Prediction of esophagogastroduodenoscopy therapeutic usefulness for in-ICU suspected upper gastrointestinal bleeding: the SUGIBI score study.

BACKGROUND: Suspected upper gastrointestinal bleeding (SUGIB) is a common issue during ICU stay. In the absence of specific guidelines on the indication and timing of esophagogastroduodenoscopy (EGD), there is substantial variability in EGD indication depending on accessibility and clinical presentation. This study aimed to investigate factors associated with the need for per-EGD hemostatic therapy and to create a score predicting therapeutic benefit of emergency bedside EGD in ICU patients with SUGIB. METHODS: We conducted a retrospective study in our ICU to identify factors associated with the need for hemostatic procedure during EGD performed for SUGIB. From this observational cohort, we derived a score predicting the need for hemostasis during EGD, the SUGIBI score. This score was subsequently validated in a retrospective multicenter cohort. RESULTS: Two hundred fifty-five patients not primarily admitted for GI bleeding who underwent a bedside EGD for SUGIB during their ICU stay were analyzed. The preeminent EGD indication were anemia (79%), melena (19%), shock (14%), and hematemesis (13%). EGD was normal in 24.7% of cases, while primary lesions reported were ulcers (23.1%), esophagitis (18.8%), and gastritis (12.5%). Only 12.9% of patients underwent hemostatic endotherapy during EGD. A SUGIBI score < 4 had a negative predictive value of 95% (91-99) for hemostatic endotherapy [AUC of 0.81; 0.75-0.91 (p < 0.0001)]. The SUGIBI score for predicting the need for an EGD-guided hemostatic procedure was next validated in a multicenter cohort with an AUC of 0.75 (0.66-0.85) (p < 0.0001), a score < 4 having a negative predictive value of 95% (92-97). CONCLUSIONS: Our study shows that the therapeutic usefulness of bedside emergency EGD for SUGIB in critically ill patients is limited to a minority of patients. The SUGIBI score should help clinicians stratify the probability of a therapeutic EGD.

Epidemiology and Clinical Patterns of Lung Abscesses in ICU: A French Multicenter Retrospective Study.

BACKGROUND: Data are scarce regarding epidemiology and management of critically ill patients with lung abscesses. RESEARCH QUESTION: What are the clinical and microbiological characteristics of critically ill patients with lung abscesses, how are they managed in the ICU, and what are the risk factors of in-ICU mortality? STUDY DESIGN AND METHODS: This was a retrospective observational multicenter study, based on International Classification of Diseases, 10th Revision, codes, between 2015 and 2022 in France. In-ICU mortality-associated factors were determined by multivariate logistic regression. RESULTS: We analyzed 171 ICU patients with pulmonary abscesses. Seventy-eight percent were male, with a mean age of 56.5 ± 16.4 years; 20.4% misused alcohol, 25.2% had a chronic lung disease (14% COPD), and 20.5% had a history of cancer. Overall, 40.9% were immunocompromised and 38% qualified for nosocomial infection. Presenting symptoms included fatigue or weight loss in 62%, fever (50.3%), and dyspnea (47.4%). Hemoptysis was reported in 21.7%. A polymicrobial infection was present in 35.6%. The most frequent pathogens were Enterobacteriaceae in 31%, Staphylococcus aureus in 22%, and Pseudomonas aeruginosa in 19.3%. Fungal infections were found in 10.5%. Several clusters of clinicoradiologic patterns were associated with specific microbiological documentation and could guide empiric antibiotic regimen. Percutaneous abscess drainage was performed in 11.7%; surgery was performed in 12.7%, and 12% required bronchial artery embolization for hemoptysis. In-ICU mortality was 21.5%, and age (OR: 1.05 [1.02-1.91], P = .007], renal replacement therapy during ICU stay (OR, 3.56 [1.24-10.57], P = .019), and fungal infection (OR, 9.12 [2.69-34.5], P = .0006) were independent predictors of mortality after multivariate logistic regression, and drainage or surgery were not. INTERPRETATION: Pulmonary abscesses in the ICU are a rare but severe disease often resulting from a polymicrobial infection, with a high proportion of Enterobacteriaceae, S aureus, and P aeruginosa. Percutaneous drainage, surgery, or arterial embolization was required in more than one-third of cases. Further prospective studies focusing on first-line antimicrobial therapy and source control procedure are warranted to improve and standardize patient management.

Burden of grade 3 or 4 liver injury associated with immune checkpoint inhibitors.

