Analysis of Calprotectin as an Early Marker of Infections Is Economically Advantageous in Intensive Care-Treated Patients.

Calprotectin is released from neutrophil granulocytes upon activation. Several studies have indicated that plasma calprotectin is an early determinant of bacterial infections, which may serve as a diagnostic tool facilitating decision making on antibiotic treatment. The study objective was to explore the health and economic implications of calprotectin as a predictive tool to initiate antimicrobial therapy in a cohort of critically ill patients. Thus, data obtained from a previously published study on calprotectin as a hypothetical early biomarker of bacterial infections in critically ill patients were evaluated regarding the potential cost-effective impact of early analysis of calprotectin on an earlier start of antibiotic treatment. Under the assumption that calprotectin is used predictively and comparators (white blood cells, procalcitonin, and C-reactive protein) are used diagnostically, a cost-effective impact of EUR 11,000-12,000 per patient would be obtained. If calprotectin would be used predictively and comparators would be used predictively for 50% of patients, it is hypothesized that cost-effectiveness would be between EUR 6000 and 7000 per patient, based on reduced stay in the ICU and general ward, respectively. Furthermore, predictive use of calprotectin seems to reduce both mortality and the length of hospital stay. This health economic analysis on the predictive use of plasma calprotectin, which facilitates clinical decision making in cases of suspected sepsis, indicates that such determination has a cost-saving and life-saving impact on the healthcare system.

Hospital costs and factors associated with days alive and at home after surgery (DAH30 ).

OBJECTIVE: To assess the relationships of patient and surgical factors and hospital costs with the number of days alive and at home during the 30 days following surgery (DAH30 ). DESIGN: Retrospective cohort study; analysis of Medibank Private health insurance hospital claims data, Australia, 1 January 2016 - 31 December 2017. SETTING, PARTICIPANTS: Admissions of adults (18 years or older) to hospitals for elective or emergency inpatient surgery with anaesthesia covered by private health insurance, Australia, 1 January 2016 - 31 December 2017. MAIN OUTCOME MEASURES: Associations between DAH30 and total hospital costs, and between DAH30 and surgery risk factors. RESULTS: Complete data were available for 126 788 of 181 281 eligible patients (69.9%); their median age was 62 years (IQR, 47-73 years), 72 872 were women (57%), and 115 117 had undergone elective surgery (91%). The median DAH30 was 27.1 days (IQR, 24.2-28.8 days), the median hospital cost per patient was $10 358 (IQR, $6624-20 174). The association between DAH30 and total hospital costs was moderate (Spearman ρ = -0.60; P < 0.001). Median DAH30 declined with age, comorbidity score, ASA physical status score, and surgical severity and duration, and was also lower for women. CONCLUSIONS: DAH30 is a validated, patient-centred outcome measure of post-surgical outcomes; higher values reflect shorter hospital stays and fewer serious complications, re-admissions, and deaths. DAH30 can be used to benchmark quality of surgical care and to monitor quality improvement programs for reducing the costs of surgical and other peri-operative care.

Cost-effectiveness of the TherMax blood warmer during continuous renal replacement therapy.

Hypothermia is a common adverse event during continuous renal replacement therapy (CRRT), affecting multiple organ systems and increasing risk of poor health outcomes among patients with acute kidney injury (AKI) undergoing CRRT. TheraMax blood warmers are the next generation of extracorporeal blood warmers which reduce risk of hypothermia during CRRT. The purpose of this study is to elucidate the potential health economic impacts of avoiding CRRT-induced hypothermia by using the novel TherMax blood warming device. This study compares health care costs associated with use of the new TherMax blood warmer unit integrated with the PrisMax system compared to CRRT with a standalone blood warming device to avoid hypothermia in continuous renal replacement therapy (CRRT). An economic model was developed in which relevant health states for each intervention were normothermia, hypothermia, discharge, and death. Clinical inputs and costs were obtained from a combination of retrospective chart review and publicly available summary estimates. The proportion of AKI patients treated with CRRT who became hypothermic (<36°C) during CRRT treatment was 34.5% in the TherMax group compared to 71.9% in the 'standalone warmer' group. Given the 78.7-year average life expectancy in the US and the assumed average patient age at discharge/death of 65.4 years, the total life-years gained by avoiding mortality related to hypothermia was 9.0 in the TherMax group compared to 8.0 in the 'standalone warmer' group. Cost per life-year gained was $8,615 in the TherMax group versus $10,115 in the 'standalone warmer' group for a difference of -$1,501 favoring TherMax. The incremental cost-effectiveness ratio was negative, indicating superior cost-effectiveness for TherMax versus 'standalone warmer'. The TherMax blood warming device used with the PrisMax system is associated with lower risk of hypothermia, which our model indicates leads to lower costs, lower risk of mortality due to hypothermia, and superior cost-effectiveness.

