Improving hospital safety for patients with chronic kidney disease: a mixed methods study.

BACKGROUND: People living with chronic kidney disease (CKD) require complex medical management and may be frequently hospitalized. Patient safety incidents during hospitalization can result in serious complications which may negatively affect health outcomes. There has been limited examination of how these patients perceive their own safety. OBJECTIVES: This study compared the safety perceptions of patients hospitalized with CKD using two approaches: (a) the Patient Measure of Safety (PMOS) questionnaire and (b) qualitative interviews. The study objectives were to: (1) assess concordance between qualitative and quantitative data on safety perceptions and (2) better understand safety as perceived by study participants. METHODS: A cross-sectional convergent mixed methods design was used. Integration at the reporting level occurred by weaving together patient narratives and survey domains through the use of a joint display. Interview data were merged with results of the PMOS on a case-by-case basis for analysis to assess for concordance or discordance between these approaches to safety data collection. RESULTS: Of the 30 inpatients with CKD, almost one quarter (23.3 %) of participants reported low levels of perceived safety in hospitals. Four major themes emerged from the interviews: receiving safe care; expecting to be taken care of; expecting to be cared for; and reporting safety concerns. Suboptimal communication, delays in care and concerns about technical aspects of care were common to both forms of data collection. Concordance was noted between qualitative and quantitative data with respect to communication/teamwork, respect and dignity, staff roles, and ward type/lay-out. While interviews allowed for participants to share specific concerns related to safety about quality of interpersonal interactions, use of the questionnaire alone did not capture this concern. CONCLUSIONS: Safety issues are a concern for in-patients with CKD. Both quantitative and qualitative approaches provided important and complementary insights into these issues. Narratives were mostly concordant with questionnaire scores. Findings from this mixed methods study suggest that communication, interpersonal interactions, and delays in care were more concerning for participants than technical aspects of care. Eliciting the concerns of people with CKD in a systematic fashion, either through interviews or a survey, ensures that hospital safety improvement efforts focus on issues important to patients.

Increased nocturnal periodic limb movements in rheumatoid arthritis patients meeting questionnaire diagnostic criteria for restless legs syndrome.

BACKGROUND: Based on questionnaire criteria, the sensorimotor disorder restless legs syndrome (RLS) has been reported to have a higher prevalence in rheumatoid arthritis (RA) patients than in the general population. There has been some speculation that peripheral arthritic symptoms may allow false positive responses to questionnaire criteria. This study evaluates whether RA patients meeting RLS questionnaire criteria also have objective evidence of increased periodic limb movements (PLMs) characteristic of RLS. METHODS: Participants were recruited from RA clinic. Questionnaire data collected at study entry included: pain scores, rheumatoid arthritis disease activity index, Epworth sleepiness scale, Pittsburgh sleep quality index and RLS diagnostic criteria. Each participant was provided a PAM-RL actigraphic monitor, which attached to the ankle. This device was worn for two consecutive nights then returned for data download. Laboratory data including hemoglobin, iron studies, renal function and C-reactive protein levels were collected. RESULTS: Of the 57 participants, 23 met RLS diagnostic criteria. Those who met RLS criteria demonstrated higher mean frequency of nocturnal PLMs (19.63/hour; SD:21.13) than those who did not meet RLS criteria (11.13/hour; SD:12.10; p=0.033). There were no significant differences between groups in terms of patient characteristics, disease activity or duration measures. Patients meeting RLS criteria did have poorer sleep quality measures (p <0.001). CONCLUSIONS: RA patients who met RLS diagnostic criteria demonstrated higher frequencies of nocturnal PLMs than RA patients who did not meet criteria for RLS. This finding supports use of the RLS diagnostic criteria in helping to differentiate between RA arthritic symptoms and RLS.

Obstructive sleep apnoea in relation to rheumatic disease.

Sleep problems are common concerns in rheumatology patients and have been independently linked to increased pain perception and fatigue severity. Evidence supports an increased prevalence of primary sleep disorders, including sleep apnoea, in some rheumatic disease populations, particularly RA. Obstructive sleep apnoea is a significant public health concern and contributes to increased cardiovascular morbidity and mortality. Patients with obstructive sleep apnoea have also been found to have elevations in circulating acute-phase markers and pro-inflammatory cytokines. Co-existence of sleep apnoea in rheumatic disease patients may influence the severity of reported symptoms of pain and fatigue, accelerate the risk of cardiovascular events and possibly influence levels of circulating inflammatory markers and mediators. In this article we review the risk factors, prevalence and impact of sleep apnoea from a rheumatological perspective. Additionally, we recommend considering sleep apnoea screening in patients with rheumatic disease and, when appropriate, referral to a specialized sleep disorders clinic.