Background & Aims: There is concern about the burden of liver injury in patients with cancer exposed to immune checkpoints inhibitors (ICIs). Methods: In a retrospective cohort study, we evaluated the likelihood of grade 3/4 liver injury, of grade 3/4 cholestatic liver injury, and of liver failure, as per the Common Terminology Criteria for Adverse Events (CTCAE) version 5, following treatment with ICIs. We compared these occurrences with a group of cancer patients who were propensity-matched and treated with conventional chemotherapy. For all ICI patients experiencing grade 3/4 liver injury, we conducted a causality assessment using the RUCAM method and examined patient outcomes. Results: Among 952 patients (median [IQR] age 66 [57-73] years, 64% males) who were treated with ICI between January 1, 2015, and December 31, 2019, a total of 86 (9%) progressed to grade 3/4 liver injury, and liver failure was not observed. Anti-PD-(L)1/anti-CTLA-4 antibodies combinations (adjusted hazard ratio 3.36 [95% CI: 1.67-6.79]; p <0.001), and chronic hepatitis B (adjusted hazard ratio 5.48 [95% CI: 1.62-18.5]; p = 0.006], were independent risk factors. Liver injury was attributed to ICI treatment in 19 (2.0%) patients. Patients with ICI toxicity typically presented with granulomatous hepatitis or cholangiocyte inflammation. ICI withdrawal was associated with cancer progression and mortality. Re-introduction of ICI was not associated with recurrent grade 3/4 liver injury. Compared with matched patients treated with conventional, non-ICI-based chemotherapy, anti-PD-(L)1/anti-CTLA-4 combinations (p <0.001) and anti-PD-(L)1 monotherapies (p = 0.053) increased the risk of grade 3/4 liver injury and of grade 3/4 cholestatic liver injury, respectively. Conclusions: An increased risk of grade 3/4 liver injury under anti-PD-(L)1/anti-CTLA-4 antibodies was observed, whereas no substantial increase in the likelihood of liver failure occurred even after treatment reintroduction. Impact and implications: There is concern about liver injury in patients with cancer exposed to immune checkpoints inhibitors (ICIs). We investigated the burden of grade 3/4 liver injury after treatment with ICIs in a multicentric cohort of patients with cancer. Overall, a 9% incidence of grade 3/4 liver injury was detected after ICIs, and direct ICI hepatotoxicity was demonstrated in 2% of patients. Anti-PD-(L)1/Anti-CTLA-4 antibody combinations, and chronic HBV infection were independent risk factors. ICI withdrawal for grade 3/4 liver injury was associated with cancer progression. Re-introduction of ICI treatment was not associated with recurrent grade 3/4 liver injury.

Risk factors for admission to the pediatric critical care unit among children hospitalized with COVID-19 in France.

Background: COVID-19 infection is less severe among children than among adults; however, some patients require hospitalization and even critical care. Using data from the French national medico-administrative database, we estimated the risk factors for critical care unit (CCU) admissions among pediatric COVID-19 hospitalizations, the number and characteristics of the cases during the successive waves from January 2020 to August 2021 and described death cases. Methods: We included all children (age < 18) hospitalized with COVID-19 between January 1st, 2020, and August 31st, 2021. Follow-up was until September 30th, 2021 (discharge or death). Contiguous hospital stays were gathered in "care sequences." Four epidemic waves were considered (cut off dates: August 11th 2020, January 1st 2021, and July 4th 2021). We excluded asymptomatic COVID-19 cases, post-COVID-19 diseases, and 1-day-long sequences (except death cases). Risk factors for CCU admission were assessed with a univariable and a multivariable logistic regression model in the entire sample and stratified by age, whether younger than 2. Results: We included 7,485 patients, of whom 1988 (26.6%) were admitted to the CCU. Risk factors for admission to the CCU were being younger than 7 days [OR: 3.71 95% CI (2.56-5.39)], being between 2 and 9 years old [1.19 (1.00-1.41)], pediatric multisystem inflammatory syndrome (PIMS) [7.17 (5.97-8.6)] and respiratory forms [1.26 (1.12-1.41)], and having at least one underlying condition [2.66 (2.36-3.01)]. Among hospitalized children younger than 2 years old, prematurity was a risk factor for CCU admission [1.89 (1.47-2.43)]. The CCU admission rate gradually decreased over the waves (from 31.0 to 17.8%). There were 32 (0.4%) deaths, of which the median age was 6 years (IQR: 177 days-15.5 years). Conclusion: Some children need to be more particularly protected from a severe evolution: newborns younger than 7 days old, children aged from 2 to 13 years who are more at risk of PIMS forms and patients with at least one underlying medical condition.

Burden of liver disease progression in hospitalized patients with type 2 diabetes mellitus.

