Trends in the Utilization of Life-Sustaining Procedures and Palliative Care Consultation Among Dying Patients With Advanced Chronic Pancreas Illnesses in US Hospitals: 2005 to 2014.

AIM: Pancreas cancer continues to carry a poor prognosis. Hospitalized patients with advanced chronic pancreatic illnesses increasingly receive palliative care due to its perceived clinical benefits. Meanwhile, a growing proportion of elderly patients are reportedly receiving life-sustaining procedures. Temporal trends in the utilization of life-sustaining procedures and palliative care consultation among dying patients with advanced chronic pancreatic illnesses in US hospitals were examined. METHODS AND MATERIALS: A serial, cross-sectional analysis was carried out using the National Inpatient Sample Database. Decedents 18 years and older with a principal diagnosis of pancreas cancer or other advanced chronic pancreatic illnesses from 2005 through 2014. The compound annual growth rates (CAGRs) and Cochrane-Armitage correction of χ2 statistic were used. The receipt of life-sustaining systemic procedures, intra-abdominal local procedures and surgeries, and palliative care consultation were examined. Multilevel multivariate logistic regressions were performed to examine the association of various procedures with the utilization of palliative care consultation. RESULTS: Among 77 394 183 hospitalizations, 29 515 patients were examined. The CAGRs of systemic procedures, intra-abdominal procedures, surgeries, and palliative care were -4.19% (P = .008), 2.17%, -1.40%, and 14.03% (P < .001), respectively. The receipt of systemic procedures (odds ratio [OR] = 2.40, 95% confidence interval [CI], 2.08-2.74), local intra-abdominal procedures (OR = 1.46, 95% CI, 1.27-1.70), and surgeries (OR = 2.51, 95% CI, 2.07-3.05) was associated with palliative care consultation (Ps < .001). CONCLUSIONS: Among adults with pancreatic cancer or other advanced chronic pancreatic illnesses in the US hospitals from 2005 to 2014, the utilization of life-sustaining systemic procedures decreased while the prevalence of palliative care consultation increased.

Changes in quality of life and health status in patients with extracorporeal life support: A prospective longitudinal study.

BACKGROUND: Extracorporeal life support (ECLS) provides emergency pulmonary and cardiac assistance for patients in respiratory or cardiac failure. Most studies evaluate the success of ECLS based on patients' survival rate. However, the trajectory of health status and quality of life (QOL) should also be important considerations. The study's aim was to explore changes in health status and QOL in adult patients weaned from ECLS who survived to hospital discharge over a one-year period. STUDY DESIGN: A prospective longitudinal study was conducted from April 2012 to September 2014. A convenience sample of patients who had undergone ECLS was followed for one-year after hospital discharge. Heath status was measured with a physical activity scale, the Centre for Epidemiologic Studies Depression scale, and a social support scale; we assessed quality of life with the physical and mental component summary scales of the Short-Form 36 Health Survey. Changes in depression, social support, physical activity and QOL were analysed with generalized estimating equations at 3-month intervals; participants' QOL at 12 months after discharge was compared with the general population. RESULTS: A total of 231 patients received ECLS during the study period. Sixty-five patients survived to hospital discharge (28% survival rate); 32 participants completed the study. Data showed scores for physical activity increased significantly over time (p < .001), while depression and social support significantly decreased (p < .05 and p < .001, respectively). Participants with veno-venous ECLS had higher scores for depression than participants with veno-arterial ECLS (p < .05). PCS scores significantly increased at 9, and 12 months after discharge (p < .05 and p < .001, respectively). There was no significant change in MCS scores. CONCLUSIONS: This was a preliminary study of patients with ECLS following hospital discharge over a one-year period. One year following hospital discharge survivors of ECLS continued to experience physical complications and some continued to have depressive symptoms; the level of social support was significantly lower after hospital discharge. Healthcare professionals should understand the trajectory of health status and QOL after discharge, which can help developing evidence-based interventions and improve QOL for survivors of ECLS.

Availability of Life Support Equipment and its Utilization by Ambulance Drivers.

