Pneumothorax in the ICU: patient outcomes and prognostic factors

STUDY OBJECTIVE: To identify the prognostic factors for pneumothorax in patients in the ICU. DESIGN: Retrospective cohort study. SETTING: ICU at a university-based teaching hospital. PATIENTS AND METHODS: Sixty patients developed pneumothoraces in the ICU during a period of 36 months. Medical records relating to patients' age, sex, underlying diseases, associated medical conditions, reasons for admission, acute physiology and chronic health evaluation (APACHE) II scores, procedures performed before the development of pneumothorax, occurrences of tension pneumothorax, duration of chest tube placement, chest tube removal, duration of ICU stay, and patient outcomes all were analyzed. A multivariate logistic regression model was applied with variables that were significantly associated with survival in the univariate analysis. The probabilities of chest tube removal were calculated using the Kaplan-Meier method. RESULTS: Thirty-five patients (58%) had procedure-related pneumothoraces. The procedure that most commonly caused pneumothoraces was thoracentesis (n = 19; 54%), followed by central vein/pulmonary artery catheterization (n = 14; 40%) and bronchoscopy/transbronchial lung biopsy (n = 8; 23%). A multivariate logistic regression analysis also showed that pneumothorax due to barotrauma (p = 0.001), tension pneumothorax (p = 0.0023), and concurrent septic shock (p = 0.0476) were significantly and independently associated with death. The log-rank test revealed that the success rate of chest tube removal was higher in patients with procedure-related pneumothoraces (p = 0.0055). CONCLUSIONS: Patients with procedure-related pneumothoraces had better outcomes. Patients with pneumothoraces occurring in the ICU due to barotrauma, or a complicating tension pneumothoraces, carry a higher risk of mortality.     

Acute-on-chronic kidney injury at hospital discharge is associated with long-term dialysis and mortality

Existing chronic kidney disease (CKD) is among the most potent predictors of postoperative acute kidney injury (AKI). Here we quantified this risk in a multicenter, observational study of 9425 patients who survived to hospital discharge after major surgery. CKD was defined as a baseline estimated glomerular filtration rate <45 ml/min per 1.73 m(2). AKI was stratified according to the maximum simplified RIFLE classification at hospitalization and unresolved AKI defined as a persistent increase in serum creatinine of more than half above the baseline or the need for dialysis at discharge. A Cox proportional hazard model showed that patients with AKI-on-CKD during hospitalization had significantly worse long-term survival over a median follow-up of 4.8 years (hazard ratio, 1.7) [corrected] than patients with AKI but without CKD.The incidence of long-term dialysis was 22.4 and 0.17 per 100 person-years among patients with and without existing CKD, respectively. The adjusted hazard ratio for long-term dialysis in patients with AKI-on-CKD was 19.8 compared to patients who developed AKI without existing CKD. Furthermore, AKI-on-CKD but without kidney recovery at discharge had a worse outcome (hazard ratios of 4.6 and 213, respectively) for mortality and long-term dialysis as compared to patients without CKD or AKI. Thus, in a large cohort of postoperative patients who developed AKI, those with existing CKD were at higher risk for long-term mortality and dialysis after hospital discharge than those without. These outcomes were significantly worse in those with unresolved AKI at discharge.     

Empirical use of fluoroquinolones improves the survival of critically ill patients with tuberculosis mimicking severe pneumonia

Introduction

Empirical use of fluoroquinolones may delay the initiation of appropriate therapy for tuberculosis (TB). This study aimed to evaluate the impact of empirical fluoroquinolone use on the survival of patients with pulmonary TB that mimicked severe community-acquired pneumonia (CAP) requiring intensive care.

Methods

Patients aged >18 years with culture-confirmed pulmonary TB who presented as severe CAP and were admitted to the ICU were divided into fluoroquinolone (FQ) and nonfluoroquinolone (non-FQ) groups based on the type of empirical antibiotics used. Those patients with previous anti-TB treatment or those who died within 3 days of hospitalization were excluded. The primary end point was 100-day survival.

Results

Of the 77 patients identified, 43 (56%) were in the FQ group and 34 (44%) were in the non-FQ group. The two groups had no statistically significant difference in co-morbidities (95% vs. 97%, P > 0.99) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores (21.2 ± 7.1 vs. 22.5 ± 7.5, P = 0.46) on ICU admission. Overall, 91% and 82% of patients in the FQ and non-FQ groups, respectively, had sputum examinations for TB within 1 week of admission (P = 0.46), and results were positive in 7% and 15% (P = 0.47), respectively. For both groups, 29% received appropriate anti-TB therapy within 2 weeks after ICU admission. The 100-day mortality rate was 40% and 68% for the FQ and non-FQ groups, respectively (P = 0.02). By Cox regression analysis, APACHE score <20, no bacteremia during the ICU stay, and empirical fluoroquinolone use were independently associated with survival.

