The metabolic cost of inspiratory muscle training in mechanically ventilated patients in critical care.

BACKGROUND: Diaphragmatic dysfunction is well documented in patients receiving mechanical ventilation. Inspiratory muscle training (IMT) has been used to facilitate weaning by strengthening the inspiratory muscles, yet the optimal approach remains uncertain. Whilst some data on the metabolic response to whole body exercise in critical care exist, the metabolic response to IMT in critical care is yet to be investigated. This study aimed to quantify the metabolic response to IMT in critical care and its relationship to physiological variables. METHODS: We conducted a prospective observational study on mechanically ventilated patients ventilated for ≥ 72 h and able to participate in IMT in a medical, surgical, and cardiothoracic intensive care unit. 76 measurements were taken on 26 patients performing IMT using an inspiratory threshold loading device at 4 cmH2O, and at 30, 50 and 80% of their negative inspiratory force (NIF). Oxygen consumption (VO2) was measured continuously using indirect calorimetry. RESULTS: First session mean (SD) VO2 was 276 (86) ml/min at baseline, significantly increasing to 321 (93) ml/min, 333 (92) ml/min, 351(101) ml/min and 388 (98) ml/min after IMT at 4 cmH2O and 30, 50 and 80% NIF, respectively (p = 0.003). Post hoc comparisons revealed significant differences in VO2 between baseline and 50% NIF and baseline and 80% NIF (p = 0.048 and p = 0.001, respectively). VO2 increased by 9.3 ml/min for every 1 cmH2O increase in inspiratory load from IMT. Every increase in P/F ratio of 1 decreased the intercept VO2 by 0.41 ml/min (CI - 0.58 to - 0.24 p < 0.001). NIF had a significant effect on the intercept and slope, with every 1 cmH2O increase in NIF increasing intercept VO2 by 3.28 ml/min (CI 1.98-4.59 p < 0.001) and decreasing the dose-response slope by 0.15 ml/min/cmH2O (CI - 0.24 to - 0.05 p = 0.002). CONCLUSIONS: IMT causes a significant load-dependent increase in VO2. P/F ratio and NIF impact baseline VO2. The dose-response relationship of the applied respiratory load during IMT is modulated by respiratory strength. These data may offer a novel approach to prescription of IMT. TAKE HOME MESSAGE: The optimal approach to IMT in ICU is uncertain; we measured VO2 at different applied respiratory loads to assess whether VO2 increased proportionally with load and found VO2 increased by 9.3 ml/min for every 1 cmH2O increase in inspiratory load from IMT. Baseline NIF has a significant effect on the intercept and slope, participants with a higher baseline NIF have a higher resting VO2 but a less pronounced increase in VO2 as the inspiratory load increases; this may offer a novel approach to IMT prescription. Trial registration ClinicalTrials.gov, registration number: NCT05101850. Registered on 28 September 2021, https://clinicaltrials.gov/ct2/show/NCT05101850.

A Large Retrospective Assessment of Voriconazole Exposure in Patients Treated with Extracorporeal Membrane Oxygenation.

BACKGROUND: Voriconazole is one of the first-line therapies for invasive pulmonary aspergillosis. Drug concentrations might be significantly influenced by the use of extracorporeal membrane oxygenation (ECMO). We aimed to assess the effect of ECMO on voriconazole exposure in a large patient population. METHODS: Critically ill patients from eight centers in four countries treated with voriconazole during ECMO support were included in this retrospective study. Voriconazole concentrations were collected in a period on ECMO and before/after ECMO treatment. Multivariate analyses were performed to evaluate the effect of ECMO on voriconazole exposure and to assess the impact of possible saturation of the circuit's binding sites over time. RESULTS: Sixty-nine patients and 337 samples (190 during and 147 before/after ECMO) were analyzed. Subtherapeutic concentrations (<2 mg/L) were observed in 56% of the samples during ECMO and 39% without ECMO (p = 0.80). The median trough concentration, for a similar daily dose, was 2.4 (1.2-4.7) mg/L under ECMO and 2.5 (1.4-3.9) mg/L without ECMO (p = 0.58). Extensive inter-and intrasubject variability were observed. Neither ECMO nor squared day of ECMO (saturation) were retained as significant covariates on voriconazole exposure. CONCLUSIONS: No significant ECMO-effect was observed on voriconazole exposure. A large proportion of patients had voriconazole subtherapeutic concentrations.

