Development of an Ordinal Scale Treatment Endpoint for Adults Hospitalized With Influenza.

BACKGROUND: An obstacle in influenza therapeutics development is the lack of clinical endpoints, especially in hospitalized patients. A single time-point binary outcome measure is limited by patients' diverse clinical trajectories and low event rates. METHODS: A 6-point ordinal scale with ascending clinical status severity (scoring: discharged; subacute care; acute care without/with respiratory failure; intensive care unit [ICU]; death) was proposed to study outcomes of adults hospitalized with influenza. Individual patient data from 2 active surveillance cohorts' datasets (2015/2016-2017/2018; Edmonton, Hong Kong) was used for evaluation. The impact of neuraminidase inhibitor (NAI) treatment on longitudinal ordinal outcome changes over 30 days was analyzed using mixed-effects ordinal logistic regression and group-based trajectory models. RESULTS: Patient (n = 1226) baseline characteristics included age (mean 68.0 years), virus-type (A 78.1%, B 21.9%), respiratory failure (57.2%), ICU admittance (14.4%), and NAI treatment within 5 days of illness (69.2%). Outcomes at 30 days included discharged (75.2%), subacute care (13.7%), acute care (4.5%), and death (6.6%). Two main clinical trajectories were identified, predictive by baseline scoring (mean ±â€…SD, 4.3 ±â€…0.6 vs 3.5 ±â€…0.6, P < .001). Improved outcomes with NAI treatment within 5 days were indicated by significantly lower clinical status scores over time (unadjusted odds ratio [OR], 0.53; 95% confidence interval [CI], .41-.69; P < .001; adjusted OR, 0.62; 95% CI, .50-.77; P < .001, for baseline score, age, and within-patient correlations). In subanalysis, influenza vaccination was also associated with lower scores (adjusted OR, 0.67; 95% CI, .50-.90; P = .007). Analyses of binary endpoints showed insignificant results. CONCLUSIONS: The ordinal outcome scale is a potentially useful clinical endpoint for influenza therapeutic trials, which could account for the diverse clinical trajectories of hospitalized patients, warranting further development.

Associations Between Oversedation and Agitation in Postanesthesia Recovery Room and Subsequent Severe Behavioral Emergencies.

OBJECTIVES: Hospital-based behavioral emergency response teams (BERT) respond to acute behavioral disturbances among hospitalized patients. We aimed to examine associations between altered mental status in postanesthesia care unit (PACU) and behavioral disturbances on surgical wards requiring BERT activation. METHODS: Electronic medical records of patients who underwent general anesthesia and were admitted to the PACU between May 2018-December 2020 were reviewed for episodes of BERT activations on surgical wards. Characteristics of BERT patients were compared with the rest of surgical population during the same period to examine risk factors for BERT. RESULTS: Of 56,275 adult surgical patients, 133 patients had 178 BERT activations (incidence 2.4, 95% confidence interval [CI] 2.0-2.8 per 1000 admissions), with 21 being for physical assault. The risk for BERT activation was increased with each decade over age of 50 as well as younger age (30 versus 50 y), male sex (odds ratio [OR] = 2.48, 95% CI 1.69, 3.62), longer procedures (OR = 1.08 per 30 minutes, 95% CI 1.05, 1.11), and alterations in mental status in PACU, with both moderate/deep sedation (OR = 1.63, 95% CI 1.04, 2.57) and agitation/combative state (OR = 8.47, 95% CI 5.13, 14.01), P < 0.001 for all comparisons. CONCLUSIONS: Early postoperative agitation and oversedation are associated with BERT activation on surgical wards. Altered mental status in PACU should be conveyed to accepting hospital units so healthcare staff can be vigilant for the potential development of behavioral disturbances.

An International Delphi Survey on Exercise Priorities in CKD.

INTRODUCTION: Defining the role of exercise in chronic kidney disease (CKD) is a top research priority for people with CKD. We aimed to achieve consensus on specific research priorities in exercise and CKD among an international panel of stakeholders. METHODS: Using the Delphi method, patients/caregivers, researchers, clinicians, and policymakers submitted their top research priorities in round 1 and ranked their importance in rounds 2 and 3 using a 9-point Likert scale. The mean, median, and proportion of scores ranked 7 to 9 were calculated. Consensus was defined as priorities that scored above the overall mean and median score within each stakeholder panel. Qualitative description was used to understand participants' rankings. RESULTS: Seventy participants (78% response) completed round 1: 15 (21.4%) clinicians, 33 (47.1%) researchers, 13 (18.6%) policymakers, and 9 (12.9%) patients; (85.7%) completed round 3. The top research priorities were defining exercise-related outcomes meaningful to patients, identifying patients' motivation and perspective towards exercise, understanding the effect of exercise on the risk of institutionalization, mortality, and mobility, and understanding the effect of pre- and post-transplant exercise on postoperative recovery. Themes from the qualitative analysis were individualization, personal experience, and holistic approach to exercise (patients), the need to address common clinical problems (clinicians), developing targeted interventions (researchers), and the importance of evidence-based development versus implementation (policymakers). CONCLUSIONS: Preventing physical disability was a common priority. Policymakers emphasized that more efficacy studies were needed. Other panels expressed the need for holistic and targeted exercise interventions and for outcomes that address common clinical problems.

Volume management in the critically ill patient with acute kidney injury.

Acute kidney injury (AKI) frequently occurs in the setting of critical illness and its management poses a challenge for the intensivist. Optimal management of volume status is critical in the setting of AKI in the ICU patient. The use of urine sodium, the fractional excretion of sodium (FeNa), and the fractional excretion of urea (FeUrea) are common clinical tools used to help guide fluid management especially further volume expansion but should be used in the context of the patient's overall clinical scenario as they are not completely sensitive or specific for the finding of volume depletion and can be misleading. In the case of oliguric or anuric AKI, diuretics are often utilized to increase the urine output although current evidence suggests that they are best reserved for the treatment of volume overload and hyperkalemia in patients who are likely to respond to them. Management of volume overload in ICU patients with AKI is especially important as volume overload has several negative effects on organ function and overall morbidity and mortality.