BACKGROUND: An effective ambulance is a vital requirement for providing an emergency medical service. Well-equipped ambulances with trained paramedics can save many lives during the golden hours of trauma care. The objective was to document the availability and utilization of basic life support equipment in the ambulances and to assess knowledge on first aid among the drivers. METHODS: Descriptive design was used. Total of 109 ambulances linked to B.P. Koirala Institute of Health Sciences were enrolled using purposive sampling method. Self- constructed observation checklist and semi structured interview schedule was used for data collection. RESULTS: More than half of the respondents had less than five years of experience and were not trained in first aid. About two-third of the respondents had adequate knowledge on first aid. About 90% of the ambulance had oxygen cylinder and adult oxygen mask which was 'usually' used equipment. More than half of ambulance had equipment less than 23% as compared to that of national guidelines. There was significant association of knowledge with the experience (p = 0.004) and training (p = 0.001). Availability of equipment was associated with training received (p = 0.007),organization (p= 0.032)and district (p = 0.023) in which the ambulance is registered. CONCLUSIONS: The study concludes that maximum ambulance linked to BPKIHS, Nepal did not have even one fourth of the equipment for basic life support. Equipment usually used was oxygen cylinder and oxygen mask. Majority of driver had adequate knowledge on first aid and it was associated with training and experience.

Evaluating the Cost and Utility of Mandating Schools to Stock Epinephrine Auto-injectors.

BACKGROUND: The Michigan Legislature mandated that all public schools stock epinephrine auto-injectors (EAIs). A minimal amount is known regarding the incremental value of EAIs in schools. Our primary objective was to describe the frequency of administration of epinephrine for EMS patients with acute allergic reactions in public schools. Our secondary objective was to estimate the cost of mandating public schools to stock EAIs. METHODS: We performed a retrospective cohort study of EMS cases with an impression of allergic reaction and who received epinephrine recorded in the 2014 Michigan EMS Information System (MI-EMSIS). We abstracted patient demographics, incident location by address to identify public schools, source of epinephrine given, and suspected allergen if known. We calculated advanced life support (ALS) response times to assess temporal impact of school EAIs in communities with ALS systems. We estimated the unsubsidized annual procurement cost of this mandate for Michigan public schools (N = 4,039), using range of costs for the required 2 EAIs (adult and pediatric) as estimated by the legislature ($140/each) and recently reported costs for commercial sources ($1,200). Training costs were not included. Descriptive statistics are reported. RESULTS: During this period, there were 1,550,009 EMS cases in the state with 631 receiving non-cardiac arrest epinephrine for presumed anaphylaxis, of which 23 cases were in public schools. Reported allergens were most often food 12 (51.2%), insect stings 4(22.2%) or unknown 7(30.4%). Among these patients, the source for epinephrine used was from the student, 7 (30.4%), EMS 7 (30.4%), school 7(30.4%), and unknown 2(8.7%). A majority (21, 91.3%) of the public school cases occurred in communities with ALS systems and ALS response was relatively rapid (median response 6 minutes, 90 percentile, 13 minutes). The unsubsidized annual cost of Michigan public schools to stock EAIs ranges from $565,460 to $4,846,800. CONCLUSION: In this study, few public school patients received epinephrine for anaphylaxis and the vast majority occurred in communities with rapid ALS response. The direct annual supply cost of the school EAI mandate is substantial.

Termination of Resuscitation Rules to Predict Neurological Outcomes in Out-of-Hospital Cardiac Arrest for an Intermediate Life Support Prehospital System.