Fifteen-Year Trends in Incidence of Cardiogenic Shock Hospitalization and In-Hospital Mortality in the United States.

Background There is a lack of contemporary data on cardiogenic shock (CS) in-hospital mortality trends. Methods and Results Patients with CS admitted January 1, 2004 to December 31, 2018, were identified from the US National Inpatient Sample. We reported the crude and adjusted trends of in-hospital mortality among the overall population and selected subgroups. Among a total of 563 949 644 hospitalizations during the period from January 1, 2004, to December 30, 2018, 1 254 358 (0.2%) were attributed to CS. There has been a steady increase in hospitalizations attributed to CS from 122 per 100 000 hospitalizations in 2004 to 408 per 100 000 hospitalizations in 2018 (Ptrend<0.001). This was associated with a steady decline in the adjusted trends of in-hospital mortality during the study period in the overall population (from 49% in 2004 to 37% in 2018; Ptrend<0.001), among patients with acute myocardial infarction CS (from 43% in 2004 to 34% in 2018; Ptrend<0.001), and among patients with non-acute myocardial infarction CS (from 52% in 2004 to 37% in 2018; Ptrend<0.001). Consistent trends of reduced mortality were seen among women, men, different racial/ethnic groups, different US regions, and different hospital sizes, regardless of the hospital teaching status. Conclusions Hospitalizations attributed to CS have tripled in the period from January 2004 to December 2018. However, there has been a slow decline in CS in-hospital mortality during the studied period. Further studies are necessary to determine if the recent adoption of treatment algorithms in treating patients with CS will further impact in-hospital mortality.

Socio-Economic Burden of Myocardial Infarction Among Cancer Patients.

Cancer patients face a higher risk of future myocardial infarction (MI), even after completion of anticancer therapies. MI is a critical source of physical and financial stress in noncancer patients, but its impacts associated with cancer patients also saddled with the worry (stress) of potential reoccurrence is unknown. Therefore, we aimed to quantify MI's stress and financial burden after surviving cancer and compare to those never diagnosed with cancer. Utilizing cross-sectional national survey data from 2013 to 2018 derived from publicly available United States datasets, the National Health Interview Survey , and economic data from the National Inpatient Sample , we compared the socio-economic outcomes in those with MI by cancer-status. We adjusted for social, demographic, and clinical factors. Overall, 19,504 (10.2%) of the 189,836 National Health Interview Survey responders reported having cancer for more than 1 year. There was an increased prevalence of MI in cancer survivors compared with noncancer patients (8.8% vs 3.2%, p <0.001). MI was associated with increased financial worry, food insecurity, and financial burden of medical bills (p <0.001, respectively); however, concurrent cancer did not seem to be an effect modifier (p >0.05). There was no difference in annual residual family income by cancer status; however, 3 lowest deciles of residual income representing 21.1% cancer-survivor with MI had a residual income of <$9,000. MI continues to represent an immense source of financial and perceived stress. In conclusion, although cancer patients face a higher risk of subsequent MI, this does not appear to advance their reported stress significantly.

Content Analysis of ACGME Accredited Urology Residency Program Webpages.

OBJECTIVE: To provide an update on the web pages of academic Urology departments in the United States and to evaluate for consistency of information available to applicants. MATERIALS AND METHODS: The American Urologic Association accredited listing of US urology residency programs was accessed in January 2018. One hundred and thirty-five urology residency program websites were then accessed and searched for the presence or absence of 44 criteria. Criteria were grouped into 7 categories: program overview and contact information, application information, program curriculum, current residents, alumni, faculty, and resident benefits. Programs were categorized based on US census bureau designated regions, program size, and by program ranking by the Doximity Urology Residency Program Navigator. RESULTS: Out of 135, 134 (99%) of the AUA accredited listing of US urology residency programs had functional websites. The most commonly available information included clinical rotation sites (84%), resident curriculum (78%), number and names of current residents (76% and 77%, respectively), and faculty names and corresponding subspecialties (74% and 72%, respectively). These trends were similar across geographic regions. The top 20 residency programs on Doximity were more likely to list alumni names (70% vs 35%, P = .005), alumni fellowships (75% vs 30% P = .0003) and alumni jobs (75% vs 29%, P = .001) compared to all other residency programs. CONCLUSION: There is high variability regarding comprehensiveness of urology residency websites. An informative and well-constructed website has the potential to improve optics and marketability of a residency program. Top notch residency programs are more likely to display fellowship and faculty information, both desirable prospects after residency.

