Contrast-induced acute kidney injury following coronary angiography: a cohort study of hospitalized patients with or without chronic kidney disease.

BACKGROUND: Contrast-induced acute kidney injury (CIAKI) has been linked to unfavorable consequences. In routine clinical practice, small increases in serum creatinine (SCr) following coronary angiography tend to be underestimated, especially in patients without chronic kidney disease (CKD). METHODS: We conducted a retrospective observational cohort study to analyze in-hospital and long-term outcomes of CIAKI following coronary angiography in patients with or without CKD (eGFR ≥ 60 mL/min/1.73 m(2)) from January 2008 through December 2009. CIAKI was defined as SCr either ≥ 25% or ≥ 0.5 mg/dL from baseline within 72 h after contrast exposure. Multivariable logistic regression for in-hospital mortality and Cox proportional hazards calculations for long-term mortality and requirement for dialysis were performed. RESULTS: A total of 1160 patients were included in the study. CIAKI occurred in 19% of CKD patients and in 18% of non-CKD patients. In CKD and non-CKD patients, CIAKI was more frequent in patients requiring mechanical ventilation or inotropes or in those given furosemide, and it was associated with adverse in-hospital (prolonged hospitalization, acute dialysis and mortality) and long-term (increased creatinine, initiation of dialysis and mortality) outcomes. In multivariable analysis, CKD patients had greater in-hospital mortality if they developed CIAKI (adjusted OR 8, 95% CI 1.9-34.5, P = 0.005), and non-CKD patients had greater long-term mortality if they developed CIAKI (adjusted HR 2.2, 95% CI 1.2-4.1, P = 0.016). CONCLUSIONS: CIAKI following coronary angiography was associated with adverse in-hospital and long-term outcomes in both CKD and non-CKD patients.

The LATCH scoring system and prediction of breastfeeding duration.

This study aimed to determine whether LATCH scores assessed by professional staff during in-hospital stays are predictive of breastfeeding at 6 weeks. Participants were English-speaking breastfeeding women, 18 years or older, with healthy singletons. LATCH scores were obtained once every 8 hours on day 1 and daily subsequently until discharge. Data were obtained from hospital charts and telephone interviews on day 4 and week 6 postdelivery. At 6 weeks, 188 of 248 (76%) women were contacted and 66.5% were breastfeeding. LATCH scores were higher among women breastfeeding than those who had weaned. Using receiver operating characteristic (ROC) curves, a score of 9 or above at 16 to 24 hours was the most discriminate of the 5 time periods examined (area under the ROC curve = 0.72). Furthermore, women who met this criterion were 1.7 times more likely to be breastfeeding at 6 weeks than women with lower scores. The LATCH assessment tool is a modest predictor of breastfeeding duration.

The differential effects of surgical harm in elderly populations. Does the adage: "they tolerate the operation, but not the complications" hold true?

BACKGROUND: Elderly patients are thought to tolerate surgical complications poorly because of low physiologic reserve. The purpose of the study was to evaluate the differential effects of surgical harm in patients over 80 years old. METHODS: Three years of data from a harm-reduction campaign were used to identify inpatient surgeries performed on patients older than 50. The rates of harm, death, cost, and length of stay (LOS) were analyzed using SPSS 21 (IBM, New York, NY). RESULTS: A total of 22,710 patients were identified. Rates of harm and mortality increased with increasing age. Harmed patients over age 80 had increased mortality (9.5% vs 7%), but lower cost, intensive care unit days, and LOS versus those aged 50 to 80. Linear regression showed increased cost with harm ($24,000) and decreased cost with age above 80 (-$7,000). CONCLUSIONS: In the elderly surgical population, there is more harm and harm events are associated with higher mortality rates, but less additional cost and LOS. Differing goals or aggressiveness of care may explain cost avoidance in the elderly.

Resuscitation bundle compliance in severe sepsis and septic shock: improves survival, is better late than never.

UNLABELLED: While clinicians' management of severe sepsis and septic shock has been positively influenced by a number of clinical research studies in the last decade, challenges remain regarding early hemodynamic optimization as envisioned in the Surviving Sepsis Campaign's (SSC) resuscitation bundle (RB). We examined the impact of a hospital-wide continuous quality improvement (CQI) initiative on patients presenting with severe sepsis and septic shock, and the impact of the sepsis RB on patient outcomes when completed beyond the 6-hour recommendation period. The study was an 18-month, prospective cohort study enrolling patients who met the definition of severe sepsis or septic shock. Compliance with the hemodynamic components of the sepsis RB was defined as achieving goal mean arterial pressure (MAP) ≥ 65 mm Hg, central venous pressure (CVP) ≥ 8 mm Hg, and central venous oxygen saturation (ScvO2) ≥ 70%. Compliance was assessed at 6 hours and 18 hours after diagnosis of severe sepsis or septic shock. In all, 498 patients with severe sepsis and/or septic shock were evaluated to determine the upper limit of the range of hours that compliance with the RB would still improve outcomes. Using 18 hours as a marker, Compliers at 18 hrs and Non-Compliers at 18 hrs were compared. There were 202 patients who had the RB completed in less than or equal to 18 hours. There were 296 patients who did not complete the RB at 18 hours. The Compliers at 18 hrs had a significant 10.2% lower hospital mortality 37.1% (22% relative reduction) compared to the Non-Compliers at 18 hrs hospital mortality of 47.3% (P < .03). When the two groups were adjusted for differences in baseline illness severity, the Compliers at 18 hrs had a greater reduction in predicted mortality of 26.8% versus 9.4%, P < 0.01. CONCLUSIONS: Initiating the sepsis RB for patients with severe sepsis and/or septic shock decreased mortality. A CQI initiative that monitored the implementation in real-time allowed for improvement in compliance and efficacy of the bundle on outcomes. Multiple studies have shown that compliance to the RB within 6 hours lowers hospital mortality. This study uniquely shows that when bundle completion is extended to 18 hours, the mortality reduction remains significant.