Febuxostat as a renoprotective agent for treatment of hyperuricaemia: a meta-analysis of randomised controlled trials.

BACKGROUND: The objective of this meta-analysis of randomised controlled clinical trials (RCT) was to evaluate the effects of febuxostat on kidney function in patients with hyperuricaemia. AIMS: Febuxostat is a xanthine oxidase inhibitor that decreases uric acid production. Recent studies suggested the renoprotective effect of febuxostat among hyperuricaemia patients. The aim of this study was to evaluate the effects of febuxostat on kidney function in patients with hyperuricaemia. METHODS: We conducted electronic searches in PubMed, Embase and Cochrane Central Register of Controlled Trials from January 1960 to July 2019 to identify RCT that examined the effects of febuxostat in adult patients with hyperuricaemia on serum creatinine, estimated glomerular filtration rate (eGFR), albuminuria, blood pressure parameters, major cardiovascular events, diarrhoea, joint pain, stroke and arrhythmia. RESULTS: Nine RCT with 2141 participants were included in this meta-analysis. Compared to placebo, the febuxostat group showed a higher eGFR at 6 months with a weighted mean difference (WMD) of 2.86 mL/min/1.73 m2 (P < 0.001), as well as the end of studies (eGFR WMD 2.69 mL/min/1.73 m2 , P < 0.001). There was also lower serum creatinine (SrCr WMD = -0.04 mg/dL, P < 0.001), reduction in systolic blood pressure (SBP WMD = -1.18 mmHg, P < 0.001) and diastolic blood pressure (DBP WMD = -1.14 mmHg, P = 0.04). There was no statistical difference between febuxostat and placebo in major cardiovascular events, diarrhoea, joint symptoms, stroke events and arrhythmia. Subgroup analysis among chronic kidney disease showed the febuxostat group had higher eGFR than the placebo group (eGFR WMD = 2.69 mL/min/1.73 m2 , P < 0.001). CONCLUSION: Treating hyperuricaemia with febuxostat may slow the progression of chronic kidney disease irrespective of baseline renal function without significantly associated increased risks of major cardiovascular events, diarrhoea, joint symptoms, arrhythmia and stroke, compared to placebo.

Implementation of a New Guideline and Educational Sessions to Reduce Low-Value Continuous Pulse Oximetry Among Hospitalized Patients.

OBJECTIVES: The use of continuous pulse oximetry (CPOX) is ubiquitous among hospitalized patients, despite limited evidence that it improves clinical outcomes. The objective of this study was to reduce the use of CPOX among hospitalized patients in the nonintensive care unit and nonprogressive care unit settings. METHODS: This interventional trial included the creation a new local guideline for CPOX use and subsequent staff education. CPOX use, patient acuity, hospital length of stay, and code blue events were measured before and after the intervention. RESULTS: Postintervention there was a clinically significant and sustained decrease in CPOX use of 18% over 1 year. There were no significant changes postintervention in hospital length of stay or number of code blue events. CONCLUSIONS: Development of a guideline for CPOX use and staff education successfully led to a decrease in CPOX use, without an increase in hospital length of stay or code blue events.

AKI after Transcatheter or Surgical Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for patients with symptomatic severe aortic stenosis who are at high risk of perioperative mortality. Previous studies showed increased risk of postoperative AKI with TAVR, but it is unclear whether differences in patient risk profiles confounded the results. To conduct a propensity-matched study, we identified all adult patients undergoing isolated aortic valve replacement for aortic stenosis at Mayo Clinic Hospital in Rochester, Minnesota from January 1, 2008 to June 30, 2014. Using propensity score matching on the basis of clinical characteristics and preoperative variables, we compared the postoperative incidence of AKI, defined by Kidney Disease Improving Global Outcomes guidelines, and major adverse kidney events in patients treated with TAVR with that in patients treated with SAVR. Major adverse kidney events were the composite of in-hospital mortality, use of RRT, and persistent elevated serum creatinine ≥200% from baseline at hospital discharge. Of 1563 eligible patients, 195 matched pairs (390 patients) were created. In the matched cohort, baseline characteristics, including Society of Thoracic Surgeons risk score and eGFR, were comparable between the two groups. Furthermore, no significant differences existed between the TAVR and SAVR groups in postoperative AKI (24.1% versus 29.7%; P=0.21), major adverse kidney events (2.1% versus 1.5%; P=0.70), or mortality >6 months after surgery (6.0% versus 8.3%; P=0.51). Thus, TAVR did not affect postoperative AKI risk. Because it is less invasive than SAVR, TAVR may be preferred in high-risk individuals.