A questionnaire assessment of physical function in hyperlipidemic patients.

BACKGROUND: A spectrum of myopathic manifestations has been recognized as associated with lipid lowering drug therapy (LLT), but their effect on quality of life and physical functioning is uncertain. We conducted a prospective cohort study in which physical functioning was the dependent variable, in patients with and without exposure to LLT. METHODS: Consecutive patients attending a risk reduction clinic were invited to participate in a questionnaire study which included demographic data, muscular symptoms, the SF-36 Physical Function Score (PF), and the modified Health Assessment Questionnaire (mHAQ). Laboratory and co-morbidity data was recorded. RESULTS: Of 117 consecutive patients invited to participate, 112 consented. Of these, 81 were receiving statins and/or fibrates as LLT and 31 were participating in a non-pharmacologic therapeutic program (NPT) of diet and exercise therapy. The mean age for the total population was 56.7 years (20-78): the LLT group 58.6 and NPT group 51.9 years. Women comprised 53% of the LLT group and 58% of the NPT. No significant differences in baseline lipid profiles, CK level, BMI, waist measurement, gender, cigarette smoking, alcohol consumption, non-steroidal anti-inflammatory drugs or acetaminophen use, frequency of myalgias, SF-36 PF or mHAQ scores were observed between groups. On comparison of gender groups, we observed that men receiving LLT had significantly better SF- 36 PF (p = 0.037) than men on NPT. There were no differences in SF-36 PF or mHAQ scores between groups for females. CONCLUSION: We found no adverse effects of LLT on physical functioning or quality of life. Indeed, men treated with LLT had significantly better SF-36 PF scores than men treated non-pharmacologically.

Suspected carpal tunnel syndrome: Do nerve conduction study results and symptoms match?

OBJECTIVE: To evaluate the diagnostic utility of nerve conduction studies (NCSs) by examining a population with a high pretest probability of carpal tunnel syndrome (CTS), including bilaterally and unilaterally symptomatic patients. DESIGN: Comparison of the results of NCSs with the results of prospective, pre-NCS, self-administered questionnaires of patients with clinical diagnoses of CTS referred for confirmatory NCSs. SETTING: A tertiary care hospital neuro-electrophysiology laboratory. PARTICIPANTS: The study population consisted of 211 patients, 156 (73.9%) of whom were female. Population mean (range) age was 46.7 (21 to 88) years. Mean (range) symptom duration was 29.3 (1 to 300) months. MAIN OUTCOME MEASURES: Patient-reported symptom localization and NCS results. RESULTS: Results of NCSs were normal in 83 (39.3%) patients, were consistent with CTS in 121 (57.3%) patients, and suggested non-CTS abnormalities in 7 (3.3%) patients. Bilateral symptoms were reported by 139 (65.9%) patients, and isolated unilateral symptoms were reported by 72 (34.1%) patients. Those reporting bilateral symptoms had the highest agreement with NCS results at 38.8%. Unilateral NCS abnormalities were seen in 18.0% of those reporting bilateral hand symptoms. Discordant findings, either bilateral or opposite-side neuropathies, were seen in 25.6% of those reporting isolated right-sided symptoms, and in 55.2% of those reporting isolated left-sided symptoms. Based on these data the sensitivity of the NCS results was 49.1%, with a specificity of 62.5%. The positive predictive value was 86.4%, and the negative predictive value was 20.2%. Overall accuracy was 51.4%. Likelihood ratios were 1.3 with positive results, and 0.8 with negative results. CONCLUSION: In our study population NCS results did little to alter the pretest probability of CTS. Physicians using NCSs for verification of clinical diagnosis should be aware of potential limitations.

Hypersomnolence and sleep disorders in a rheumatic disease patient population.

