Mean Airway Pressure As a Predictor of 90-Day Mortality in Mechanically Ventilated Patients.

OBJECTIVES: To determine the association between mean airway pressure and 90-day mortality in patients with acute respiratory failure requiring mechanical ventilation and to compare the predictive ability of mean airway pressure compared with inspiratory plateau pressure and driving pressure. DESIGN: Prospective observational cohort. SETTING: Five ICUs in Lima, Peru. SUBJECTS: Adults requiring invasive mechanical ventilation via endotracheal tube for acute respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of potentially eligible participants (n = 1,500), 65 (4%) were missing baseline mean airway pressure, while 352 (23.5%) were missing baseline plateau pressure and driving pressure. Ultimately, 1,429 participants were included in the analysis with an average age of 59 ± 19 years, 45% female, and a mean PaO2/FIO2 ratio of 248 ± 147 mm Hg at baseline. Overall, 90-day mortality was 50.4%. Median baseline mean airway pressure was 13 cm H2O (interquartile range, 10-16 cm H2O) in participants who died compared to a median mean airway pressure of 12 cm H2O (interquartile range, 10-14 cm H2O) in participants who survived greater than 90 days (p < 0.001). Mean airway pressure was independently associated with 90-day mortality (odds ratio, 1.38 for difference comparing the 75th to the 25th percentile for mean airway pressure; 95% CI, 1.10-1.74) after adjusting for age, sex, baseline Acute Physiology and Chronic Health Evaluation III, baseline PaO2/FIO2 (modeled with restricted cubic spline), baseline positive end-expiratory pressure, baseline tidal volume, and hospital site. In predicting 90-day mortality, baseline mean airway pressure demonstrated similar discriminative ability (adjusted area under the curve = 0.69) and calibration characteristics as baseline plateau pressure and driving pressure. CONCLUSIONS: In a multicenter prospective cohort, baseline mean airway pressure was independently associated with 90-day mortality in mechanically ventilated participants and predicts mortality similarly to plateau pressure and driving pressure. Because mean airway pressure is readily available on all mechanically ventilated patients and all ventilator modes, it is a potentially more useful predictor of mortality in acute respiratory failure.

Sedation practices and clinical outcomes in mechanically ventilated patients in a prospective multicenter cohort.

OBJECTIVES: We sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting. DESIGN: A longitudinal study of critically ill participants on mechanical ventilation. SETTING: Five intensive care units (ICUs) in four public hospitals in Lima, Peru. PATIENTS: One thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90. RESULTS: After excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23-6.95; p < 0.001) and a significant decrease in ventilator (- 7.27; p < 0.001), ICU (- 4.38; p < 0.001), and hospital (- 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53-243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12-1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22-0.44, p < 0.001). CONCLUSIONS: Deep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study.

Multilevel competing risks in the evaluation of nosocomial infections: time to move on from proportional hazards and even from hazards altogether.

A competing risk is an event (for example, death in the ICU) that hinders the occurrence of an event of interest (for example, nosocomial infection in the ICU) and it is a common issue in many critical care studies. Not accounting for a competing event may affect how results related to a primary event of interest are interpreted. In the previous issue of Critical Care, Wolkewitz and colleagues extended traditional models for competing risks to include random effects as a means to quantify heterogeneity among ICUs. Reported results from their analyses based on cause-specific hazards and on sub-hazards of the cumulative incidence function were indicative of lack of proportionality of these hazards over time. Here, we argue that proportionality of hazards can be problematic in competing-risk problems and analyses must consider time by covariate interactions as a default. Moreover, since hazards in competing risks make it difficult to disentangle the effects of frequency and timing of the competing events, their interpretation can be murky. Use of mixtures of flexible and succinct parametric time-to-event models for competing risks permits disentanglement of the frequency and timing at the price of requiring stronger data and a higher number of parameters. We used data from a clinical trial on fluid management strategies for patients with acute respiratory distress syndrome to support our recommendations.

Low rates of antibiotics prescribed during telehealth primary-care visits persisted during the coronavirus disease 2019 (COVID-19) pandemic.

For primary care clinics at a Veterans' Affairs (VA) medical center, the shift from in-person to telehealth visits during the coronavirus disease 2019 (COVID-19) pandemic was associated with low rates of antibiotic prescription. Understanding contextual factors associated with antibiotic prescription practices during telehealth visits may help promote antibiotic stewardship in primary care settings.

Group B Streptococcus in the urine in nonpregnant adults: Disease or distraction?

In this large, retrospective cohort study, we used administrative data to evaluate nonpregnant adults with group B Streptococcus (GBS) bacteriuria. We found greater all-cause mortality in those with urinary tract infections compared to asymptomatic bacteriuria. Differences in patients' baseline characteristics and the 1-year mortality rate raise the possibility that provider practices contribute to differences observed.

Shared decision making in senior medical students: results from a national survey.

PURPOSE: To explore perceptions and experiences of Peruvian medical students about observed, preferred, and feasible decision-making approaches. METHODS: We surveyed senior medical students from 19 teaching hospitals in 4 major cities in Peru. The self-administered questionnaire collected demographic information, current approach, exposure to role models for and training in shared decision making, and perceptions of the pertinence and feasibility of the different decision-making approaches in general as well as in challenging scenarios. RESULTS: A total of 327 senior medical students (51% female) were included. The mean age was 25 years. Among all respondents, 2% reported receiving both theoretical and practical training in shared decision making. While 46% of students identified their current decision-making approach as clinician-as-perfect-agent, 50% of students identified their teachers with the paternalistic approach. Remarkably, 53% of students thought shared decision making should be the preferred approach and 50% considered it feasible in Peru. Among the 10 challenging scenarios, shared decision making reached a plurality (40%) in only one scenario (terminally ill patients). CONCLUSION: Despite limited exposure and training, Peruvian medical students aspire to practice shared decision making but their current attitude reflects the less participatory approaches they see role modeled by their teachers.