Long-term outcome after intensive care for COVID-19: differences between men and women-a nationwide cohort study.

BACKGROUND: Questions remain about long-term outcome for COVID-19 patients in general, and differences between men and women in particular given the fact that men seem to suffer a more dramatic course of the disease. We therefore analysed outcome beyond 90 days in ICU patients with COVID-19, with special focus on differences between men and women. METHODS: We identified all patient ≥ 18 years with COVID-19 admitted between March 6 and June 30, 2020, in the Swedish Intensive Care Registry. Patients were followed until death or study end-point October 22, 2020. Association with patient sex and mortality, in addition to clinical variables, was estimated using Cox regression. We also performed a logistic regression model estimating factors associated with 90-day mortality. RESULTS: In total, 2354 patients with COVID-19 were included. Four patients were still in the ICU at study end-point. Median follow-up time was 183 days. Mortality at 90-days was 26.9%, 23.4% in women and 28.2% in men. After 90 days until end of follow-up, only 11 deaths occurred. On multivariable Cox regression analysis, male sex (HR 1.28, 95% CI 1.06-1.54) remained significantly associated with mortality even after adjustments. Additionally, age, COPD/asthma, immune deficiency, malignancy, SAPS3 and admission month were associated with mortality. The logistic regression model of 90-day mortality showed almost identical results. CONCLUSIONS: In this nationwide study of ICU patients with COVID-19, men were at higher risk of poor long-term outcome compared to their female counterparts. The underlying mechanisms for these differences are not fully understood and warrant further studies.

Calprotectin as an early biomarker of bacterial infections in critically ill patients: an exploratory cohort assessment.

BACKGROUND: Calprotectin is the most abundant protein in the cytosolic fraction of neutrophils, and neutrophil degranulation is a major response to bacterial infections. OBJECTIVES: To assess the value of plasma calprotectin as an early marker of bacterial infections in critically ill patients and compare it with the corresponding values for procalcitonin (PCT), C-reactive protein (CRP) and white blood cell count (WBC). METHODS: We measured daily plasma calprotectin levels in 110 intensive care unit patients using a newly developed turbidimetric assay run on clinical chemistry analysers. The likelihood of infection was determined according to the International Sepsis Forum criteria. RESULTS: Overall, 58 patients (52.7%) developed a suspected or confirmed bacterial infection. Plasma calprotectin predicted such infections within 24 hours with an area under the receiver operating characteristics curve (ROC area) of 0.78 (95% CI, 0.68-0.89). The ROC area for calprotectin was significantly greater than the corresponding ROC areas for WBC (P < 0.001) and PCT (P = 0.02) but only marginally better than the ROC area for CRP (0.71; 95% CI, 0.68-0.89). CONCLUSION: Plasma calprotectin appears to be a useful early marker of bacterial infections in critically ill patients, with better predictive characteristics than WBC and PCT.

Assessment of cell-cycle arrest biomarkers to predict early and delayed acute kidney injury.

