Negative predictive value of procalcitonin to rule out bacterial respiratory co-infection in critical covid-19 patients.

BACKGROUND: Procalcitonin (PCT) and C-Reactive Protein (CRP) are useful biomarkers to differentiate bacterial from viral or fungal infections, although the association between them and co-infection or mortality in COVID-19 remains unclear. METHODS: The study represents a retrospective cohort study of patients admitted for COVID-19 pneumonia to 84 ICUs from ten countries between (March 2020-January 2021). Primary outcome was to determine whether PCT or CRP at admission could predict community-acquired bacterial respiratory co-infection (BC) and its added clinical value by determining the best discriminating cut-off values. Secondary outcome was to investigate its association with mortality. To evaluate the main outcome, a binary logistic regression was performed. The area under the curve evaluated diagnostic performance for BC prediction. RESULTS: 4635 patients were included, 7.6% fulfilled BC diagnosis. PCT (0.25[IQR 0.1-0.7] versus 0.20[IQR 0.1-0.5]ng/mL, p<0.001) and CRP (14.8[IQR 8.2-23.8] versus 13.3 [7-21.7]mg/dL, p=0.01) were higher in BC group. Neither PCT nor CRP were independently associated with BC and both had a poor ability to predict BC (AUC for PCT 0.56, for CRP 0.54). Baseline values of PCT<0.3ng/mL, could be helpful to rule out BC (negative predictive value 91.1%) and PCT≥0.50ng/mL was associated with ICU mortality (OR 1.5,p<0.001). CONCLUSIONS: These biomarkers at ICU admission led to a poor ability to predict BC among patients with COVID-19 pneumonia. Baseline values of PCT<0.3ng/mL may be useful to rule out BC, providing clinicians a valuable tool to guide antibiotic stewardship and allowing the unjustified overuse of antibiotics observed during the pandemic, additionally PCT≥0.50ng/mL might predict worsening outcomes.

Corticosteroid treatment and mortality in mechanically ventilated COVID-19-associated acute respiratory distress syndrome (ARDS) patients: a multicentre cohort study.

BACKGROUND: Some unanswered questions persist regarding the effectiveness of corticosteroids for severe coronavirus disease 2019 (COVID-19) patients. We aimed to assess the clinical effect of corticosteroids on intensive care unit (ICU) mortality among mechanically ventilated COVID-19-associated acute respiratory distress syndrome (ARDS) patients. METHODS: This was a retrospective study of prospectively collected data conducted in 70 ICUs (68 Spanish, one Andorran, one Irish), including mechanically ventilated COVID-19-associated ARDS patients admitted between February 6 and September 20, 2020. Individuals who received corticosteroids for refractory shock were excluded. Patients exposed to corticosteroids at admission were matched with patients without corticosteroids through propensity score matching. Primary outcome was all-cause ICU mortality. Secondary outcomes were to compare in-hospital mortality, ventilator-free days at 28 days, respiratory superinfection and length of stay between patients with corticosteroids and those without corticosteroids. We performed survival analysis accounting for competing risks and subgroup sensitivity analysis. RESULTS: We included 1835 mechanically ventilated COVID-19-associated ARDS, of whom 1117 (60.9%) received corticosteroids. After propensity score matching, ICU mortality did not differ between patients treated with corticosteroids and untreated patients (33.8% vs. 30.9%; p = 0.28). In survival analysis, corticosteroid treatment at ICU admission was associated with short-term survival benefit (HR 0.53; 95% CI 0.39-0.72), although beyond the 17th day of admission, this effect switched and there was an increased ICU mortality (long-term HR 1.68; 95% CI 1.16-2.45). The sensitivity analysis reinforced the results. Subgroups of age < 60 years, severe ARDS and corticosteroids plus tocilizumab could have greatest benefit from corticosteroids as short-term decreased ICU mortality without long-term negative effects were observed. Larger length of stay was observed with corticosteroids among non-survivors both in the ICU and in hospital. There were no significant differences for the remaining secondary outcomes. CONCLUSIONS: Our results suggest that corticosteroid treatment for mechanically ventilated COVID-19-associated ARDS had a biphasic time-dependent effect on ICU mortality. Specific subgroups showed clear effect on improving survival with corticosteroid use. Therefore, further research is required to identify treatment-responsive subgroups among the mechanically ventilated COVID-19-associated ARDS patients.