AIM: Futile resuscitation can lead to unnecessary transports for out-of-hospital cardiac arrest (OHCA). The Basic Life Support (BLS) and Advanced Life Support (ALS) termination of resuscitation (TOR) guidelines have been validated with good results in North America. This study aims to evaluate the performance of these two rules in predicting neurological outcomes of OHCA patients in Singapore, which has an intermediate life support Emergency Medical Services (EMS) system. METHODS: A retrospective cohort study was carried out on Singapore OHCA data collected from April 2010 to May 2012 for the Pan-Asian Resuscitation Outcomes Study (PAROS). The outcomes of each rule were compared to the actual neurological outcomes of the patients. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and predicted transport rates of each test were evaluated. RESULTS: A total of 2,193 patients had cardiac arrest of presumed cardiac etiology. TOR was recommended for 1,411 patients with the BLS-TOR rule, with a specificity of 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.7, 100.0), sensitivity 65.7% (63.6, 67.7), NPV 5.6% (4.1, 7.5), and transportation rate 35.6%. Using the ALS-TOR rule, TOR was recommended for 587 patients, specificity 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.4, 100.0), sensitivity 27.3% (25.4, 29.3), NPV 2.7% (2.0, 3.7), and transportation rate 73.2%. BLS-TOR predicted survival (any neurological outcome) with specificity 93.4% (95% CI 85.3, 97.8) versus ALS-TOR 98.7% (95% CI 92.9, 99.8). CONCLUSION: Both the BLS and ALS-TOR rules had high specificities and PPV values in predicting neurological outcomes, the BLS-TOR rule had a lower predicted transport rate while the ALS-TOR rule was more accurate in predicting futility of resuscitation. Further research into unique local cultural issues would be useful to evaluate the feasibility of any system-wide implementation of TOR.

Extracorporeal life support for refractory out-of-hospital cardiac arrest: Should we still fight for? A single-centre, 5-year experience.

BACKGROUND: Cardiopulmonary resuscitation displays low survival rate after out-of-hospital cardiac arrest (OHCA). Extracorporeal life support (ECLS) could be suggested as a rescue therapeutic option in refractory OHCA. The aim of this report is to analyze our experience of ECLS implantation for refractory OHCA. METHODS: We performed a retrospective observational analysis of our prospectively collected database. Patients were divided into a shockable rhythm (SH-R) and a non-shockable rhythm (NSH-R) group according to cardiac rhythm at ECLS implantation. The primary endpoint was survival to hospital discharge with good neurological recovery. RESULTS: From January 2010 to December 2014 we used ECLS in 68 patients (SH-R, n=19, 27.9% vs. NSH-R, n=49, 72.1%) for refractory OHCA. The clinical profile before ECLS implantation was comparable between the groups. Eight (11.7%) patients were successfully weaned from ECLS (SH-R=31.5% vs. NSH-R=4.0%, p=0.01) after a mean period of support of 2.1 days (SH-R=4.1 days vs. NSH-R=1.4 days, p=0.01). Six (8.8%) patients survived to discharge (SH-R=31.5% vs. NSH-R=0%, p=0.00). In the SH-R group 50% of the survivors were discharged without neurological complications. CONCLUSIONS: ECLS for refractory OHCA should be limited in consideration of its poor, especially neurological, outcome. Non-shockable rhythms could be considered as a formal contraindication allowing a concentration of our efforts on the shockable rhythms, where the chances of success are substantial.

Therapeutic plasma exchange may improve hemodynamics and organ failure among children with sepsis-induced multiple organ dysfunction syndrome receiving extracorporeal life support.