BACKGROUND & AIMS: There are uncertainties regarding the burden of liver disease in patients with type 2 diabetes (T2D). Thus, we aimed to quantify the burden of liver disease, identify risk factors, and estimate attributable risks in patients with T2D. METHODS: We measured adjusted hazard ratios of liver disease progression to hepatocellular carcinoma and/or decompensated cirrhosis in a 2010-2020 retrospective, bicentric, longitudinal, cohort of 52,066 hospitalized patients with T2D. RESULTS: Mean age was 64±14 years and 58% were men. Alcohol use disorders accounted for 57% of liver-related complications and were associated with all liver-related risk factors. Non-metabolic liver-related risk factors accounted for 37% of the liver burden. T2D control was not associated with liver disease progression. The incidence (95% CI) of liver-related complications and of competing mortality were 3.9 (3.5-4.3) and 27.8 (26.7-28.9) per 1,000 person-years at risk, respectively. The cumulative incidence of liver disease progression exceeded the cumulative incidence of competing mortality only in the presence of well-identified risk factors of liver disease progression, including alcohol use. The incidence of hepatocellular carcinoma was 0.3 (95% CI 0.1-0.5) per 1,000 person-years in patients with obesity and it increased with age. The adjusted hazard ratios of liver disease progression were 55.7 (40.5-76.6), 3.5 (2.3-5.2), 8.9 (6.9-11.5), and 1.5 (1.1-2.1), for alcohol-related liver disease, alcohol use disorders without alcohol-related liver disease, non-metabolic liver-related risk factors, and obesity, respectively. The attributable fractions of alcohol use disorders, non-metabolic liver-related risk factors, and obesity to the liver burden were 55%, 14%, and 7%, respectively. CONCLUSIONS: In this analysis of data from 2 hospital-based cohorts of patients with T2D, alcohol use disorders, rather than obesity, contributed to most of the liver burden. These results suggest that patients with T2D should be advised to drink minimal amounts of alcohol. LAY SUMMARY: There is uncertainty on the burden of liver-related complications in patients with type 2 diabetes. We studied the risks of liver cancer and complications of liver disease in over 50,000 patients with type 2 diabetes. We found that alcohol was the main factor associated with complications of liver disease. This finding has major implications on the alcohol advice given to patients with type 2 diabetes.

Autoimmune manifestations associated with lymphoma: characteristics and outcome in a multicenter retrospective cohort study.

This French multicenter retrospective cohort study aimed to describe the autoimmune manifestations (AIMs) associated with lymphoma among patients hospitalized between 2005 and 2016 in three French University Hospitals. Among 2503 patients with lymphoma, 108 (4.3%) had AIMs, mostly autoimmune cytopenias (71.3%), neurological diseases (10.2%), kidney diseases (6.5%), systemic vasculitis (5.6%) and others. As compared with the 2395 lymphoma patients without AIMs, those with AIMs were older (p = .01), more frequently had B-cell chronic lymphocytic leukemia (p < .01) and less frequently diffuse large B-cell lymphomas (p = .01) and Hodgkin lymphoma (p = .01). The 5-year overall survival with lymphoma was 65% and 79% (p = .03) with and without AIMs. This large cohort study shows that various types of AIMs, mostly cytopenias, could be associated with lymphoma and affect the overall outcome with lymphoma, in particular for B-cell non-Hodgkin lymphoma (p = .01) and T-cell non-Hodgkin lymphoma (p = .01), with no survival difference noted for other types of lymphoma (p = .2).

The 2003 heat wave in France: hydratation status changes in older inpatients.

Little is known about the impact of behavioral changes after the 2003 heat wave on hydration status of elderly citizens in France. We used an administrative data file provided information about 23,022 inpatients aged > or =70 years admitted between 2000 and 2006, including vital status at discharge and Charlson comorbidity index and matched it with the result of five blood tests (sodium, potassium, glucose, urea nitrogen, creatinine) within the first 24 h after admission and with daily temperatures before admission. We then measured the prevalence of plasma tonicity (PT) <275 mOsm/l or >300 mOsm/l, blood urea nitrogen/creatinine ratio (BUNC) >100 and inhospital mortality. In 2000-2002, 2003, 2004-2006, prevalence (%) was, respectively 7.5, 8.0, 9.5 (P < 0.0001) for PT < 275 mMol/l, 8.4, 10.4, 7.2 (P < 0.0001) for PT > 300 mOsm/l, and 35.4, 30.7, 26.7 (P < 0.0001) for BUNC > 100. Inhospital mortality rate was 10.8, 10.8 and 9.0%, respectively (P < 0.0001). After adjustment for covariates, OR (95% CI) in 2004-2006 with reference to 2000-2002 was 1.26 (1.13-1.39) for PT < 275 mMol/l, 0.85 (0.76-0.94) for PT > 300 mOsm/l, and 0.65 (0.61-0.69) for BUNC > 100. Inhospital mortality risk associated with hydration disorders did not vary significantly over periods for PT < 275 mMol/l (HR 1.06 to 1.40) and PT > 300 mOsm/l (HR 1.76 to 1.96) but was lower for BUNC > 100 in 2003 (HR 1.27) than in 2000-2002 (HR 1.64) or 2004-2006 (HR 1.77) (P = 0.04). So, since the 2003 heat wave, significant shifts in prevalence of intracellular hydration disorders indicate behavioral changes with positive impact on hydration status.