Persistent acute kidney injury following transcatheter aortic valve replacement.

BACKGROUND: Acute kidney injury (AKI) and its severity after transcatheter aortic valve replacement (TAVR) have been associated with worse outcomes. Studies have shown that AKI duration (transient or persistent) affects outcomes independently of AKI severity. This study was undertaken to determine the association, risk factors, and outcomes associated with persistent AKI (pAKI) after TAVR. METHODS: Adult patients undergoing TAVR at Mayo Clinic between January 1, 2008 and June 30, 2014 were enrolled. pAKI was defined as an increased serum creatinine at hospital discharge (≥0.3 mg/dL or ≥50% from baseline). Risk factors associated with pAKI were identified with multivariate logistic regression. RESULTS: A total of 386 patients met the inclusion criteria. Fifty patients (13%) had pAKI. Independent risk factors for pAKI on multivariate analysis included diabetes mellitus (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.29-4.66), prior percutaneous coronary intervention (PCI) (OR, 2.39; 95%CI, 1.24-4.80), intra-aortic balloon pump (IABP) use (OR, 8.14; 95%CI, 1.60-45.78), and blood transfusion (OR, 2.22; 95%CI, 1.15-4.27). Protective factors for pAKI included a higher baseline estimated glomerular filtration rate (eGFR) (OR, 0.83 per 10-mL/min/1.73 m2 increase in eGFR; 95%CI, 0.71-0.99). After adjusting for the Society of Thoracic Surgeons cardiac surgery risk score, pAKI occurrence remained significantly associated with increased 2-year mortality among hospital survivors (hazard ratio, 2.65; 95%CI, 1.51-4.41). CONCLUSION: pAKI was significantly associated with higher mortality risk following TAVR. Baseline eGFR, diabetes mellitus, previous PCI, IABP, and blood transfusion were risk factors for post-procedural pAKI.

Transapical versus transfemoral approach and risk of acute kidney injury following transcatheter aortic valve replacement: a propensity-adjusted analysis.

BACKGROUND: The aim of this study was to compare the incidence of post-procedural acute kidney injury (AKI) and other renal outcomes in patients undergoing transapical (TA) and transfemoral (TF) approaches for transcatheter aortic valve replacement (TAVR). METHODS: All consecutive adult patients undergoing TAVR for aortic stenosis from 1 January 2008 to 30 June 2014 at a tertiary referral hospital were included. AKI was defined based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. Logistic regression adjustment, propensity score stratification, and propensity matching were performed to assess the independent association between procedural approach and AKI. RESULTS: Of 366 included patients, 171 (47%) underwent TAVR via a TA approach. AKI occurrence in this group was significantly higher compared to the TF group (38% vs. 18%, p < .01). The TA approach remained significantly associated with increased risk of AKI after logistic regression (OR 3.20; CI 1.68-4.36) and propensity score adjustment: OR 2.83 (CI 1.66-4.80) for stratification and 3.82 (CI 2.04-7.44) for matching. Nonetheless, there was no statistically significant difference among the TA and TF groups with respect to major adverse kidney events (MAKE) or estimated glomerular filtration rate (eGFR) at six months post-procedure. CONCLUSION: In a cohort of patients undergoing TAVR for aortic stenosis, a TA approach significantly increases the AKI risk compared with a TF approach. However, the TAVR approach did not affect severe renal outcomes or long-term renal function.

The Effect of an Electronic Checklist on Critical Care Provider Workload, Errors, and Performance.

PURPOSE: The strategy used to improve effective checklist use in intensive care unit (ICU) setting is essential for checklist success. This study aimed to test the hypothesis that an electronic checklist could reduce ICU provider workload, errors, and time to checklist completion, as compared to a paper checklist. METHODS: This was a simulation-based study conducted at an academic tertiary hospital. All participants completed checklists for 6 ICU patients: 3 using an electronic checklist and 3 using an identical paper checklist. In both scenarios, participants had full access to the existing electronic medical record system. The outcomes measured were workload (defined using the National Aeronautics and Space Association task load index [NASA-TLX]), the number of checklist errors, and time to checklist completion. Two independent clinician reviewers, blinded to participant results, served as the reference standard for checklist error calculation. RESULTS: Twenty-one ICU providers participated in this study. This resulted in the generation of 63 simulated electronic checklists and 63 simulated paper checklists. The median NASA-TLX score was 39 for the electronic checklist and 50 for the paper checklist (P = .005). The median number of checklist errors for the electronic checklist was 5, while the median number of checklist errors for the paper checklist was 8 (P = .003). The time to checklist completion was not significantly different between the 2 checklist formats (P = .76). CONCLUSION: The electronic checklist significantly reduced provider workload and errors without any measurable difference in the amount of time required for checklist completion. This demonstrates that electronic checklists are feasible and desirable in the ICU setting.