Epidemiology and Predictors of 30-Day Readmission in Patients With Sepsis.

BACKGROUND: Patients with sepsis are particularly vulnerable to readmissions. We describe the associated etiology and risk factors for readmission in patients with sepsis using a large administrative database inclusive of patients of all ages and insurance status. METHODS: Our study cohort was derived from the Healthcare Cost and Utilization Project's National Readmission Data from 2013 to 2014 by identifying patients admitted with sepsis. The primary outcome was 30-day readmission with etiology identified by using International Classification of Diseases, Ninth Revision, Clinical Modification, codes. RESULTS: From a total 1,030,335 index admissions; mean age, 66.8 ± 17.4 years (60% age ≥65 years), 898,257 patients (87.2%) survived to discharge. A total of 157,235 (17.5%) patients had a 30-day readmission; median time to readmission was 11 days (interquartile range, 5-19). Infectious etiology (42.16%; including sepsis, 22.86%) was the most commonly associated cause for 30-day readmission followed by gastrointestinal (9.6%), cardiovascular (8.73%), pulmonary (7.82%), and renal causes (4.99%). Significant predictors associated with increased 30-day readmission included diabetes (OR, 1.07; 95% CI, 1.06-1.08; P < .001), chronic kidney disease (1.12;1.10-1.14, P < .001), congestive heart failure (OR, 1.16; 95% CI, 1.14-1.18; P < .001), discharge to short-/long-term facility (OR, 1.13; 95% CI, 1.11-1.14; P < .001), Charlson comorbidity index ≥ 2, and length of stay ≥ 3 days during the index admission. The mean cost per readmission was $16,852; annual cost was > $3.5 billion within the United States. CONCLUSION: We describe that readmission after a sepsis hospitalization is common and costly. The majority of readmissions were associated with infectious etiologies. The striking rate of readmission demands efforts to further clarify the determinants of readmission and develop strategies in terms of quality of care and care transitions to prevent this outcome.

Trends in the use of echocardiography in pulmonary embolism.

Pulmonary embolism (PE) is a devastating diagnosis which carries a high mortality risk. Echocardiography is often performed to risk stratify patients diagnosed with PE, and guide management strategies. Trends in the performance of echocardiography among patients with PE and its role in influencing outcomes is unknown.We analyzed the 2005 to 2014 National Inpatient Sample Database to identify patients with primary diagnosis of PE or secondary diagnosis of PE and ≥1 of the following diagnoses: syncope, thrombolysis, acute deep vein thrombosis, acute cardiorespiratory failure, and secondary pulmonary hypertension. Trends in the performance of echocardiography and in-hospital mortality were analyzed. The admissions were divided into 2 groups with echocardiography, and without echocardiography, and 1:2 propensity score matching (PSM) was performed for comparison. The primary end-point was in-hospital mortality. The secondary endpoints were length of stay and total hospitalization costs. Odd ratios (OR) with confidence intervals (CI) were reported.A total of 299,536 unweighted PE cases were studied. Performance of echocardiography among patients with PE patients increased from 3.5% to 5.6%, whereas in-hospital mortality decreased from 4.2% to 3.7% between years 2005 and 2014. Before matching, patients who received an echocardiogram were more likely to be younger, African American, admitted to a large, urban teaching institute, and had higher rates of concurrent acute deep vein thrombosis, and acute respiratory failure. Post-PSM, patients who received echocardiography during hospitalization had lower in-hospital mortality (odds ratio 0.75, 95% confidence intervals (CI) 0.68-0.83; P < 0.001), longer length of stay (median 6 days vs 5 days; P < .001) and higher mean hospitalization costs ($34,379 vs $27,803; P < .001) compared to those without echocardiography.Performance of echocardiography among patients with a PE is increasing and is associated with lower in-hospital mortality.

Etiologies, predictors, and economic impact of readmission within 1 month among patients with takotsubo cardiomyopathy.