A Machine Learning decision-making tool for extubation in Intensive Care Unit patients.

BACKGROUND AND OBJECTIVE: To increase the success rate of invasive mechanical ventilation weaning in critically ill patients using Machine Learning models capable of accurately predicting the outcome of programmed extubations. METHODS: The study population was adult patients admitted to the Intensive Care Unit. Target events were programmed extubations, both successful and failed. The working dataset is assembled by combining heterogeneous data including time series from Clinical Information Systems, patient demographics, medical records and respiratory event logs. Three classification learners have been compared: Logistic Discriminant Analysis, Gradient Boosting Method and Support Vector Machines. Standard methodologies have been used for preprocessing, hyperparameter tuning and resampling. RESULTS: The Support Vector Machine classifier is found to correctly predict the outcome of an extubation with a 94.6% accuracy. Contrary to current decision-making criteria for extubation based on Spontaneous Breathing Trials, the classifier predictors only require monitor data, medical entry records and patient demographics. CONCLUSIONS: Machine Learning-based tools have been found to accurately predict the extubation outcome in critical patients with invasive mechanical ventilation. The use of this important predictive capability to assess the extubation decision could potentially reduce the rate of extubation failure, currently at 9%. With about 40% of critically ill patients eventually receiving invasive mechanical ventilation during their stay and given the serious potential complications associated to reintubation, the excellent predictive ability of the model presented here suggests that Machine Learning techniques could significantly improve the clinical outcomes of critical patients.

What is the relevance of an ambulatory quick diagnosis unit or inpatient admission for the diagnosis of pancreatic cancer? A retrospective study of 1004 patients.

Quick diagnosis units (QDU) have become an alternative hospital-based ambulatory medicine strategy to inpatient hospitalization for potentially serious illnesses in Spain. Whether diagnosis of pancreatic cancer is better accomplished by an ambulatory or inpatient approach is unknown. The main objective of this retrospective study was to examine and compare the diagnostic effectiveness of a QDU or inpatient setting in patients with pancreatic cancer.Patients with a diagnosis of pancreatic adenocarcinoma who had been referred to a university, tertiary hospital-based QDU or hospitalized between 2005 and 2018 were eligible. Presenting symptoms and signs, risk and prognostic factors, and time to diagnosis were compared. The costs incurred during the diagnostic assessment were analyzed with a microcosting method.A total of 1004 patients (508 QDU patients and 496 inpatients) were eligible. Admitted patients were more likely than QDU patients to have weight loss, asthenia, anorexia, abdominal pain, jaundice, and palpable hepatomegaly. Time to diagnosis of inpatients was similar to that of QDU patients (4.1 [0.8 vs 4.3 [0.6] days; P = .163). Inpatients were more likely than QDU patients to have a tumor on the head of the pancreas, a tumor size >2 cm, a more advanced nodal stage, and a poorer histological differentiation. No differences were observed in the proportion of metastatic and locally advanced disease and surgical resections. Microcosting revealed a cost of &OV0556;347.76 (48.69) per QDU patient and &OV0556;634.36 (80.56) per inpatient (P < .001).Diagnosis of pancreatic cancer is similarly achieved by an inpatient or QDU clinical approach, but the latter seems to be cost-effective. Because the high costs of hospitalization, an ambulatory diagnostic assessment may be preferable in these patients.

Time to diagnosis and associated costs of an outpatient vs inpatient setting in the diagnosis of lymphoma: a retrospective study of a large cohort of major lymphoma subtypes in Spain.