PURPOSE: To assess urinary tissue inhibitor of metalloproteinases-2 and insulin-like growth factor binding protein 7 ([TIMP-2]·[IGFBP7]), urinary neutrophil gelatinase-associated lipocalin (NGAL), and urinary cystatin-C as acute kidney injury predictors (AKI) exploring the association of nonrenal factors with elevated biomarker levels. METHODS: We studied 94 patients with urine collected within 48 hours of ICU admission and no AKI at sampling. AKI was defined by the Kidney Disease: Improving Global Outcomes criteria. Predictive performance was assessed by the area under the receiver operating characteristics (ROC) curve. Associations between biomarkers and clinical factors were assessed by multivariate linear regression. RESULTS: Overall, 19 patients (20%) developed AKI within 48 hours. [TIMP-2]·[IGFBP7], NGAL, or cystatin-C admission levels did not differ between patients without AKI and patients developing AKI. [TIMP-2]·[IGFBP7], NGAL, and cystatin-C were poor AKI predictors (ROC areas 0.34-0.51). Diabetes was independently associated with higher [TIMP-2]·[IGFBP7] levels (P = 0.02) but AKI was not (P = 0.24). Sepsis was independently associated with higher NGAL (P < 0.001) and cystatin-C (P = 0.003) levels. CONCLUSIONS: Urinary [TIMP-2]·[IGFBP7], NGAL, and cystatin-C should be used cautiously as AKI predictors in general ICU patients since urine levels of these biomarkers are affected by factors other than AKI and their performance can be poor.

Acute kidney injury following coronary artery bypass grafting: early mortality and postoperative complications.

OBJECTIVES: To investigate the prognostic importance of acute kidney injury on early mortality, postoperative stroke, and mediastinitis in patients undergoing a first isolated coronary artery bypass grafting. DESIGN: 7594 patients undergoing coronary artery bypass grafting with information on pre- and postoperative serum-creatinine values were included. Patients were classified using the Acute Kidney Injury Network classification. Odds ratios (OR) for mortality and postoperative complications within 60 days of surgery were calculated after adjustment for confounders separately for stage 1 and for stages 2 and 3 together. RESULTS: 1047 (14%) patients developed acute kidney injury. There were 132 (1.7%) deaths, 103 (1.4%) strokes and 118 (1.6%) cases of mediastinitis during follow-up. Among patients in stage 1 the adjusted odds ratio for death was 4.36 (95% confidence interval 2.83-6.71) and for stage 2 plus 3; 21.5 (12.0-38.6) compared to patients without acute kidney injury. Corresponding OR for stroke were 2.34 (1.43-3.82) and 6.52 (2.97-14.3) and for mediastinitis 2.88 (1.84-4.50) and 4.68 (2.07-10.6), respectively. CONCLUSIONS: Acute kidney injury following coronary artery bypass grafting is related to postoperative mortality, stroke, and mediastinitis. Patients undergoing coronary artery bypass grafting should be assessed for presence of acute kidney injury postoperatively, in order to predict early prognosis.

Prevalence and sensitivity of MET-criteria in a Scandinavian University Hospital.

OBJECTIVE: To make a preliminary estimation of the workload for a medical emergency team (MET) in a Scandinavian University Hospital by recording prevalent physiological data on all adult patients and to see if the patients with deviating physiology (i.e. fulfilling the study criteria, in essence a set of simplified MET-criteria) had an elevated mortality. We also tested sensitivity and specificity by altering the cut-off levels of the calling criteria. DESIGN: Cross sectional prevalence study. SETTING: University hospital in the capital of Sweden. PATIENTS: Adult patients treated in the general wards of the hospital. Patients from psychiatric wards and intensive care units were excluded from the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 4.5% of the scored patients fulfilled the study criteria. These patients had a 30-day mortality of 25% (confidence interval 12.7-41.2) as compared to 3.5% (2.4-5) for the patients not fulfilling the study criteria. Extended criteria revealed 18 deaths within 30 days, 8 more deaths than the original study criteria. However, 123 patients - equalling 13.8% of the cohort (CI 11.6-16.2) - fulfilled these criteria as compared to the 40 patients fulfilling the original study criteria. Thus, the 30-day mortality of the patients with positive extended criteria totalled 14.6% (CI 8.9-22.1). Restricted criteria showed a mere 20 patients (2.2%; CI 1.4-3.5) and only 4 deaths, making 30-day mortality 20% (CI 5.7-43.7); thus, sensitivity was actually lower using restricted criteria. CONCLUSIONS: Even these modified - and simplified - MET-criteria proved to be able to single out patients with elevated mortality as compared to the rest of the hospital population. Extending the criteria significantly lowered sensitivity and would extend the MET-workload enormously. Restricting the criteria led to missed mortalities where intervention could be beneficial. The results suggest that a routine use of simple physiological tests can be of help in the identification of patients at risk.