OBJECTIVE: To determine the effect of therapeutic plasma exchange on hemodynamics, organ failure, and survival in children with multiple organ dysfunction syndrome due to sepsis requiring extracorporeal life support. DESIGN: A retrospective analysis. SETTING: A PICU in an academic children's hospital. PATIENTS: Fourteen consecutive children with sepsis and multiple organ dysfunction syndrome who received therapeutic plasma exchange while on extracorporeal life support from 2005 to 2013. INTERVENTIONS: Median of three cycles of therapeutic plasma exchange with median of 1.0 times the estimated plasma volume per exchange. MEASUREMENTS AND MAIN RESULTS: Organ Failure Index and Vasoactive-Inotropic Score were measured before and after therapeutic plasma exchange use. PICU survival in our cohort was 71.4%. Organ Failure Index decreased in patients following therapeutic plasma exchange (mean ± SD: pre, 4.1 ± 0.7 vs post, 2.9 ± 0.9; p = 0.0004). Patients showed improved Vasoactive-Inotropic Score following therapeutic plasma exchange (median [25th-75th]: pre, 24.5 [13.0-69.8] vs post, 5.0 [1.5-7.0]; p = 0.0002). Among all patients, the change in Organ Failure Index was greater for early therapeutic plasma exchange use than late use (early, -1.7 ± 1.2 vs late, -0.9 ± 0.6; p = 0.14), similar to the change in Vasoactive-Inotropic Score (early, -67.5 [28.0-171.2] vs late, -12.0 [7.2-18.5]; p = 0.02). Among survivors, the change in Organ Failure Index was greater among early therapeutic plasma exchange use than late use (early, -2.3 ± 1.0 vs late, -0.8 ± 0.8; p = 0.03), as was the change in Vasoactive-Inotropic Score (early, -42.0 [16.0-76.3] vs late, -12.0 [5.3-29.0]; p = 0.17). The mean duration of extracorporeal life support after therapeutic plasma exchange according to timing of therapeutic plasma exchange was not statistically different among all patients or among survivors. CONCLUSIONS: The use of therapeutic plasma exchange in children on extracorporeal life support with sepsis-induced multiple organ dysfunction syndrome is associated with organ failure recovery and improved hemodynamic status. Initiating therapeutic plasma exchange early in the hospital course was associated with greater improvement in organ dysfunction and decreased requirement for vasoactive and/or inotropic agents.

Rate and patterns of ICU admission among colorectal cancer patients: a single-center experience.

PURPOSE: The purposes of this study were to evaluate, in colorectal cancer patients, the cause of ICU admission and to find predictors of death during and after hospitalization. METHODS: This is a retrospective study including all patients with colorectal cancer admitted in the ICU of a cancer hospital from January 1st 2003 to December 31 2012. RESULTS: Among 3721 ICU admissions occurring during the study period, 119 (3.2 %) admissions dealt with colorectal cancer, of whom 89 were eligible and assessable. The main reasons for admission were of metabolic (24 %), hemodynamic (19 %), cardiovascular (18 %), gastrointestinal (16 %), respiratory (13 %), or neurologic (6 %) origin. These complications were due to cancer in 43 %, to the antineoplastic treatment in 25 %, or were unrelated to the cancer or its treatment in 33 %. A quarter of the patients died during hospitalization. Independent predictors of death were the Sequential Organ Failure Assessment (SOFA) score (with risk of dying increasing by 42 % per unit of SOFA score), fever (with risk of dying multiplied by three per °C), and high values of GOT (with risk of dying multiplied by 1 % per unit increase), while cancer control (i.e., stage progression or not), compliance to the initial cancer treatment plan, and LDH ≤ median levels had prognostic significance for further longer survival after hospital discharge. CONCLUSION: This is the first study looking at specific causes for unplanned ICU admission of patients with colorectal cancer. Hospital mortality was influenced by the characteristics of the complication that entailed the ICU admission while cancer characteristics retained their prognostic influence on survival after hospital discharge.

Multi-scale symbolic entropy analysis provides prognostic prediction in patients receiving extracorporeal life support.