OBJECTIVES: There is increasing awareness of the importance of sleep in health maintenance. Our primary objective was to evaluate prevalence of excess daytime sleepiness in a rheumatic disease patient population. Secondary objectives included evaluation of prevalence of abnormal sleep quality and primary sleep disorders. METHODS: Consecutive Rheumatology clinic patients were invited to participate in a self-administered questionnaire study. Included were measures for pain, fatigue, and global functioning, modified Health Assessment Questionnaire, Epworth Sleepiness Score (ESS), Pittsburgh Sleep Quality Index (PSQI), Berlin Score, diagnostic criteria for restless legs syndrome (RLS), Centre for Epidemiologic Studies Depression score (CES-D), stress scores, and the short form-36 quality of life instrument. RESULTS: Of 507 consecutive patients invited to participate, 423 agreed. Mean age was 52.1 years; 26% were male. Prevalence of excessive sleepiness (ESS >10) was 25.7%, abnormal sleep quality (PSQI >5) was 67.3%, high risk for obstructive sleep apnea Berlin scores were present in 35.2% and 24% of participants met criteria for RLS. Significantly worse pain, fatigue, global function, short form-36 summary scores, modified Health Assessment Questionnaire, depression, and stress scores were present in patients with higher ESS and PSQI scores. No significant differences in sleep assessment scores were observed between specific rheumatic disease groups. CONCLUSIONS: Our findings suggest a high prevalence of unrecognized hypersomnolence, poor sleep quality, and primary sleep disorders in rheumatology patients. We suggest evaluation of sleep health be incorporated into standard clinical assessments of all rheumatology patients. We would recommend this evaluation include the ESS and the criteria for RLS.

Restless legs syndrome in a rheumatoid arthritis patient cohort.

OBJECTIVE: To use the 2003 International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria and to evaluate restless legs syndrome (RLS) prevalence in a rheumatoid arthritis (RA) and osteoarthritis (OA) population. Further, we wished to evaluate physician awareness of this disorder by as reflected in prevalence of preexisting diagnoses of RLS in these populations. METHODS: This was a questionnaire study of Saskatchewan RA and OA patients enrolled in a longitudinal database study. A data collection instrument, including the 2003 IRLSSG criteria for RLS was distributed to the patients enrolled. RESULTS: Of the 193 respondents, 158 (81.9%) were women. The population consisted of 148 RA and 45 OA patients. RA patients were younger (mean age, 65.8 years) in comparison with those in the OA group (mean age, 72.8 years; P < 0.001). All criteria for RLS were met by 27.7% of RA patients and by 24.4% of OA patients. A previous diagnosis of RLS was reported by 2.6% of patients. CONCLUSIONS: A quarter of all our patients met the 2003 IRLSSG criteria, in both RA and OA groups; however, only 2.6% of study patients reported a previous diagnosis of RLS. As RLS can significantly affect quality of life, increased awareness with improvement in surveillance, recognition, and treatment would be beneficial to patient care. We advocate screening for symptoms of sleep disorders to be incorporated into the routine rheumatologic history for all patients with RA and OA.

A case of deforming pachydermodactyly.

We report a 39-year-old man with pachydermodactyly resulting in progressive digital deformation. Pachydermodactyly is a rare superficial benign digital fibromatosis affecting the proximal interphalangeal joints (PIPs). Our patient had flexion deformities and mal-alignment primarily at the PIPs with associated soft tissue swelling. Radiographs revealed nonerosive subluxation. Surgical examination and biopsy with subsequent immunohistopathological study, revealed increased collagen production and proliferation from both fibroblasts and myofibroblasts consistent with pachydermodactyly. This patient differs from cases previously reported as the extent of soft tissue involvement altered the integrity of the articular supporting structures. This has resulted in deformity and functional impairment.

Exploring the quality of dying of patients with chronic obstructive pulmonary disease in the intensive care unit: a mixed methods study.

RATIONALE FOR THE STUDY: Improving the quality of end-of-life (EOL) care in critical care settings is a high priority. Patients with advanced chronic obstructive pulmonary disease (COPD) are frequently admitted to and die in critical care units. To date, there has been little research examining the quality of EOL care for this unique subpopulation of critical care patients. AIMS: The aims of this study were (a) to examine critical care clinician perspectives on the quality of dying of patients with COPD and (b) to compare nurse ratings of the quality of dying and death between patients with COPD with those who died from other illnesses in critical care settings. DESIGN AND SAMPLE: A sequential mixed method design was used. Three focus groups provided data describing the EOL care provided to patients with COPD dying in the intensive care unit (ICU). Nurses caring for patients who died in the ICU completed a previously validated, cross-sectional survey (Quality of Dying and Death) rating the quality of dying for 103 patients. DATA ANALYSIS: Thematic analysis was used to analyse the focus group data. Total and item scores for 34 patients who had died in the ICU with COPD were compared with those for 69 patients who died from other causes. RESULTS: Three primary themes emerged from the qualitative data are as follows: managing difficult symptoms, questioning the appropriateness of care and establishing care priorities. Ratings for the quality of dying were significantly lower for patients with COPD than for those who died from other causes on several survey items, including dyspnoea, anxiety and the belief that the patient had been kept alive too long. The qualitative data allowed for in-depth explication of the survey results. CONCLUSIONS: Attention to the management of dyspnoea, anxiety and treatment decision-making are priority concerns when providing EOL care in the ICU to patients with COPD.