BACKGROUND: Limited data exist on readmission among patients with takotsubo cardiomyopathy (TC), a commonly reversible cause of heart failure. HYPOTHESIS: We sought to identify etiologies and predictors for readmission among TC patients. METHODS: We queried the National Readmissions Database for 2013-2014 to identify patients with primary admission for TC using ICD-9-CM code 429.83. Patients readmitted to hospital within 1 month after discharge were further evaluated to identify etiologies, predictors, and resultant economic burden of readmission. Additionally, we analyzed readmission for TC at 6 months. RESULTS: We studied 5997 patients admitted with TC, of whom 1.2% experienced in-hospital mortality. Median age was 67 years, with 91.5% being female. Among survivors, 10.3% were readmitted within 1 month; 25% of the initial 1-month readmissions occurred within 4 days, 50% within 10 days, and 75% within 20 days from discharge. The most common etiologies for readmission were cardiac (26%), respiratory (16%), and gastrointestinal (11%) causes. Heart failure was the most common cardiac etiology. Significant predictors of increased 1-month readmission included systemic thromboembolic events, length of stay ≥3 days, and underlying psychoses. Obesity and private insurance predicted lower 1-month readmission. The annual national cost impact for index admission and 1-month readmissions was ≈$112 million. Recurrent TC was seen among 1.9% of patients readmitted within 6 months. CONCLUSIONS: Though the overall rate of 1-month readmission following TC is low, associated economic burden from readmission is still significant. Patients are readmitted mostly for noncardiac causes. Readmission for another episode of TC within 6 months was uncommon.

Etiologies, Predictors, and Economic Impact of 30-Day Readmissions Among Patients With Peripartum Cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a pregnancy-associated cause of heart failure. Given the significant impact of heart failure on healthcare, we sought to identify etiologies and predictive factors for readmission in PPCM. We queried the 2013 to 2014 National Readmissions Database to identify patients admitted with a diagnosis of PPCM. Patients who were readmitted within 30 days were evaluated to identify etiologies and predictors of readmission. We identified 6,977 index admissions with PPCM. Of the 6,880 (98.6%) patients who survived the index hospitalization, 30-day readmission rate was 13%. Seventy-six percent of readmitted patients were admitted once, and the other 24% were readmitted at least twice within 30 days of discharge. Length of stay was ≥8 days (adjusted odds ratio [aOR] 2.80, 95% confidence interval [CI] 2.08 to 3.77), multiparity (aOR 2.07, 95% CI 1.09 to 3.92), coronary artery disease (aOR 2.28, 95% CI 1.42 to 3.67), and long-term anticoagulation use (aOR 2.51, 95% CI 1.73 to 3.64) were independently associated with increased risk of 30-day readmission. Among the readmissions, 48% were due to cardiac causes, where PPCM and related complications (24%) were the most common cardiac cause followed by heart failure (16%). The annual cost of stay for index admissions was $64.2 million (average cost for index admission was $16,892). The annual charges attributed to readmission within 30 days were ≈$9 million. Cardiac etiologies were the most common cause for 30-day readmissions in PPCM patients, with a readmission rate of 13%. Long-term anticoagulation use, multiparity, coronary disease and length of stay predicted higher 30-day readmission.

Thirty-day readmissions after cardiac implantable electronic devices in the United States: Insights from the Nationwide Readmissions Database.

BACKGROUND: Limited data are available regarding true estimates of individual complications contributing to readmissions after cardiac implantable electronic device (CIED) implantation. OBJECTIVE: The purpose of this study was to identify predictors of 30-day readmission in patients admitted for CIED implantation. METHODS: The study cohort consisted of patients who underwent CIED implantation in 2014, identified from the National Readmission Database. Readmission was defined as a subsequent hospital admission within 30 days after the discharge day of index admission. If patients had more than 1 readmission within 30 days, only the first readmission was included. RESULTS: Our final cohort consisted of 70,223 cases, 61,738 (88%) in the no-readmission group and 8485 patients (12%) in the readmission group. Female gender (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.04-1.14; P = .001), atrial fibrillation/flutter (OR 1.23; 95% CI 1.17-1.29, P <.001), acute renal failure (OR 1.65; 95% CI 1.56-1.74; P <.001), coronary artery disease (OR 1.09; 95% CI 1.03-1.14; P = .002), length of stay (OR 1.70; 95% CI 1.51-1.89; P <.001), device placement on the day of admission (OR 0.87; 95% CI 0.80-0.95, P = .001), and fourth quartile of hospital procedure volume (OR 0.91; 95% CI 0.84-0.99; P = .03; first quartile of hospital procedure volume as reference) were independent predictors of 30-day readmissions. The 30-day readmission resulted in additional median charges of $30,692 per patient. Device-related complications were seen in 10.7% of readmitted patients. The most common complications were mechanical (2.8%) and infectious (2.6%). CONCLUSION: Several patient and hospital-related factors were identified to be independent predictors of 30-day readmission, accounting for increased health care cost.

