The association of age, gender and race with renal outcomes in patients with severe sepsis and septic shock (SEP) is not completely elucidated. We aimed to shed light on these relationships.
We ...performed a retrospective cohort study of hospitalized patients in the USA discharged between January 1st, 2005 and December 31st, 2014 using the National Inpatient Sample. We adjusted analyses using the Charlson comorbidity index.
65,772,607 records were included of which 1,064,790 had SEP. There were 60% female and 12% African American (AA). The incidence of SEP was 1.6% and patients with SEP were older, had more AA and less females. Acute kidney injury (AKI) and mortality among patients with SEP were 62% and 30.7% respectively. AA race was associated with increased risk of SEP, AKI and dialysis, (OR = 1.12, 1.25 and 1.7 respectively, all p < 0.001). Female gender was associated with lower risk of all measured outcomes with odds ratios ranging from 0.65 to 0.78 (p < 0.001). Increasing age was associated with a higher risk of all outcomes except for dialysis.
Female gender is associated with a lower risk of poor renal outcomes and death among patients with SEP, while AA race places patients at higher risk of poor outcomes in that setting. Increasing age is generally associated with adverse outcomes.
•Female gender is associated with better renal outcomes and death among patients with severe sepsis and septic shock.•African American ethnicity places patients at higher risk of poor outcomes in that setting.•Increased age is generally associated with worse outcomes.•These results may help guide future studies into the mechanisms behind the gender, ethnic and age differences.•Our findings may help in the design of future trials to assess the differential impact of interventions in these populations.
Renal Replacement Therapy in the ICU Rachoin, Jean-Sebastien; Weisberg, Lawrence S
Critical care medicine,
05/2019, Letnik:
47, Številka:
5
Journal Article
Recenzirano
The incidence of acute kidney injury in critically ill patients is increasing steeply. Acute kidney injury in this setting is associated with high morbidity and mortality. There is no doubt that ...renal replacement therapy for the most severe forms of acute kidney injury can be life saving, but there are a number of uncertainties about the optimal application of renal replacement therapy for patients with acute kidney injury. The objective of this synthetic review is to present current evidence supporting best practices in renal replacement therapy for critically ill patients with acute kidney injury.
We reviewed literature regarding timing of initiation of renal replacement therapy, optimal vascular access for renal replacement therapy in acute kidney injury, modality selection and dose or intensity of renal replacement therapy, and anticoagulation during renal replacement therapy, using the following databases: MEDLINE and PubMed. We also reviewed bibliographic citations of retrieved articles.
We reviewed only English language articles.
Current evidence sheds light on many areas of controversy regarding renal replacement therapy in acute kidney injury, providing a foundation for best practices. Nonetheless, important questions remain to be answered by ongoing and future investigation.
Healthcare disparities can affect access and quality of care among many in the United States (US). In addition to race, we sought to assess if geography affected rates of cardiac arrest, and the ...subsequent outcomes.
Using the National Inpatient Sample database from 2006–2018, we assessed rates of cardiac arrest (out of hospital that survived to admission and in-hospital) and cardiac catheterization, and length of stay (LOS) in four regions: Northeast (NE), South (SO) West (W) and Midwest (MW).
Cardiac arrest increased from 27,611 (2006) to 43,333 (2018). The proportion of African American (AA) patients experiencing cardiac arrest significantly increased from 11.9% to 18.8%. The mortality decreased from 65.4% to 60.8% in all patients and 70.2% to 61.4% in AA. Mortality in AA remained higher than non-AA (OR, 1.09 1.08–1.11, p < 0.001). When regions were compared for mortality, MW had a lower risk than NE 0.940.92–9.96; SO 1.051.04–1.07 and W 1.111.09–1.13 were higher compared to NE. LOS decreased slightly from 9.0 days to 8.7 in all patients. LOS for AA was longer than non-AA (11.3 vs 8.6 days) with the NE having the longest LOS. AA were less likely to receive cardiac catheterization than non-AA (9.5% vs 15%) with the largest racial gap in the MW region.
The proportion of AA with cardiac arrests increased over the study period. Mortality and LOS improved significantly in AA from 2006 to 2018 but remain significantly higher than non-AA patients. Future research should identify contributors to these concerning trends.
Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most ...commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.
Introduction. Limited access to healthy food in areas that are predominantly food deserts or food swamps may be associated with obesity. Other unhealthy behaviors may also be associated with obesity ...and poor food environments. Methods. We calculated Modified Retail Food Environment Index (mRFEI) to assess food retailers. Using data collected from the Behavioral Risk Factor Surveillance System (BRFSS) survey, the NJ Department of Health (NJDOH), and the US Census Bureau, we conducted a cross-sectional analysis of the interaction of obesity with the food environment and assessed smoking, leisure-time physical activity (LPA), and poor sleep. Results. There were 17.9% food deserts and 9.3% food swamps in NJ. There was a statistically significant negative correlation between mRFEI and obesity rate (Pearson’s r −0.13, p<0.001), suggesting that lack of access to healthy food is associated with obesity. Regression analysis was significantly and independently associated with increased obesity prevalence (adjusted R square 0.74 and p=0.008). Obesity correlated positively with unhealthy behaviors. Each unhealthy behavior was negatively correlated with mRFEI. The mean prevalence for smoking, LPA, and sleep <7 hours was 15.4 (12.5–18.6), 26.5 (22.5–32.3), and 37.3 (34.9–40.4), respectively. Conclusion. Obesity tracks with food deserts and especially food swamps. It is also correlated with other unhealthy behaviors (smoking, LPA, and poor sleep).