Caring for critically ill patients with advanced COPD at the end of life: a qualitative study.

Providing expert critical care for the high acuity patient with a diagnosis of COPD at the end of life is both complex and challenging. The purpose of this descriptive study was to examine intensive care unit (ICU) clinicians' perspectives on the obstacles to providing quality care for individuals with COPD who die within the critical care environment. Transcripts of three focus groups of ICU clinicians were analyzed using thematic analysis. The three themes of "managing difficult symptoms", "questioning the appropriateness of life-sustaining care" and "conflicting care priorities" were noted to be significant challenges in providing high quality end of life care to this population. Difficulties in palliating dyspnea and anxiety were associated with caregiver feelings of helplessness, empathy and fears about "killing the patient". A sense of futility, concerns about "torturing the patient" and questions about the patient/family's understanding of treatment pervaded much of the discourse about caring for people with advanced COPD in the ICU. The need to prioritize care to the most unstable ICU patients meant that patients with COPD did not always receive the attention clinicians felt they should ideally have. Organizational support must be made available for critical care clinicians to effectively deal with these issues.

Mobile communication devices causing interference in invasive and noninvasive ventilators.

PURPOSE: The aim of this study was to assess if common mobile communication systems would cause significant interference on mechanical ventilation devices and at what distances would such interference occur. MATERIALS AND METHODS: We tested all the invasive and noninvasive ventilatory devices used within our region. This consisted of 2 adult mechanical ventilators, 1 portable ventilator, 2 pediatric ventilators, and 2 noninvasive positive pressure ventilatory devices. We operated the mobile devices from the 2 cellular communication systems (digital) and 1 2-way radio system used in our province at varying distances from the ventilators and looked at any interference they created. We tested the 2-way radio system, which had a fixed operation power output of 3.0 watts, the Global Systems for Mobile Communication cellular system, which had a maximum power output of 2.0 watts and the Time Division Multiple Access cellular system, which had a maximum power output of 0.2 watts on our ventilators. The ventilators were ventilating a plastic lung at fixed settings. The mobile communication devices were tested at varying distances starting at zero meter from the ventilator and in all operation modes. RESULTS: The 2-way radio caused the most interference on some of the ventilators, but the maximum distance of interference was 1.0 m. The Global Systems for Mobile Communication system caused significant interference only at 0 m and minor interference at 0.5 m on only 1 ventilator. The Time Division Multiple Access system caused no interference at all. Significant interference consisted of a dramatic rise and fluctuation of the respiratory rate, pressure, and positive end-expiratory pressure of the ventilators with no normalization when the mobile device was removed. CONCLUSIONS: From our experiment on our ventilators with the communication systems used in our province, we conclude that mobile communication devices such as cellular phones and 2-way radios are safe and cause no interference unless operated at very close distances of less than 1 meter.

An empirical continuous positive airway pressure trial for suspected obstructive sleep apnea.

BACKGROUND: Standard practice in obstructive sleep apnea (OSA) management requires that a positive diagnostic, overnight polysomnography (PSG) test be obtained before initiating treatment. However, long waiting times due to lack of access to PSG testing facilities may delay the initiation of definitive treatment for OSA. OBJECTIVES: To evaluate the response of patients who had a high clinical suspicion for OSA and who were waiting for a PSG test to an empirical continuous positive airway pressure (CPAP) trial. METHODS: A retrospective study of all patients who had been offered empirical CPAP therapy for suspected OSA was conducted. After outpatient assessment, 183 patients with a high pretest probability of having OSA began empirical CPAP testing using an arbitrary CPAP pressure. The presence of OSA, the accuracy of empirical CPAP pressure prescription, the adherence to empirical CPAP and the improvement in daytime somnolence were evaluated at the time of PSG. RESULTS: Of 183 patients on a CPAP trial, 91% had OSA, which was at least moderate (more than 15 apneas and hypopneas per hour of sleep) in 75% of the patients. Eighty per cent of the patients had significant daytime somnolence (Epworth Sleepiness Scale [ESS] greater than 10, mean +/- SD ESS 14+/-5), which improved with CPAP (ESS 9.0+/-5, P<0.01). In 40% of the patients, the arbitrary CPAP pressure was lower than that determined by manual titration. Adherence to a trial of CPAP (longer than 2 h/night) predicted OSA with a sensitivity of 82% and a specificity of 41%; the positive and negative predictive values were 92% and 22%, respectively. CONCLUSIONS: At the time of PSG testing, OSA was present in 91% of the patients who had received empirical CPAP. An empirical CPAP provided satisfactory interim treatment for excessive somnolence, despite the fact that the CPAP pressure was suboptimal in 40% of the patients.