BACKGROUND: Mainly because of the diversity of clinical presentations, diagnostic delays in lymphoma can be excessive. The time spent in primary care before referral to the specialist may be relatively short compared with the interval between hospital appointment and diagnosis. Although studies have examined the diagnostic intervals and referral patterns of patients with lymphoma, the time to diagnosis of outpatient compared to inpatient settings and the costs incurred are unknown. METHODS: We performed a retrospective study at two academic hospitals to evaluate the time to diagnosis and associated costs of hospital-based outpatient diagnostic clinics or conventional hospitalization in four representative lymphoma subtypes. The frequency, clinical and prognostic features of each lymphoma subtype and the activities of the two settings were analyzed. The costs incurred during the evaluation were compared by microcosting analysis. RESULTS: A total of 1779 patients diagnosed between 2006 and 2016 with classical Hodgkin, large B-cell, follicular, and mature nodal peripheral T-cell lymphomas were identified. Clinically aggressive subtypes including large B-cell and peripheral T-cell lymphomas were more commonly diagnosed in inpatients than in outpatients (39.1 vs 31.2% and 18.9 vs 13.5%, respectively). For each lymphoma subtype, inpatients were older and more likely than outpatients to have systemic symptoms, worse performance status, more advanced Ann Arbor stages, and high-risk prognostic scores. The admission time for diagnosis (i.e. from admission to excisional biopsy) of inpatients was significantly shorter than the time to diagnosis of outpatients (12.3 [3.3] vs 16.2 [2.7] days; P < .001). Microcosting revealed a mean cost of €4039.56 (513.02) per inpatient and of €1408.48 (197.32) per outpatient, or a difference of €2631.08 per patient. CONCLUSIONS: Although diagnosis of lymphoma was quicker with hospitalization, the outpatient approach seems to be cost-effective and not detrimental. Despite the considerable savings with the latter approach, there may be hospitalization-associated factors which may not be properly managed in an outpatient unit (e.g. aggressive lymphomas with severe symptoms) and the cost analysis did not account for this potentially added value. While outcomes were not analyzed in this study, the impact on patient outcome of an outpatient vs inpatient diagnostic setting may represent a challenging future research.

Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients.

BACKGROUND: Whereas there are numerous studies on unintentional weight loss (UWL), these have been limited by small sample sizes, short or variable follow-up, and focus on older patients. Although some case series have revealed that malignancies escaping early detection and uncovered subsequently are exceptional, reported follow-ups have been too short or unspecified and necropsies seldom made. Our objective was to examine the etiologies, characteristics, and long-term outcome of UWL in a large cohort of outpatients. METHODS: We prospectively enrolled patients referred to an outpatient diagnosis unit for evaluation of UWL as a dominant or isolated feature of disease. Eligible patients underwent a standard baseline evaluation with laboratory tests and chest X-ray. Patients without identifiable causes 6 months after presentation underwent a systematic follow-up lasting for 60 further months. Subjects aged ≥65 years without initially recognizable causes underwent an oral cavity examination, a videofluoroscopy or swallowing study, and a depression and cognitive assessment. RESULTS: Overall, 2677 patients (mean age, 64.4 [14.7] years; 51% males) were included. Predominant etiologies were digestive organic disorders (nonmalignant in 17% and malignant in 16%). Psychosocial disorders explained 16% of cases. Oral disorders were second to nonhematologic malignancies as cause of UWL in patients aged ≥65 years. Although 375 (14%) patients were initially diagnosed with unexplained UWL, malignancies were detected in only 19 (5%) within the first 28 months after referral. Diagnosis was established at autopsy in 14 cases. CONCLUSION: This investigation provides new information on the relevance of follow-up in the long-term clinical outcome of patients with unexplained UWL and on the role of age on this entity. Although unexplained UWL seldom constitutes a short-term medical alert, malignancies may be undetectable until death. Therefore, these patients should be followed up regularly (eg yearly visits) for longer than reported periods, and autopsies pursued when facing unsolved deaths.