Assessing organizational performance in intensive care units: a French experience.

OBJECTIVE: The objective of the study was to assess and to explain variation of organizational performance in intensive care units (ICUs). DESIGN: This was a prospective multicenter study. SETTING: The study involved 26 ICUs located in the Paris area, France, participating in a regional database. METHODS: Data were collected through answers of 1000 ICU personnel to the Culture, Organization, and Management in Intensive Care questionnaire and from the database. Organizational performance was assessed through a composite score related to 5 dimensions: coordination and adaptation to uncertainty, communication, conflict management, organizational change, and organizational learning, Skills developed in relationship with patients and their families. Statistical comparisons between ICUs were performed by analysis of variance with a Scheffé pairwise procedure. A multilevel regression model was used to analyze both individual and structural variables explaining differences of ICU's organizational performance. RESULTS: The organizational performance score differed among ICUs. Some cultural values were negatively correlated with a high level of organizational performance, suggesting improvement potential. Several individual and structural factors were also related to the quality of ICU organization, including absence of burnout, older staff, satisfaction to work, and high workload (P < .02 for each). CONCLUSIONS: A benchmarking approach can be used by ICU managers to assess the organizational performance of their ICU based on a validated questionnaire. Differences are mainly explained by cultural values and individual well-being factors, introducing new requirements for managing human resources in ICUs.

Culture, organization, and management in intensive care: construction and validation of a multidimensional questionnaire.

OBJECTIVE: The objective of this study is to develop and validate a questionnaire designed to assess the culture, organization, and management of intensive care units. DESIGN: This is a prospective multicenter study. SETTING: The study was conducted in 26 intensive care units located in Paris. PARTICIPANTS: All personnel were asked to complete the questionnaire. INTERVENTION: The questionnaire was developed in 2 steps: (1) development of a theoretical framework based on organizational theory and (2) testing of the reliability and validity of a comprehensive set of measures. METHOD: The internal consistency of the items composing each scale was tested by using the Cronbach alpha. Convergent, and discriminant validity was assessed by factor analysis with varimax rotation. RESULTS: The overall completion rate was 74% with 1000 respondents (750 nurses, 26 head nurses, 168 physicians, and 56 medical secretaries). Starting with a 220-item questionnaire, we constructed a short version-conserving metrological characteristics with good reliability and validity. The short questionnaire, entitled Culture, Organization, and Management in Intensive Care, consists of 106 items distributed in 9 dimensions and 22 scales: culture (n = 3), coordination and adaptation to uncertainty (n = 3), communication (n = 3), problem solving and conflict management (n = 2), organizational learning and organizational change (n = 2), skills developed in a patient-caregiver relationship (n = 1), subjective unit performance (n = 3), burnout (n = 3), and job satisfaction and intention to quit (n = 2). All the scales showed good-to-high reliability, with Cronbach alpha scores higher than .7 (with the exception of coordination [.6]). Team satisfaction-oriented culture is positively correlated with good managerial practices and individual well-being. CONCLUSIONS: The Culture, Organization, and Management in Intensive Care questionnaire enables staff and managers to assess the organizational performance of their intensive care unit.

SAPS II revisited.

OBJECTIVE: To construct and validate an update of the Simplified Acute Physiology Score II (SAPS II) for the evaluation of clinical performance of Intensive Care Units (ICU). DESIGN AND SETTING: Retrospective analysis of prospectively collected multicenter data in 32 ICUs located in the Paris area belonging to the Cub-Rea database and participating in a performance evaluation project. PATIENTS: 33,471 patients treated between 1999 and 2000. MEASUREMENTS AND RESULTS: Two logistic regression models based on SAPS II were developed to estimate in-hospital mortality among ICU patients. The second model comprised reevaluation of original items of SAPS II and integration of the preadmission location and chronic comorbidity. Internal and external validation were performed. In the two validation samples the most complex model had better calibration than the original SAPS II for in-hospital mortality but its discrimination was not significantly higher (area under ROC curve 0.89 vs. 0.87 for SAPS II). Second-level customization and integration of new items improved uniformity of fit for various categories of patients except for diagnosis-related groups. The rank order of ICUs was modified according to the model used. CONCLUSIONS: The overall performance of SAPS II derived models was good, even in the context of a community cohort and routinely gathered data. However, one-half the variation of outcome remains unexplained after controlling for admission characteristics, and uniformity of prediction across diagnostic subgroups was not achieved. Differences in case-mix still limit comparisons of quality of care.