Treatments for carpal tunnel syndrome: who does what, when ... and why?

OBJECTIVE: To determine how frequently treatments had been offered to patients with suspected diagnoses of carpal tunnel syndrome (CTS) who had been referred for confirmatory nerve conduction studies (NCSs) and to identify potential predictors of such treatment. A follow-up survey was conducted to determine the effect of NCS results on subsequent treatment. DESIGN: Self-administered survey questionnaire and follow-up telephone survey. SETTING: Royal University Hospital at the University of Saskatchewan in Saskatoon. PARTICIPANTS: Two hundred eleven patients with clinically suspected CTS who had been referred for confirmatory NCS. MAIN OUTCOME MEASURES: Results of NCSs, number of patients prescribed wrist splints or nonsteroidal anti-inflammatory drugs (NSAIDs) before and after NCSs, patient characteristics associated with being prescribed therapy, and reporting benefit of therapy. RESULTS: Nerve conduction studies confirmed CTS in 121 (57.3%) of the 211 study patients. Before NCSs, wrist splints and NSAIDs had been prescribed to 33.2% and 38.8% of patients, respectively. Splints and NSAIDs were reported to alleviate symptoms by 78.3% and 74% of patients, respectively, who received such treatments. No significant differences in age, sex, body mass index, symptom duration, symptom or function scores, or subsequent NCS results were noted between patients who were and were not prescribed these therapies or between those who did or did not report improvement in symptoms. Results of the follow-up survey indicated that the number of recommendations for splints and NSAIDs had doubled after NCSs were completed and that surgical intervention had been at least discussed in most cases. Treatment recommendations, including surgery, however, were not associated with identifiable patient factors, including patients' NCS results. CONCLUSION: Some patients were prescribed conservative treatments before NCSs. Following NCSs, prescriptions for wrist splints or NSAIDs approximately doubled. Interestingly, NCS results did not appear to influence subsequent therapeutic decision-making for either conservative treatment or surgical options. We think these findings suggest a lack of confidence in electrodiagnostic study results. It would be interesting to evaluate a larger population of primary care patients prospectively to examine further the use of NCSs in current clinical decision-making.

The American Thoracic Society's spirometric criteria alone is inadequate in asthma diagnosis.

BACKGROUND: The diagnosis of asthma is based on clinical symptoms, physical examination and pulmonary function tests, and can be very challenging. Most patients with asthma have a significant postbronchodilator response on spirometry indicating airway hyperresponsiveness. However, having a significant bronchodilator response by itself is not diagnostic of asthma. The definition of a 'significant' response has also been controversial. Many respirologists use the American Thoracic Society (ATS) postbronchodilator response criteria of 12% (provided it is 200 mL or greater) improvement in forced expiratory volume in 1 s (or forced vital capacity) from the baseline spirometry. METHODS: In the present study, 644 patients who met the ATS criteria for a significant postbronchodilator spirometric response were retrospectively reviewed. The staff respirologist's diagnosis of asthma, based on all clinical and pulmonary function data, was used as the standard for the diagnosis of asthma. RESULTS: Relying on spirometric criteria alone was inadequate in asthma diagnosis because only 54.7% of 310 patients who met the ATS bronchodilator response criteria were thought to have clinical asthma. Increasing the postbronchodilator percentage improvement from the ATS criteria only marginally improved diagnostic specificity and resulted in a decline in sensitivity. CONCLUSIONS: The results of the present study further emphasize the need to use spirometric criteria as a guide but not as an unimpeachable gold standard with which to make a diagnosis of asthma. The diagnosis of asthma depends on expert physician correlation of patient history, physical examination and pulmonary function test results.