The comparison of the commonly used surrogates for baseline renal function in acute kidney injury diagnosis and staging.

BACKGROUND: Baseline serum creatinine (SCr) level is frequently not measured in clinical practice. The aim of this study was to investigate the effect of various methods of baseline SCr determination measurement on accuracy of acute kidney injury (AKI) diagnosis in critically ill patients. METHODS: This was a retrospective cohort study. All adult intensive care unit (ICU) patients admitted at a tertiary referral hospital from January 1, 2011 through December 31, 2011, with at least one measured SCr value during ICU stay, were included in this study. The baseline SCr was considered either an admission SCr (SCrADM) or an estimated SCr, using MDRD formula, based on an assumed glomerular filtration rate (GFR) of 75 ml/min/1.73 m(2) (SCrGFR-75). Determination of AKI was based on the KDIGO SCr criterion. Propensity score to predict the likelihood of missing SCr was used to generate a simulated cohort of 3566 patients with baseline outpatient SCr, who had similar characteristics with patients whose outpatient SCr was not available. RESULTS: Of 7772 patients, 3504 (45.1 %) did not have baseline outpatient SCr. Among patients without baseline outpatient SCr, AKI was detected in 571 (16.3 %) using the SCrADM and 997 (28.4 %) using SCrGFR-75 (p < .001). Compared with non-AKI patients, patients who met AKI only by SCrADM, but not SCrGFR-75, were significantly associated with 60-day mortality (OR 2.90; 95 % CI 1.66-4.87), whereas patients who met AKI only by SCrGFR-75, but not SCrADM, had a non-significant increase in 60-day mortality risk (OR 1.33; 95 % CI 0.94-1.88). In a simulated cohort of patients with baseline outpatient SCr, SCrGFR-75 yielded a higher sensitivity (77.2 vs. 50.5 %) and lower specificity (87.8 vs. 94.8 %) for the AKI diagnosis in comparison with SCrADM. CONCLUSIONS: When baseline outpatient SCr was not available, using SCrGFR-75 as surrogate for baseline SCr was found to be more sensitive but less specific for AKI diagnosis compared with using SCrADM. This resulted in higher incidence of AKI with larger likelihood of false-positive cases.

Testing modes of computerized sepsis alert notification delivery systems.

BACKGROUND: The number of electronic health record (EHR)-based notifications continues to rise. One common method to deliver urgent and emergent notifications (alerts) is paging. Despite of wide presence of smartphones, the use of these devices for secure alerting remains a relatively new phenomenon. METHODS: We compared three methods of alert delivery (pagers, EHR-based notifications, and smartphones) to determine the best method of urgent alerting in the intensive care unit (ICU) setting. ICU clinicians received randomized automated sepsis alerts: pager, EHR-based notification, or a personal smartphone/tablet device. Time to notification acknowledgement, fatigue measurement, and user preferences (structured survey) were studied. RESULTS: Twenty three clinicians participated over the course of 3 months. A total of 48 randomized sepsis alerts were generated for 46 unique patients. Although all alerts were acknowledged, the primary outcome was confounded by technical failure of alert delivery in the smartphone/tablet arm. Median time to acknowledgment of urgent alerts was shorter by pager (102 mins) than EHR (169 mins). Secondary outcomes of fatigue measurement and user preference did not demonstrate significant differences between these notification delivery study arms. CONCLUSIONS: Technical failure of secure smartphone/tablet alert delivery presents a barrier to testing the optimal method of urgent alert delivery in the ICU setting. Results from fatigue evaluation and user preferences for alert delivery methods were similar in all arms. Further investigation is thus necessary to understand human and technical barriers to implementation of commonplace modern technology in the hospital setting.

Improving the Accuracy of Cardiovascular Component of the Sequential Organ Failure Assessment Score.