A comprehensive evaluation of the gastrointestinal tract in iron-deficiency anemia with predefined hemoglobin below 9mg/dL: A prospective cohort study.

BACKGROUND: Anemia is defined as hemoglobin below the cutoff of normal in studies examining the gastrointestinal (GI) tract in iron-deficiency anemia (IDA). Although the risk of GI cancer (GIC) increases as hemoglobin decreases, guidelines do not usually recommend hemoglobin thresholds for IDA investigation. METHODS: To elucidate whether underlying GI disorders explain the different hemoglobin values and clinical outcomes observed initially in IDA patients referred for GI workup, we prospectively investigated the diagnostic yield of a thorough GI examination in consecutive IDA adults with predefined hemoglobin <9g/dL and no extraintestinal bleeding. RESULTS: 4552 patients were enrolled over 10 years. 96% of 4038 GI lesions were consistent with occult bleeding disorders and 4% with non-bleeding disorders. Predominant bleeding disorders included upper GI ulcerative/erosive lesions (51%), GIC (15%), and angiodysplasias (12%). Diffuse angiodysplasias (45% of angiodysplasias) and GIC showed the lowest hemoglobin values (6.3 [1.5] and 6.4 [1.3]g/dL, respectively). While the spread (diffuse vs. localized) and number (<3 vs. ≥3) of angiodysplasias correlated with the degree of anemia, hemoglobin values were lower in GIC with vs. without ulcerated/friable lesions (6.0 [1.1] vs. 7.0 [1.2]g/dL, P<0.001). CONCLUSION: Not only GIC but also diffuse angiodysplasias caused the most severe anemia in IDA with predefined hemoglobin values <9g/dL.

Calidad percibida por los usuarios de una unidad de cuidados intensivos: análisis de una encuesta de opinión / Quality perceived by the users of an intensive care unit: analysis of an opinion survey

El objetivo de este trabajo es evaluar la calidad percibida por los usuarios de una Unidad de Cuidados Intensivos mediante una encuesta de opinión con 25 variables. Se han analizado 109 encuestas. La valoración global de los servicios proporcionados por la Unidad fue de 8,64 puntos. Las mejores puntuaciones se han obtenido en relación al trato recibido en el momento del ingreso y al respeto a la dignidad e intimidad de los pacientes. Las quejas más frecuentes fueron respecto a las restricciones horarias en las visitas a los pacientes y a la calidad de la información proporcionada por el médico. La encuesta de opinión aporta elementos que pueden implementarse a la práctica diaria y pueden repercutir en la calidad percibida por los usuarios (AU)

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[Central-venous catheter-related infections and intensive care unit organization systems (EPIC Study, Spain)]. / Infecciones relacionadas con el uso de catéteres venosos centrales y sistemas organizativos de las unidades de cuidados intensivos (estudio EPIC).

BACKGROUND AND OBJECTIVE: Central venous catheter (CVC)-related nosocomial bacteremia is an important problem at the ICU. The possible role of organizational factors, as well as health care workers experience, for developing these infections is not well known. We aimed to identify the possible relationships and differences between the health care process, organizational features of the institutions and the development of CVC-related nosocomial infections. We also compared the results of the Spanish participating hospital with those of an international group of hospitals. PATIENTS AND METHOD: The EPIC study (Evaluation of Processes and Indicators in Infection Control) includes a total of 56 hospitals from different countries. The Hospital Clínic of Barcelona was the only Spanish participant. Each Hospital selects, by means of a random process, 5 ICU patients per month with a recently placed CVC. Data related to the CVC insertion process, follow-up and care of the CVC, time dedication of nursing personnel, days of stay and episodes of CVC-related bacteremia per 1000 patient-days of CVC use were recorded. RESULTS: A total of 3,298 patients with a CVC were included, and 89 episodes of CVC-related nosocomial bacteremia were identified (3.86 episodes per 1000 CVC-days). The Hospital Clínic included 67 patients with a CVC and identified 1.96 episodes of CVC-related nosocomial bacteremia per 1000 CVC-days. When compared to the international group of hospitals, the Spanish centre used sterile drapes more frequently for fixing the CVC (70% vs. 23%), each Health Care Worker inserted fewer CVC (average over last 6 months: 24 vs 50) and CVC were more frequently inserted by Registered Nurses (48% vs. 4%). The type of CVC more commonly used in Spain was a peripherically-inserted CVC (48% vs. 6%), and the CVC was withdrawn from patients less commonly before discharge from the ICU (16% vs. 43%). Mean total number of hours of nursing dedication was lower in Spain, with lower personnel ratios (number of nurses' hours) per day of stay (12 vs. 15). CONCLUSIONS: The EPIC study provides a valid tool for assessing the results of the process of health care, and for linking the outcomes to this process. The results registered at the Spanish hospital seem to be adequate, yet some differences in the health care process are identified.

