.5%) patients, arrhythmia--in 60 (13.4%), perioperative MI--in 13 (2.9%) patients. CONCLUSION: The most significant risk factors of postoperative complications in the above patients are the following: UAP, MI, CF, low EF. These risk factors should be allowed for in preparation of patients for coronary bypass surgery.     

Thrombocytopenia in medical-surgical critically ill patients: prevalence, incidence, and risk factors

OBJECTIVE: The purpose of this study is to describe the prevalence, to analyze the incidence and independent risk factors for thrombocytopenia, and to examine the impact of thrombocytopenia developing in the intensive care unit (ICU) on patient outcome in a well-defined cohort of critically ill patients in a medical-surgical ICU. MATERIALS AND METHODS: As part of a prospective cohort study examining the frequency and clinical importance of venous thromboembolism in the ICU, we enrolled consecutive patients older than 18 years expected to be in the ICU for more than 72 hours. Exclusion criteria were an admitting diagnosis of trauma, orthopedic surgery or cardiac surgery, pregnancy, and life support withdrawal. Patients had platelet counts performed as directed by clinical need. We defined thrombocytopenia as a platelet count of less than 150 x 10(9)/L and severe thrombocytopenia as a platelet count of less than 50 x 10(9)/L. Protocol-directed care included routine thromboprophylaxis and twice weekly screening ultrasonography of the legs. Patients were followed to hospital discharge. RESULTS: Of the 261 enrolled patients, 121 (46%, 95% confidence interval [CI], 40%-53%) had thrombocytopenia (62 on ICU admission and 59 acquired during their ICU stay). Patients who developed a platelet count less than 150 x 10(9)/L during their ICU stay had higher ICU and hospital mortality (P = .03 and .005, respectively), required longer mechanical ventilation (P = .05), and were more likely to receive platelets (P < .001), fresh frozen plasma (P = .005), and red blood cell transfusions (P = .004) than patients who did not develop thrombocytopenia. The only independent risk factors for thrombocytopenia developing during the ICU stay were administration of nonsteroidal anti-inflammatory drugs before ICU admission (hazard ratio, 2.8; 95% CI, 1.3-6.0) and dialysis during the ICU stay (hazard ratio, 3.1; 95% CI, 1.2-7.8). Of the 33 patients who underwent 36 tests for heparin-induced thrombocytopenia, none tested positive. CONCLUSIONS: We found that about 50% of the patients admitted to the ICU had at least one platelet count of less than 150 x 10(9)/L during their ICU stay. Patients who developed thrombocytopenia were more likely to die, required longer duration of mechanical ventilation, and were more likely to require blood product transfusion. Heparin-induced thrombocytopenia was frequently suspected but did not develop in these critically ill patients.     

Risk factors for treatment failure in patients with ventilator-associated pneumonia receiving appropriate antibiotic therapy

PURPOSE: The aim of this study was to investigate modifiable risk factors and predictors for treatment failure (TF) in patients with ventilator-associated pneumonia (VAP) receiving appropriate antibiotic therapy. MATERIALS AND METHODS: An observational cohort study performed in an intensive care unit (ICU) of a University hospital. Eighty-nine patients with VAP were enrolled in the study consecutively. Treatment failure was defined as lack of clinical and microbiological response to therapy within 2 weeks. Potential risk factors for TF, related with patients, microorganisms, and ICU therapies, were evaluated. RESULTS: Mean age was 72 +/- 13 years. Fifty-three of the patients had TF. Patients with TF were older, had more comorbidities, higher admission and Acute Physiology and Chronic Health Evaluation Score (APACHE II)-VAP scores, lower daily carbohydrate intake, and lymphocyte number below 1000/mm(3) than the treatment success group. Transfusions, bacteremia, infection with multidrug-resistant microorganisms, initial bacterial load (CFU/mL), and steroid therapy were similar across the groups. Comorbidity (odds ratio [OR], 4.4; 95% CI, 1.2-16.8; P = .030), VAP-APACHE II scores above 16 (OR, 6.4; 95% CI, 2.1-18.6; P = .001), daily carbohydrate intake below 190 g/d (OR, 3; 95% CI,1.1-8.6; P = .038), lymphocyte number below 1000/mm3 (OR, 4.1; 95% CI, 1.3-12.9; P = .014) were independent predictors for TF. CONCLUSIONS: Patients with comorbidities, who are severely ill and lymphocytopenic at the time of VAP diagnosis, are at high risk for TF.     

Durability of insulin pump use in pediatric patients with type 1 diabetes

OBJECTIVE: To examine longitudinal outcomes, rate of and reasons for discontinuation, and predictors of insulin pump success in a cohort of youth initiating pump therapy. RESEARCH DESIGN AND METHODS: We followed a cohort of youth with type 1 diabetes (n = 161) starting the pump between 1998 and 2001 and recorded natural history of treatment. RESULTS: At pump start, patients (71% female) had a mean age of 14.1 +/- 3.7 years, diabetes duration of 7.1 +/- 4.0 years, daily blood glucose monitoring (BGM) frequency of 4.0 +/- 1.2, a daily insulin dose of 1.0 +/- 0.3 units/kg, and an HbA(1c) (A1C) of 8.4 +/- 1.4%. After 1 year, mean daily BGM frequency was 4.5 +/- 1.7, daily insulin dose was 0.8 +/- 0.2 units/kg, and A1C was 8.1 +/- 1.3% (all baseline versus 1-year data, P < 0.01). As of 2005, 29 patients (18%) had resumed injection therapy at a mean age of 17.0 +/- 2.9 years after a mean duration of pump use of 2.1 +/- 1.3 years. BGM frequency at baseline and at 1 year was significantly lower in the patients who resumed injection therapy (P < 0.02). In addition, patients who remained on the pump had lower A1C than those who resumed injection therapy at both 1 year (P = 0.04) and at the most recent clinic visit (P = 0.01). CONCLUSIONS: After an average of 3.8 years, >80% of pediatric patients maintained pump therapy with preservation of baseline A1C. Patients discontinuing the pump were less adherent and did not achieve equivalent glycemic benefit compared with continued users; these patients require ongoing support aimed at improving adherence and outcomes.