OBJECTIVES: The Sequential Organ Failure Assessment score is an attractive risk prediction model because of its simplicity and graded assessment of morbidity and mortality. Due to changes in clinical practice over time, the cardiovascular component of the Sequential Organ Failure Assessment score no longer accurately reflects current clinical practice. To address this limitation, we developed and validated a modified cardiovascular component of the Sequential Organ Failure Assessment score that takes into account all vasoactive agents used in current clinical practice, uses shock index as a substitute for mean arterial pressure, and incorporates serum lactate as a biomarker for shock states. DESIGN: Retrospective cohort. SETTING: Mayo Clinic, Rochester, MN. PATIENTS: Adult patients admitted to one of six ICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Score performance was assessed via area under the receiver operator characteristic curve. A total of 16,386 ICU admissions were included: 9,204 in the derivation cohort and 7,182 in the validation cohort. area under the receiver operator characteristic curve was significantly higher for modified cardiovascular component of the Sequential Organ Failure Assessment score than for cardiovascular component of the Sequential Organ Failure Assessment for in-ICU mortality (0.801 vs 0.718; difference = 0.083; p < 0.001), in-hospital mortality (0.783 vs 0.651; difference = 0.132; p < 0.001), and 28-day mortality (0.737 vs 0.655; difference = 0.082; p < 0.001). When modified cardiovascular component of the Sequential Organ Failure Assessment score was added to the remaining Sequential Organ Failure Assessment components, the modified Sequential Organ Failure Assessment score again outperformed the existing Sequential Organ Failure Assessment score: in-ICU mortality (0.836 vs 0.822; difference = 0.014; p < 0.001), in-hospital mortality (0.799 vs 0.784; difference = 0.015; p < 0.001), and 28-day mortality (0.798 vs 0.783; difference = 0.015; p < 0.001). Similar results were seen in the validation cohort. CONCLUSIONS: The modified cardiovascular component of the Sequential Organ Failure Assessment score outperforms the existing cardiovascular component of the Sequential Organ Failure Assessment score in predicting patient outcomes and improves the overall performance of the Sequential Organ Failure Assessment model. This score is easily calculated, includes serum lactate as a biomarker for shock states, and incorporates all vasopressors used in current clinical practice.

Interaction Time with Electronic Health Records: A Systematic Review.

BACKGROUND: The amount of time that health care clinicians (physicians and nurses) spend interacting with the electronic health record is not well understood. OBJECTIVE: This study aimed to evaluate the time that health care providers spend interacting with electronic health records (EHR). METHODS: Data are retrieved from Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily, (Ovid) Embase, CINAHL, and SCOPUS. STUDY ELIGIBILITY CRITERIA: Peer-reviewed studies that describe the use of EHR and include measurement of time either in hours, minutes, or in the percentage of a clinician's workday. Papers were written in English and published between 1990 and 2021. PARTICIPANTS: All physicians and nurses involved in inpatient and outpatient settings. STUDY APPRAISAL AND SYNTHESIS METHODS: A narrative synthesis of the results, providing summaries of interaction time with EHR. The studies were rated according to Quality Assessment Tool for Studies with Diverse Designs. RESULTS: Out of 5,133 de-duplicated references identified through database searching, 18 met inclusion criteria. Most were time-motion studies (50%) that followed by logged-based analysis (44%). Most were conducted in the United States (94%) and examined a clinician workflow in the inpatient settings (83%). The average time was nearly 37% of time of their workday by physicians in both inpatient and outpatient settings and 22% of the workday by nurses in inpatient settings. The studies showed methodological heterogeneity. CONCLUSION: This systematic review evaluates the time that health care providers spend interacting with EHR. Interaction time with EHR varies depending on clinicians' roles and clinical settings, computer systems, and users' experience. The average time spent by physicians on EHR exceeded one-third of their workday. The finding is a possible indicator that the EHR has room for usability, functionality improvement, and workflow optimization.

A nationwide assessment of perceptions of research-intense academic careers among predoctoral MD and MD-PhD trainees.