INTRODUCTION: Extracorporeal life support (ECLS) can temporarily support cardiopulmonary function, and is occasionally used in resuscitation. Multi-scale entropy (MSE) derived from heart rate variability (HRV) is a powerful tool in outcome prediction of patients with cardiovascular diseases. Multi-scale symbolic entropy analysis (MSsE), a new method derived from MSE, mitigates the effect of arrhythmia on analysis. The objective is to evaluate the prognostic value of MSsE in patients receiving ECLS. The primary outcome is death or urgent transplantation during the index admission. METHODS: Fifty-seven patients receiving ECLS less than 24 hours and 23 control subjects were enrolled. Digital 24-hour Holter electrocardiograms were recorded and three MSsE parameters (slope 5, Area 6-20, Area 6-40) associated with the multiscale correlation and complexity of heart beat fluctuation were calculated. RESULTS: Patients receiving ECLS had significantly lower value of slope 5, area 6 to 20, and area 6 to 40 than control subjects. During the follow-up period, 29 patients met primary outcome. Age, slope 5, Area 6 to 20, Area 6 to 40, acute physiology and chronic health evaluation II score, multiple organ dysfunction score (MODS), logistic organ dysfunction score (LODS), and myocardial infarction history were significantly associated with primary outcome. Slope 5 showed the greatest discriminatory power. In a net reclassification improvement model, slope 5 significantly improved the predictive power of LODS; Area 6 to 20 and Area 6 to 40 significantly improved the predictive power in MODS. In an integrated discrimination improvement model, slope 5 added significantly to the prediction power of each clinical parameter. Area 6 to 20 and Area 6 to 40 significantly improved the predictive power in sequential organ failure assessment. CONCLUSIONS: MSsE provides additional prognostic information in patients receiving ECLS.

Variation in decisions to forgo life-sustaining therapies in US ICUs.

BACKGROUND: The magnitude and implication of variation in end-of-life decision-making among ICUs in the United States is unknown. METHODS: We reviewed data on decisions to forgo life-sustaining therapy (DFLSTs) in 269,002 patients admitted to 153 ICUs in the United States between 2001 and 2009. We used fixed-effects logistic regression to create a multivariable model for DFLST and then calculated adjusted rates of DFLST for each ICU. RESULTS: Patient factors associated with increased odds of DFLST included advanced age, female sex, white race, and poor baseline functional status (all P < .001). However, associations with several of these factors varied among ICUs (eg, black race had an OR for DFLST from 0.18 to 2.55 across ICUs). The ICU staffing model was also found to be associated with DFLST, with an open ICU staffing model associated with an increased odds of a DFLST (OR = 1.19). The predicted probability of DFLST varied approximately sixfold among ICUs after adjustment for the fixed patient and ICU effects and was directly correlated with the standardized mortality ratios of ICUs (r = 0.53, 0.41-0.68). CONCLUSION: Although patient factors explain much of the variability in DFLST practices, significant effects of ICU culture and practice influence end-of-life decision-making. The observation that an ICU's risk-adjusted propensity to withdraw life support is directly associated with its standardized mortality ratio suggests problems with using the latter as a quality measure.

Short- and long-term survival of nonsurgical intensive care patients and its relation to diagnosis, severity of disease, age and comorbidities.

OBJECTIVE: To identify variables associated with mortality in the ICU and 1 year following discharge. DESIGN: Prospective observational cohort study. SETTING: ICU of a tertiary care center and university hospital. PATIENTS: A total of 3,119 medical and neurological intensive care patients. MEASUREMENTS AND MAIN RESULTS: Pre-admission health status was quantified by the sum of risk factors and chronic diseases. Severity of the acute disease was estimated by counting the number of organ dysfunctions and the Acute Physiology Score. Concerning the primarily affected organ system, ICU mortality was highest in hematological diseases (63%) and 1-year mortality was 82%. Lowest death rates were observed with metabolic (ICU 4%, 1-yr 18%) and psychiatric diagnoses (ICU 5%, 1-yr 13%). Greater severity of illness with the need for mechanical life support was associated with decreased 1-year survival. In the respiratory and in renal diseases, the artificial support of the primarily affected organ system incurred an ICU mortality equaling the average (23%) or below (14%) that of the whole ICU population. Pre-admission health status increased the probability of developing multiple organ failure and worsened outcome 1 year after discharge in non-cardiovascular patients. Age showed a weak correlation with chronic diseases and severity of the acute illness and was related to long-term, but not short-term survival. CONCLUSIONS: The most important risk factors associated with short- and long-term mortality in non-surgical intensive care patients are disease severity and the primarily affected organ system that necessitates admission. The artificial support of this organ system can improve only short-term outcome.

The role of child life in pediatric pain management: a survey of child life specialists.