[Chronic obstructive pulmonary disease by biomass smoke exposure]. / Enfermedad pulmonar obstructiva crónica por exposición al humo de biomasa.

In this article, the relationship between chronic obstructive pulmonary disease (COPD) and biomass smoke will be discussed. More than half of the world population uses biomass for fuel, especially in rural areas and in developing countries where usage reaches 80%. Biomass smoke inhalation creates an inflammatory chronic state, which is accompanied by metalloproteinases activation and mucociliary mobility reduction. This could explain the existing association between biomass exposure and COPD, revealed by observational and epidemiological studies from developing and developed countries. In this review, the differences between COPD caused by tobacco and biomass were explored. It was found that despite the pathophysiological differences, most of the clinical characteristics, quality of life and mortality were similar. In the last ten years there have been interventions to reduce the biomass smoke exposure by using improved stoves and cleaner fuels. However, these strategies have not yet been successful due to inability to reduce contamination levels to those recommended by the World Health Organization as well as due to the lack of use. Therefore, there is an urgent need for carefully conducted, randomized field trials to determine the actual range of potentially reachable contamination reductions, the probability of use and the long term benefits of reducing the global burden of COPD.

Clinicians' involvement of patients in decision making. A video based comparison of their behavior in public vs. private practice.

BACKGROUND: Little is known about the extent to which Peruvian physicians seek to involve patients in shared decision making, or about the variation in these efforts across different settings. OBJECTIVE: To measure the extent to which Peruvian clinicians involve their patients in decision making and to explore the differences between clinicians' behavior in private vs. public practice. DESIGN: Videographic analysis. PARTICIPANTS AND SETTING: Seven academic physicians who provided care to patients in a public and a private setting participate in this study. All the encounters in both settings were filmed on one random day of February 2012. APPROACH: Two raters, working independently and in duplicate used the 12-item OPTION scale to quantify the extent of physician effort to involve patients in shared decision making (with 0 indicating no effort and 100 maximum possible effort) in 58 video recordings of usual clinical encounters in private and public practice. RESULTS: The mean OPTION score was 14.3 (SD 7.0). Although the OPTION score in the private setting (mean 16.5, SD 7.3) was higher than in the public setting (mean 12.3 SD 6.1) this difference was not statistically significant (p = .09). CONCLUSION: Peruvian academic physicians in this convenience sample barely sought to involve their patients in shared decision making. Additional studies are required to confirm these results which suggest that patient-centered care remains an unfulfilled promise and a source of inequity within and across the private and the public sectors in Peru.

Enfermedad pulmonar obstructiva crónica por exposición al humo de biomasa / Chronic obstructive pulmonary disease by biomass smoke exposure

En este artículo se discute la relación existente entre la enfermedad pulmonar obstructiva crónica (EPOC) y el humo de biomasa. Más de la mitad de la población utiliza biomasa como combustible principal, sobre todo en áreas rurales y en países en vías de desarrollo donde su uso llega hasta el 80%. La inhalación del humo de biomasa crea un estado inflamatorio crónico, que se acompaña de una activación de metaloproteinasas y una reducción de la movilidad mucociliar. Esto podría explicar la gran asociación existente entre la exposición a biomasa y EPOC, revelada por estudios observacionales y epidemiológicos provenientes de países en vías de desarrollo y de países desarrollados. En esta revisión exploramos también las diferencias entre la EPOC causada por tabaco y por biomasa, y encontramos que, a pesar de las diferencias fisiopatológicas, la mayoría de las características clínicas, calidad de vida y mortalidad fueron parecidas. En los últimos diez años se han realizado intervenciones para disminuir la exposición a biomasa mediante el uso de cocinas mejoradas y combustibles limpios, sin embargo, estas estrategias todavía no han sido exitosas debido a su incapacidad para reducir los niveles de contaminación a niveles recomendados por la Organización Mundial de la Salud, y por su falta de uso. Por lo tanto, hay una necesidad urgente de ensayos de campo aleatorios, cuidadosamente realizados, para determinar la verdadera gama de reducciones de contaminación potencialmente alcanzables, la probabilidad de su uso y los beneficios a largo plazo en la reducción de la gran carga mundial de EPOC.

In this article, the relationship between chronic obstructive pulmonary disease (COPD) and biomass smoke will be discussed. More than half of the world population uses biomass for fuel, especially in rural areas and in developing countries where usage reaches 80%. Biomass smoke inhalation creates an inflammatory chronic state, which is accompanied by metalloproteinases activation and mucociliary mobility reduction. This could explain the existing association between biomass exposure and COPD, revealed by observational and epidemiological studies from developing and developed countries. In this review, the differences between COPD caused by tobacco and biomass were explored. It was found that despite the pathophysiological differences, most of the clinical characteristics, quality of life and mortality were similar. In the last ten years there have been interventions to reduce the biomass smoke exposure by using improved stoves and cleaner fuels. However, these strategies have not yet been successful due to inability to reduce contamination levels to those recommended by the World Health Organization as well as due to the lack of use. Therefore, there is an urgent need for carefully conducted, randomized field trials to determine the actual range of potentially reachable contamination reductions, the probability of use and the long term benefits of reducing the global burden of COPD.