INTRODUCTION: While previous studies have described career outcomes of physician-scientist trainees after graduation, trainee perceptions of research-intensive career pathways remain unclear. This study sought to identify the perceived interests, factors, and challenges associated with academic and research careers among predoctoral MD trainees, MD trainees with research-intense (>50%) career intentions (MD-RI), and MD-PhD trainees. METHODS: A 70-question survey was administered to 16,418 trainees at 32 academic medical centers from September 2012 to December 2014. MD vs. MD-RI (>50% research intentions) vs. MD-PhD trainee responses were compared by chi-square tests. Multivariate logistic regression analyses were performed to identify variables associated with academic and research career intentions. RESULTS: There were 4433 respondents (27% response rate), including 2625 MD (64%), 653 MD-RI (15%), and 856 MD-PhD (21%) trainees. MD-PhDs were most interested in pursuing academia (85.8%), followed by MD-RIs (57.3%) and MDs (31.2%). Translational research was the primary career intention for MD-PhD trainees (42.9%). Clinical duties were the primary career intention for MD-RIs (51.9%) and MDs (84.2%). While 39.8% of MD-PhD respondents identified opportunities for research as the most important career selection factor, only 12.9% of MD-RI and 0.5% of MD respondents shared this perspective. Interest in basic research, translational research, clinical research, education, and the ability to identify a mentor were each independently associated with academic career intentions by multivariate regression. CONCLUSIONS: Predoctoral MD, MD-RI, and MD-PhD trainees are unique cohorts with different perceptions and interests toward academic and research careers. Understanding these differences may help to guide efforts to mentor the next generation of physician-scientists.

Rate of kidney function decline and factors predicting progression of kidney disease in type 2 diabetes mellitus patients with reduced kidney function: A nationwide retrospective cohort study.

Currently, the data on independent risk factors for the progression of kidney disease in type 2 diabetes mellitus (T2DM) patients with CKD are limited. This study aimed to investigate CKD progression in T2DM patients who have reduced kidney function with baseline estimated glomerular filtration rate (eGFRs) between 15 and 59 mL/min/1.73 m2 . This study was composed of a nationwide retrospective cohort of adult T2DM patients from 831 public hospitals in Thailand during the year 2015. T2DM patients with CKD stages 3 and 4 were followed up, until development of CKD stage 5, requirement of chronic dialysis, loss to follow-up, death, or 31 May 2018, whichever came first. Cox proportional hazard regression was utilized for analysis. A total of 8464 participants were included; 30.4% were male. The mean age was 69 ± 10 years. The mean eGFR was 45 ± 11 mL/min/1.73 m2 . The incidence of CKD stage 5 or the need for chronic dialysis was 16.4 per 1000 person-years. The annual rate of eGFR decline during a mean follow-up of 29 months was -2.3 mL/min/1.73 m2 ; 14.4% had a rapid decline in eGFR. The risk factors associated with progression to CKD stage 5 or the need for chronic dialysis were diabetes duration, systolic blood pressure, serum uric acid, albuminuria, and baseline eGFR. Conversely, older age and the use of renin-angiotensin aldosterone system blockade were associated with decreased risks for rapid CKD progression and incidence CKD stage 5 or dialysis. This study identifies multiple predictive risk factors that support a multifaceted approach to prevent progression of advanced CKD.

Clinical impact of intraoperative electronic health record downtime on surgical patients.

OBJECTIVE: Despite increased use of electronic health records (EHRs), the clinical impact of system downtime is unknown. MATERIALS AND METHODS: This retrospective matched cohort study evaluated the impact of EHR downtime episodes lasting more than 60 minutes over a 6-year study period. Patients age 18 years or older who underwent surgical procedures at least 60 minutes in duration with an inpatient stay exceeding 24 hours within the study period were eligible for inclusion. Out of 4115 patients exposed to 1 of 176 EHR downtime episodes, 4103 patients were matched to an unexposed cohort in a 1:1 ratio. Multivariable regression analysis, as well as trend analysis for effect of duration of downtime on outcomes, was performed. RESULTS: Downtime-exposed patients had operating room duration 1.1 times longer (p < .001) and postoperative length of stay 1.04 times longer (p = .007) compared to unexposed patients. The 30-day mortality rates were similar between these groups (odds ratio 1.26, p > .05). In trend analysis, there was no association between duration of downtime with respect to evaluated outcomes, postoperative length of stay, and 30-day mortality. CONCLUSION: EHR downtime had no impact on 30-day mortality. Potential associations for increased postoperative length of stay and duration of time spent in the operating room were observed among downtime-exposed patients. No trend effect was observed with respect to duration of downtime and postoperative length of stay and 30-day mortality rates.

Elevated admission serum calcium phosphate product as an independent risk factor for acute kidney injury in hospitalized patients.