Hemodynamic Response to Upper Airway Obstruction in Hypertensive and Normotensive Pregnant Women.

Background. Mild obstructive sleep apnea is common in pregnancy and may have an exacerbating role in gestational hypertension, although currently the interaction between these two diseases is uncertain. Methods. We analyzed 43 pregnant subjects, 28 with gestational hypertension (GH) and 15 with normal healthy pregnancy, by level I polysomnography. Additionally, diastolic and systolic blood pressure changes in response to obstructive respiratory events were measured by noninvasive beat-by-beat monitoring. We also assessed a subgroup (n = 27) of women with respiratory disturbance indexes <5, for blood pressure responses to very subtle obstructive respiratory disturbances ("airflow reductions"). Results. The mean ± standard deviation respiratory disturbance index of our 28 GH women and 15 healthy pregnant women was 10.1 ± 9.9 mmHg and 3.0 ± 3.8 mmHg, respectively. Systolic and diastolic pressure responses to these events were 30.1 ± 12.8 mmHg and 16.0 ± 6.1 mmHg for GH women and 29.1 ± 14.2 mmHg and 14.3 ± 7.7 mmHg for healthy women. For the 27 women in whom we assessed for airflow reduction events, the hemodynamic responses were 27.1 ± 12.3 mmHg systolic and 14.4 ± 6.7 mmHg diastolic. Interpretation. Upper airway obstructive events of any severity are associated with a substantial transient blood pressure response in both healthy pregnant and GH women. Whether or not these events have a clinically significant impact on women with GH remains uncertain.

Improvement in obstructive sleep apnea diagnosis and management wait times: A retrospective analysis of home management pathway for obstructive sleep apnea.

Obstructive sleep apnea is a common condition within the Canadian population. The current gold standard for diagnosis and management of patients is in-laboratory (in-lab) polysomnography; however, the limited availability of testing options for patients has led to long wait times and increased disease burden within the population. The Sleep Research Laboratory in Saskatoon (Saskatchewan) implemented a home management program to run in parallel with the in-lab system several years ago in an effort to increase their capacity and reduce wait times. The present study was a retrospective analysis of all patients referred to the program between 2009 and 2012. The home management system has improved wait times by diagnosing and managing up to one-half of the referred patient population, reducing the wait for in-lab treatment from a median of 152 days in 2009 to 92 days in 2012 (P<0.0001). Moving forward, home management can provide a viable alternative to in-lab testing for patients who meet strict entry criteria, reducing the in-lab workload and, ultimately, reducing wait times.

The association between obesity and outcomes in critically ill patients.

BACKGROUND: Obesity rates are increasing worldwide, particularly in North America. The impact of obesity on the outcome of critically ill patients is unclear. METHODS: A prospective observational cohort study of consecutive patients admitted to a tertiary critical care unit in Canada between January 10, 2008 and March 31, 2009 was conducted. Exclusion criteria were age <18 years, admission <24 h, planned cardiac surgery, pregnancy, significant ascites, unclosed surgical abdomen and brain death on admission. Height, weight and abdominal circumference were measured at the time of intensive care unit (ICU) admission. Coprimary end points were ICU mortality and a composite of ICU mortality, reintubation, ventilator-associated pneumonia, line sepsis and ICU readmission. Subjects were stratified as obese or nonobese, using two separate metrics: body mass index (BMI) ≥ 30 kg/m(2) and a novel measurement of 75th percentile for waist-to-height ratio (WHR). RESULTS: Among 449 subjects with a BMI ≥ 18.5 kg/m(2), both BMI and WHR were available for comparative analysis in 348 (77.5%). Neither measure of obesity was associated with the primary end points. BMI ≥ 3 0 kg/m(2) was associated with a lower odds of six-month mortality than the BMI <30 kg/m(2) group (adjusted OR 0.59 [95% CI 0.36 to 0.97]; P=0.04) but longer intubation times (adjusted RR 1.56 [95% CI 1.17 to 2.07]; P=0.003) and longer ICU length of stay (adjusted RR 1.67 [95% CI 1.21 to 2.31]; P=0.002). Conversely, measurement of 75th percentile for WHR was associated only with decreased ICU readmission (OR 0.23 [95% CI 0.07 to 0.79]; P=0.02). CONCLUSIONS: Obesity was not necessarily associated with worse outcomes in critically ill patients.