Development of modelling method selection tool for health services management: from problem structuring methods to modelling and simulation methods.

BACKGROUND: There is an increasing recognition that modelling and simulation can assist in the process of designing health care policies, strategies and operations. However, the current use is limited and answers to questions such as what methods to use and when remain somewhat underdeveloped. AIM: The aim of this study is to provide a mechanism for decision makers in health services planning and management to compare a broad range of modelling and simulation methods so that they can better select and use them or better commission relevant modelling and simulation work. METHODS: This paper proposes a modelling and simulation method comparison and selection tool developed from a comprehensive literature review, the research team's extensive expertise and inputs from potential users. Twenty-eight different methods were identified, characterised by their relevance to different application areas, project life cycle stages, types of output and levels of insight, and four input resources required (time, money, knowledge and data). RESULTS: The characterisation is presented in matrix forms to allow quick comparison and selection. This paper also highlights significant knowledge gaps in the existing literature when assessing the applicability of particular approaches to health services management, where modelling and simulation skills are scarce let alone money and time. CONCLUSIONS: A modelling and simulation method comparison and selection tool is developed to assist with the selection of methods appropriate to supporting specific decision making processes. In particular it addresses the issue of which method is most appropriate to which specific health services management problem, what the user might expect to be obtained from the method, and what is required to use the method. In summary, we believe the tool adds value to the scarce existing literature on methods comparison and selection.

The STAT-MI (ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction) trial improves outcomes.

OBJECTIVES: The goal of this study was to evaluate the impact of the STAT-MI (ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction) network on outcomes in the treatment of patients presenting with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Shortening door-to-balloon (D2B) time remains a national priority for the treatment of STEMI. We previously reported a fully automated wireless network (STAT-MI) for transmission of electrocardiograms (ECGs) for suspected STEMI from the field to offsite cardiologists, allowing early triage with shortening of subsequent D2B times. We now report the impact of the STAT-MI wireless network on infarct size, length of hospital stay (LOS), and mortality. METHODS: A fully automated wireless network (STAT-MI) was developed to enable automatic 12-lead ECG transmission and direct communication between emergency medical services personnel and offsite cardiologists that facilitated direct triage of patients to the cardiac catheterization laboratory. Demographic, laboratory, and time interval data of STAT-MI network patients were prospectively collected over a 33-month period and compared with concurrent control patients who presented with STEMI through non-STAT-MI pathways. RESULTS: From June 2006 through February 2009, 92 patients presented via the STAT-MI network, and 50 patients presented through non-STAT-MI pathways (control group). Baseline clinical and demographic variables were similar in both groups. Overall, compared with control subjects, STAT-MI patients had significantly shorter D2B times (63 [42 to 87] min vs. 119 [96 to 178] min, U = 779.5, p < 0.00004), significantly lower peak troponin I (39.5 [11 to 120.5] ng/ml vs. 87.6 [38.4 to 227] ng/ml, U = 889.5, p = 0.005) and creatine phosphokinase-MB (126.1 [37.2 to 280.5] ng/ml vs. 290.3 [102.4 to 484] ng/ml, U = 883, p = 0.001), higher left ventricular ejection fractions (50% [35 to 55] vs. 35% [25 to 52], U = 1,075, p = 0.004), and shorter LOS (3 [2 to 4] days vs. 5.5 [3.5 to 10.5] days, U = 378, p < 0.001). CONCLUSIONS: A fully automated, field-based, wireless network that transmits ECGs automatically to offsite cardiologists for the early evaluation and triage of patients with STEMI shortens D2B times, reduces infarct size, limits ejection fraction reduction, and shortens LOS.