Conclusion

Empirical use of fluoroquinolones may improve the survival of ICU patients admitted for pulmonary TB mimicking severe CAP.     

Integrated postdischarge transitional care in a hospitalist system to improve discharge outcome: an experimental study

Background

Low levels of physical activity may increase the risk of developing metabolic syndrome, a cluster of metabolic factors that are associated with the risk of premature death. It has been suggested that physical activity may reduce the impact of factors associated with metabolic syndrome, but it is not known whether physical activity may reduce mortality in people with metabolic syndrome.

Methods

In a prospective study of 50,339 people, 13,449 had metabolic syndrome at baseline and were followed up for ten years to assess cause-specific mortality. The population was divided into two age groups: those younger than 65 years of age and those older than age 65. Information on their physical activity levels was collected at baseline.

Results

Metabolic syndrome was associated with higher mortality from all causes (hazard ratio (HR) 1.35, 95% confidence interval (95% CI) 1.20 to 1.52) and from cardiovascular causes (HR 1.78, 95% CI 1.39 to 2.29) in people younger than 65 years old than among other populations. In older people, there was no overall association of metabolic syndrome with mortality. People with metabolic syndrome who reported high levels of physical activity at baseline were at a reduced risk of death from all causes compared to those who reported no physical activity, both in the younger age group (HR 0.52, 95% CI 0.37 to 0.73) and in the older age group (HR 0.59, 95% CI 0.47 to 0.74).

Conclusion

Among people with metabolic syndrome, physical activity was associated with reduced mortality from all causes and from cardiovascular causes. Compared to inactivity, even low levels of physical activity were associated with reduced mortality.     

Increased prevalence of primary drug-resistant pulmonary tuberculosis in immunocompromised patients

Background and objective: Drug‐resistant tuberculosis (DR‐TB) is difficult and expensive to treat, and is associated with a higher rate of mortality. We conducted a long‐term survey to compare the prevalence of primary drug‐resistance, adverse effects of drugs and duration of treatment in immunocompetent and immunocompromised patients. Factors associated with primary drug resistance were also investigated. Methods: The patients studied had culture‐confirmed pulmonary TB but had not previously received anti‐TB treatment. These patients were divided into immunocompetent (IMCPe) and immunocompromised (IMCPr) groups. Baseline data, the prevalence of DR‐TB, duration of treatment and adverse effects of drugs were analysed. The rates of resistance to individual first‐line anti‐TB drugs in the two groups and in subgroups of the IMCPr group were calculated. Multinomial regression analysis was performed to investigate the risk factors associated with primary DR‐TB. Results: Among the 394 patients, 159 (40.4%) were in the IMCPr group. The baseline data for the two groups were similar, except that the IMCPr group was slightly older. The prevalence of drug‐resistance was higher in the IMCPr group (25.8% vs 17.0%, OR 1.69, 95% CI: 1.04–2.77), especially for isoniazid, rifampicin and streptomycin, and patients with liver cirrhosis, malignancies and those receiving immunosuppressants. The incidence of adverse drug effects was similar in the IMCPr and IMCPe groups. Multinomial regression analysis showed that being in the IMCPr group, and especially treatment with immunosuppressants, were independent risk factors for DR‐TB. Conclusions: Immunocompromised patients with underlying diseases had an increased prevalence of primary pulmonary DR‐TB but a similar incidence of drug‐related adverse effects. Diagnosis and investigation of drug‐resistance is important before initiating anti‐TB treatment in this group of patients.     

Prediction of the tuberculosis reinfection proportion from the local incidence

BACKGROUND: Reinfection is a major contributor to tuberculosis (TB). It seems that the higher the local incidence, the higher the proportion of reinfection. METHODS: Based on a systematic review of the literature, we established a regression model to predict the reinfection proportion from the local incidence. We then used our local data to verify the algorithm. RESULTS: Of the 23 studies addressing reinfection in recurrent TB, 6 were population based. The reinfection proportion was correlated with the local incidence (reinfection proportion=-29.7+36.8 x log Incidence) (95% confidence interval [CI] for coefficient, 15.3-58.3; R2=0.849). The reinfection proportion in Taiwan (incidence, 62.4/100,000 people) was estimated to be 36% (95% CI, 3%-69%). Of our 49 recurrent patients, 51% had reinfection. Patients with reactivation seemed more likely to have underlying diseases and less likely to be smear positive. The relapse isolates seemed more resistant than the initial isolates. CONCLUSIONS: The regression model could possibly predict the TB reinfection proportion from the local incidence. This algorithm is probably helpful in policy making for TB control programs. In areas where TB is endemic, reinfection might be responsible for >50% of TB cases, and aggressive surveillance to detect asymptomatic carriers could be an important strategy for controlling the disease.