Infecciones relacionadas con el uso de catéteres venosos centrales y sistemas organizativos de las unidades de cuidados intensivos (estudio EPIC) / Central-venous catheter-related infections and intensive care unit organization systems (EPIC Study, Spain)

FUNDAMENTO Y OBJETIVO: La bacteriemia nosocomial relacionada con el empleo de catéteres venosos centrales (CVC) es un problema importante en las unidades de cuidados intensivos (UCI). El papel que desempeñan el sistema organizativo y la experiencia de los profesionales sanitarios en este proceso es poco conocido. El objetivo de este estudio fue identificar posibles relaciones y diferencias entre los procesos asistenciales, la organización de las UCI y el desarrollo de bacteriemia nosocomial relacionada con el uso de CVC y analizar los resultados de un hospital español junto a los registrados en un grupo internacional de hospitales. PACIENTES Y MÉTODO: El estudio EPIC (Evaluation of Processes and Indicators in Infection Control) incluyó hospitales de distintos países. El Hospital Clínic de Barcelona fue el único participante español. Cada centro seleccionó, mediante un muestreo aleatorio, a 5 pacientes por mes, ingresados en una misma UCI, a los que se había colocado recientemente (en un intervalo inferior a 24 h) un CVC. Se obtuvieron datos relativos al proceso de inserción del CVC, su seguimiento y sus cuidados, dedicación del personal de enfermería, número de días de estancia en UCI y episodios de bacteriemia nosocomial por 1.000 días de uso de CVC. RESULTADOS: Se incluyó a un total de 3.298 pacientes portadores de CVC, en los que se registraron 89 episodios de bacteriemia nosocomial (3,86 episodios por 1.000 días de uso de catéter). El Hospital Clinic incluyó a 67 pacientes, en los que se registraron 1,96 episodios de bacteriemia nosocomial por 1.000 días de uso de CVC. El centro español empleaba con más frecuencia gasa estéril y cinta adhesiva para la fijación del CVC que el grupo internacional de 55 hospitales (70 frente al 23 por ciento), cada profesional sanitario español colocaba menos CVC en promedio en los 6 meses precedentes que sus colegas internacionales (24 frente a 50) y los CVC eran colocados en el Hospital Clínic con mayor frecuencia por personal de enfermería (48 frente al 4 por ciento). El tipo de CVC más empleado en el Hospital Clínic era el de inserción periférica (48 frente al 6 por ciento), y era retirado antes del alta del paciente de la UCI en menos ocasiones (16 frente al 43 por ciento). La media de horas totales de dedicación de personal de enfermería era más baja en España, con índices de personal (número de horas de enfermería) por día de estancia del paciente también inferiores a los internacionales (12 frente a 15). CONCLUSIONES: El estudio EPIC proporciona un conjunto de instrumentos válidos para evaluar el proceso asistencial y relacionar este proceso con sus resultados. Los resultados finales observados en el hospital español son adecuados, y se observan diferencias notables en el proceso asistencial (AU)