BACKGROUND: Increased serum calcium-phosphate product (CaP) can result in acute kidney injury (AKI) due to tubular and interstitial calcium phosphate deposits. CaP of > 55 mg2/dL2 is also associated with systemic calcification. However, the risk of AKI development among hospitalized patients with different admission calcium-phosphate product levels remains unclear. METHODS: All adult hospitalized patients who had both admission serum calcium and phosphate levels available from 2009 through 2013 were enrolled. Admission CaP was categorized based on its distribution into six groups (<22, 22- < 27, 27- < 32, 32- < 37, 37- < 42 and ≥42 mg2/dL2). The odds ratio (OR) of in-hospital mortality by admission CaP, using the CaP category of < 22 mg2/dL2 as the reference group, was obtained by logistic regression analysis. RESULTS: After excluding patients with end-stage renal disease, without serum creatinine measurement, and those who presented with AKI at the time of admission, a total of 9,864 patients were studied. In-hospital AKI occurred in 1,478 patients (15.0%). The incidence of AKI among patients with admission CaP < 22, 22 to < 27, 27 to < 32, 32 to < 37, 37 to < 42, and ≥42 mg2/dL2 was 11.1%, 12.4%, 14.9%, 15.2%, 17.5%, and 19.9%, respectively. After adjusting for potential confounders, a CaP ≥37 mg2/dL2 was associated with an increased risk of developing AKI with OR of 1.53 (CI 1.19-1.96) and 1.63 (CI 1.25-2.14) in patients with admission CaP 37- < 42 and ≥42, respectively. Subgroup analysis based on eGFR consistently demonstrated that CaP ≥37 mg2/dL2 was associated with an increased risk of developing AKI in both chronic kidney disease (CKD) and non-CKD patients. CONCLUSION: Elevated admission CaP was independently associated with an increased risk for in-hospital AKI.

Prognostic Importance of Low Admission Serum Creatinine Concentration for Mortality in Hospitalized Patients.

OBJECTIVE: The study objective was to assess the association between low serum creatinine value at admission and in-hospital mortality in hospitalized patients. METHODS: This was a retrospective single-center cohort study conducted at a tertiary referral hospital. All hospitalized adult patients between 2011 and 2013 who had an admission creatinine value available were identified for inclusion in this study. Admission creatinine value was categorized into 7 groups: ≤0.4, 0.5 to 0.6, 0.7 to 0.8, 0.9 to 1.0, 1.1 to 1.2, 1.3 to 1.4, and ≥1.5 mg/dL. The primary outcome was in-hospital mortality. Logistic regression analysis was performed to obtain the odds ratio of in-hospital mortality for the various admission creatinine levels, using a creatinine value of 0.7 to 0.8 mg/dL as the reference group in the analysis of all patients and female patients and of 0.9 to 1.0 mg/dL in the analysis of male patients because it was associated with the lowest in-hospital mortality. RESULTS: Of 73,994 included patients, 973 (1.3%) died in the hospital. The association between different categories of admission creatinine value and in-hospital mortality assumed a U-shaped distribution, with both low and high creatinine values associated with higher in-hospital mortality. After adjustment for age, sex, ethnicity, principal diagnosis, and comorbid conditions, very low creatinine value (≤0.4 mg/dL) was significantly associated with increased mortality (odds ratio, 3.29; 95% confidence interval, 2.08-5.00), exceeding the risk related to a markedly increased creatinine value of ≥1.5 mg/dL (odds ratio, 2.56; 95% confidence interval, 2.07-3.17). The association remained significant in the subgroup analysis of male and female patients. CONCLUSIONS: Low creatinine value at admission is independently associated with increased in-hospital mortality in hospitalized patients.

Comparison of methods of alert acknowledgement by critical care clinicians in the ICU setting.

BACKGROUND: Electronic Health Record (EHR)-based sepsis alert systems have failed to demonstrate improvements in clinically meaningful endpoints. However, the effect of implementation barriers on the success of new sepsis alert systems is rarely explored. OBJECTIVE: To test the hypothesis time to severe sepsis alert acknowledgement by critical care clinicians in the ICU setting would be reduced using an EHR-based alert acknowledgement system compared to a text paging-based system. STUDY DESIGN: In one arm of this simulation study, real alerts for patients in the medical ICU were delivered to critical care clinicians through the EHR. In the other arm, simulated alerts were delivered through text paging. The primary outcome was time to alert acknowledgement. The secondary outcomes were a structured, mixed quantitative/qualitative survey and informal group interview. RESULTS: The alert acknowledgement rate from the severe sepsis alert system was 3% (N = 148) and 51% (N = 156) from simulated severe sepsis alerts through traditional text paging. Time to alert acknowledgement from the severe sepsis alert system was median 274 min (N = 5) and median 2 min (N = 80) from text paging. The response rate from the EHR-based alert system was insufficient to compare primary measures. However, secondary measures revealed important barriers. CONCLUSION: Alert fatigue, interruption, human error, and information overload are barriers to alert and simulation studies in the ICU setting.