UNLABELLED: Pain management is often described as a component of child life specialists' work. No research has described the specific pain management strategies used by child life specialists. The objectives of this study were to determine child life specialists' use of nonpharmacological strategies, to describe the perceived efficacy of these strategies, to determine how much training child life specialists had in these various strategies, and to determine what demographic characteristics predict the use of evidence-based techniques. Six hundred seven child life specialists from hospitals and health centers across North America responded to an online survey (response rate: 85.4%). Results indicate that child life specialists use a variety of techniques with varying degrees of perceived efficacy. The most commonly endorsed techniques were providing information/preparation, comforting/reassurance, and positive reinforcement. Respondents reported receiving substantial training in some techniques (eg, providing information/preparation, medical play) and high interest in receiving additional training in all techniques. Certification status, the proportion of patients for whom participants reported providing pain management services, and participants' perceived levels of knowledge and skill emerged as significant predictors of the use of evidence-based strategies. The results of this survey suggest that child life specialists are actively involved in pediatric pain management. PERSPECTIVE: American and Canadian child life specialists were surveyed to assess their involvement in managing the pain of pediatric patients. Findings of the survey indicate that child life specialists are involved in the management of pediatric pain and are receptive to additional training in evidence-based techniques.

[Anaesthesiological management in orthotopic liver transplantation -- results of a survey]. / Anästhesiologisches Vorgehen bei orthotopen Lebertransplantationen (LTX) -- Ergebnisse einer Umfrage.

OBJECTIVE: Since there is no therapeutical standard for the anaesthesiological approach during liver transplantation (LTX) in Germany at the moment, we have evaluated the current anaesthesiological procedures during LTX. METHODS: All departments of anaesthesiology (n = 24) cooperating with transplantation centers in Germany received a questionnaire via mail regarding following complexes: anaesthesiological methods, anaesthetics, blood components therapy, perioperative monitoring, supportive cardiovascular therapy and staff. RESULTS: The answers (n = 16) showed following results: Balanced anaesthesia with continuous application of opioids was the standard method (80 %). Different volatile anaesthetics as well as different opioids were used, isoflurane (66.7 %) and fentanyl (53.3 %) were the most common. Veno-venous bypass was never or occasionally used (86.7 %). The differentiated use of catecholamines, based on discussions in the last years, was also reflected in the results. Dobutamine/noradrenaline as combination seemed to be the first choice (46.7 %). Whereas there was an accordance with the employment of blood components, there was a large variation in the effectively applied blood products. Aprotinin was given in 60 % of all clinics occasionally, in 20 % every time and in 20 % aprotinine was never used. In most departments > or = 2 anaesthesiologists (80 %) and 1 nurse (53.3 %) were needed for intraoperative observation. Postoperative medical attendance was provided on anaesthesiological as well as surgical guided intensive care units (ICU). Generally accepted was an early extubation after arrival at the ICU (86.7 %). CONCLUSION: Even though there was a consensus in the anaesthesiological approach during LTX some departments still use different procedures. This is the first study that will give a basis for discussion of anaesthesiological approaches during LTX.

Health, 'small-worlds', fractals and complex networks: an emerging field.

The importance of 'small-worlds', fractals and complex networks to medicine are discussed. The interrelationship between the concepts is highlighted. 'Small-worlds'--where large populations are linked at the level of the individual have considerable importance for understanding disease transmission. Complex networks where linkages are based on the concept 'the rich get richer' are fundamental in the medical sciences--from enzymatic interactions at the subcellular level to social interactions such as sexual liaisons. Mathematically 'the rich get richer' can be modeled as a power law. Fractal architecture and time sequences can also be modeled by power laws and are ubiquitous in nature with many important examples in medicine. The potential of fractal life support--the return of physiological time sequences to devices such as mechanical ventilators and cardiopulmonary bypass pumps--is presented in the context of a failing complex network. Experimental work suggests that using fractal time sequences improves support of failing organs. Medicine, as a science has much to gain by embracing the interrelated concepts of 'small-worlds', fractals and complex networks. By so doing, medicine will move from the historical reductionist approach toward a more holistic one.