Intravenous contrast media (CM) is often used in clinical practice to enhance CT scan imaging. For many years, contrast-induced nephropathy (CIN) was thought to be a common occurrence and to result ...in dire consequences. When treating patients with abnormal renal function, it is not unusual that clinicians postpone, cancel, or replace contrast-enhanced imaging with other, perhaps less informative tests. New studies however have challenged this paradigm and the true risk attributable to intravenous CM for the occurrence of CIN has become debatable. In this article, we review the latest relevant medical literature and aim to provide an evidence-based answer to questions surrounding the risk, outcomes, and potential mitigation strategies of CIN after intravenous CM administration.
Abstract
Introduction
During the preclinical years, students typically do not have extensive exposure to clinical medicine. When they begin their clinical rotations, usually in the third year, the ...majority of the time is spent on core rotations with limited experience in other fields of medicine. Students then must decide on their careers early in their fourth year. We aimed to analyze how often medical students change their career preferences between the end of their second and their fourth year.
Methods
We conducted a retrospective, cohort study using the American Association of Medical Colleges Year 2 Questionnaire (Y2Q) and Graduating Questionnaire (GQ) from 2016 to 2020.
Results
20,408 students answered both surveys, but 2,165 had missing values on the career choice question and were excluded. Of the remaining students, 10,233 (56%) changed their career choice between the Y2 and GQ surveys. Fields into which students preferentially switched by the GQ survey included anesthesia, dermatology, ENT, family medicine, OB/GYN, pathology, PM&R, psychiatry, radiology, urology, and vascular surgery. Many characteristics, including future salary, the competitiveness of the field, and the importance of work-life balance, were significantly associated with a higher likelihood of changing career choices. On the other hand, having a mentor and the specialty content were associated with a lower likelihood of change.
Conclusion
A majority of students switched their career preferences from the Y2Q to the GQ. Additional research should be focused on curricular design that optimizes student satisfaction with career decisions. This may include early integration of a variety of specialties.
To investigate if the timing of initiation of invasive mechanical ventilation (IMV) for critically ill patients with COVID-19 is associated with mortality.
The data for this study were derived from a ...multicenter cohort study of critically ill adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 1 to July 1, 2020. We examined the association between early (ICU days 1-2) versus late (ICU days 3-7) initiation of IMV and time-to-death. Patients were followed until the first of hospital discharge, death, or 90 days. We adjusted for confounding using a multivariable Cox model.
Among the 1879 patients included in this analysis (1199 male 63.8%; median age, 63 IQR, 53-72 years), 1526 (81.2%) initiated IMV early and 353 (18.8%) initiated IMV late. A total of 644 of the 1526 patients (42.2%) in the early IMV group died, and 180 of the 353 (51.0%) in the late IMV group died (adjusted HR 0.77 95% CI, 0.65-0.93).
In critically ill adults with respiratory failure from COVID-19, early compared to late initiation of IMV is associated with reduced mortality.
Given the success of recent platform trials for COVID-19, Bayesian statistical methods have become an option for complex, heterogenous syndromes like sepsis. However, study design will require ...careful consideration of how statistical power varies using Bayesian methods across different choices for how historical data are incorporated through a prior distribution and how the analysis is ultimately conducted. Our objective with the current analysis is to assess how different uses of historical data through a prior distribution, and type of analysis influence results of a proposed trial that will be analyzed using Bayesian statistical methods.
We conducted a simulation study incorporating historical data from a published multicenter, randomized clinical trial in the US and Canada of polymyxin B hemadsorption for treatment of endotoxemic septic shock. Historical data come from a 179-patient subgroup of the previous trial of adult critically ill patients with septic shock, multiple organ failure and an endotoxin activity of 0.60-0.89. The trial intervention consisted of two polymyxin B hemoadsorption treatments (2 h each) completed within 24 h of enrollment.
In our simulations for a new trial of 150 patients, a range of hypothetical results were observed. Across a range of baseline risks and treatment effects and four ways of including historical data, we demonstrate an increase in power with the use of clinically defensible incorporation of historical data. In one possible trial result, for example, with an observed reduction in risk of mortality from 44 to 37%, the probability of benefit is 96% with a fixed weight of 75% on prior data and 90% with a commensurate (adaptive-weighting) prior; the same data give an 80% probability of benefit if historical data are ignored.
Using Bayesian methods and a biologically justifiable use of historical data in a prior distribution yields a study design with higher power than a conventional design that ignores relevant historical data. Bayesian methods may be a viable option for trials in critical care medicine where beneficial treatments have been elusive.
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