Admission hyperuricemia increases the risk of acute kidney injury in hospitalized patients(.).

BACKGROUND: The association between elevated admission serum uric acid (SUA) and risk of in-hospital acute kidney injury (AKI) is limited. The aim of this study was to assess the risk of developing AKI in all hospitalized patients with various admission SUA levels. METHODS: This is a single-center retrospective study conducted at a tertiary referral hospital. All hospitalized adult patients who had admission SUA available from January 2011 through December 2013 were analyzed in this study. Admission SUA was categorized based on its distribution into six groups (<3.4, 3.4-4.5, 4.5-5.8, 5.8-7.6, 7.6-9.4 and >9.4 mg/dL). The primary outcome was in-hospital AKI occurring after hospital admission. Logistic regression analysis was performed to obtain the odds ratio (OR) of AKI of various admission SUA levels using the most common SUA level range (5.8-7.6 mg/dL) as the reference group. RESULTS: Of 1435 patients enrolled, AKI occurred in 263 patients (18%). The incidence of AKI and need for dialysis was increased in patients with higher admission SUA levels. After adjusting for potential confounders, SUA >9.4 mg/dL was associated with an increased risk of developing AKI, with ORs of 1.79 [95% confidence interval (CI) 1.13-2.82]. Conversely, admission SUA <3.4 and 3.4-4.5 mg/dL were associated with a decreased risk of developing AKI, with ORs of 0.38 (95% CI 0.17-0.75) and 0.50 (95% CI 0.28-0.87), respectively. CONCLUSIONS: Elevated admission SUA was associated with an increased risk for in-hospital AKI.

Development and Implementation of Sepsis Alert Systems.

Development and implementation of sepsis alert systems is challenging, particularly outside the monitored intensive care unit (ICU) setting. Barriers to wider use of sepsis alerts include evolving clinical definitions of sepsis, information overload, and alert fatigue, due to suboptimal alert performance. Outside the ICU, barriers include differences in health care delivery models, charting behaviors, and availability of electronic data. Current evidence does not support routine use of sepsis alert systems in clinical practice. Continuous improvement in the afferent and efferent aspects will help translate theoretic advantages into measurable patient benefit.

Temporal trends in the utilization of vasopressors in intensive care units: an epidemiologic study.

BACKGROUND: The choice of vasopressor use in the intensive care unit (ICU) depends primarily on provider preference. This study aims to describe the rate of vasopressor utilization and the trends of each vasoactive agent usage in the ICU over the span of 7 years in a tertiary referral center. METHODS: All adult ICU admissions, including medical, cardiac, and surgical ICUs from January 1st, 2007 through December 31st, 2013 were included in this study. Vasopressor use was defined as the continuous intravenous administration of epinephrine, norepinephrine, phenylephrine, dopamine, or vasopressin within a given ICU day. The vasopressor utilization index (VUI) was defined as the proportion of ICU days on each vasoactive agent divided by the total ICU days with vasopressor usage. RESULTS: During the study period, 72,005 ICU admissions and 272,271 ICU days were screened. Vasopressors were used in 19,575 ICU admissions (27 %) and 59,811 ICU days (22 %). Vasopressin was used in 24,496 (41 %), epinephrine in 23,229 (39 %), norepinephrine in 20,648 (34 %), dopamine in 9449 (16 %), and phenylephrine in 7508 (13 %) ICU days. The VUInorepinephrine increased from 0.24 in 2007 to 0.46 in 2013 and VUIphenylephrine decreased from 0.20 in 2007 to 0.08 in 2013 (p < 0.001 both). For epinephrine, dopamine, and vasopressin VUI did not change over the course of study. CONCLUSION: Vasopressors were used in about one fourth of ICU admissions and about one-fifth of ICU days. Although vasopressin is the most commonly used vasopressor, the use of norepinephrine found to have an increasing trajectory.