Association between ICU admission during morning rounds and mortality.

BACKGROUND: No previous study has evaluated the association between admission to ICUs during round time and patient outcome. The objective of this study was to determine the association between round-time ICU admission and patient outcome. METHODS: This retrospective study included 49,844 patients admitted from October 1994 to December 2007 to four ICUs (two surgical, one medical, and one multispecialty) of an academic medical center. Of these patients, 3,580 were admitted to the ICU during round time (8:00 am to 10:59 am) and 46,264 were admitted during nonround time (from 1:00 pm to 6:00 am). The medical ICU had 24-h/7-day per week intensivist coverage during the last 2 years of the study. We compared the baseline characteristics and outcome of patients admitted to the ICU between the two groups. Data were abstracted from the acute physiology and chronic health evaluation (APACHE) III database. RESULTS: The round-time and non-round-groups were similar in gender, ethnicity, and age. The predicted hospital mortality rate of the round time group was higher (17.4% vs 12.3% predicted, respectively; p < 0.001). The hospital length of stay was similar between the two groups. The round-time group had a higher hospital mortality rate (16.2% vs 8.8%, respectively; p < 0.001). Most of the round-time ICU admissions and deaths occurred in the medical ICU. Round-time admission was an independent risk factor for hospital death (odds ratio, 1.321; 95% CI, 1.178 to 1.481). This independent association was present for the whole study period except for the last 2 years. CONCLUSIONS: Patients admitted to the ICU during morning rounds have higher severity of illness and mortality rates.

The hospital mortality of patients admitted to the ICU on weekends.

STUDY OBJECTIVES: Previous studies have suggested that patients are more likely to die in the hospital if they are admitted on a weekend than on a weekday. This study was conducted to determine whether weekend admission to the ICU increases the risk of dying in the hospital. DESIGN: Retrospective cohort study. SETTING: ICU of a single tertiary care medical center. PATIENTS: A total of 29,084 patients admitted to medical, surgical, and multispecialty ICUs from October 1994 through September 2002. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The weekend ICU admissions comprised 27.9% of all ICU admissions (8,108 ICU admissions). The overall hospital mortality rate was 8.2% (2,385 deaths). Weekend ICU admission was associated with a higher unadjusted hospital mortality rate than that for weekday ICU admission (11.3% vs 7.0%, respectively; odds ratio [OR], 1.70; 95% confidence interval [CI], 1.55 to 1.85). In multivariable analyses controlling for the factors associated with mortality such as APACHE (acute physiology and chronic health evaluation) III predicted mortality rate, ICU admission source, and intensity of treatment, no statistically significant difference in hospital mortality was found between weekend and weekday admissions in the overall study population (OR, 1.06; 95% CI, 0.95 to 1.17). For weekend ICU admissions, the observed hospital mortality rates of the medical, multispecialty, and surgical ICUs were 15.2%, 17.2%, and 6.4%, respectively, and for weekday ICU admissions the rates were 16.3%, 10.1%, and 3.5%, respectively. Subgroup analyses showed that weekend ICU admission was associated with higher adjusted hospital mortality rates than was weekday ICU admission in the surgical ICU (OR, 1.23; 95% CI, 1.03 to 1.48), but not in the medical or multispecialty ICUs. CONCLUSIONS: The overall adjusted hospital mortality rate of patients admitted to the ICU on a weekend was not higher than that of patients admitted on a weekday. However, weekend ICU admission to the surgical ICU was associated with an increased hospital mortality rate.

Hospital mortality rate and length of stay in patients admitted at night to the intensive care unit.

OBJECTIVE: Although admission of patients to a medical ward after 5:00 pm has been associated with increased mortality rate and possibly shorter hospital stay, the association between timing of admission to the intensive care unit and outcome has not been studied. The objective of this study was to determine whether there are any associations between the timing of patient admission to a medical intensive care unit and hospital outcome. DESIGN: A retrospective cohort study that used an Acute Physiology and Chronic Health Evaluation III database containing prospectively collected demographic, clinical, and outcome information for patients. Patients were divided according to the time of admission into daytime (from 7:00 am to 5:00 pm) and nighttime admissions. We further subdivided nighttime admissions into two groups (regular and heavy workload) according to the number of patients who were admitted during the same shift. SETTING: Medical intensive care unit (a 15-bed unit in an academic referral hospital). PATIENTS: 6,034 patients consecutively admitted to our medical intensive care unit over a 5-yr period starting April 10, 1995. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The patients admitted at night had a lower mortality rate (13.9 vs. 17.2%, p < .0001), adjusted for admission source and severity of illness. Their hospital stay was shorter, 11.0 days +/- 13.5 (median 7) vs. 12.7 +/- 14.8 (median 8; p < .0001), as was their intensive care unit stay, 3.5 +/- 4.4 days (median 2) vs. 3.9 +/- 4.7 (median 2; p < .0001), compared with the daytime admission group. The nighttime shifts that admitted three or more patients (heavy workload) had the same mortality rate (13.2%) as those with fewer admissions (14.5%; p = .5961). Hospital and intensive care unit stays were also similar in both workload groups. CONCLUSIONS: Nighttime admission to our intensive care unit is not associated with a higher mortality rate or a longer hospital or intensive care unit stay compared with daytime admission.

Characterization of a lanosterol 14 alpha-demethylase from Pneumocystis carinii.

Pneumocystis carinii (PC) causes severe pneumonia in immunocompromised patients. PC is intrinsically resistant to treatment with azole antifungal medications. The enzyme lanosterol 14 alpha-demethylase (Erg11) is the target for azole antifungals. We cloned PCERG11 and compared its sequence to Erg11 proteins present in azole-resistant organisms, and performed chromosomal and Northern blot analysis for PCERG11. Of 13 potential sites which could confer resistance to azoles, two were identical to azole-resistant Candida. By site-directed mutagenesis we changed these two sites in PCERG11 to those present in azole-sensitive Candida to generate PCERG11-SDM (E113D, T125K). We tested the susceptibility of ERG11 deletion strains of Saccharomyces cerevisiae (SC) expressing PCERG11, PCERG11-SDM, and wild-type SCERG11 to three azole antifungals: fluconazole, itraconazole, and voriconazole. PCERG11 required a 2.2-fold higher dose of voriconazole and 3.5-fold higher dose of fluconazole than SCERG11 for a 50% reduction in growth. No difference was observed in the sensitivity to itraconazole. PCERG11-SDM has increased sensitivity to fluconazole and voriconazole, but not itraconazole. We believe that the molecular structure of the lanosterol 14 alpha-demethylase encoded by PCERG11 confers inherent resistance to azole antifungals and plays an integral part in the overall resistance of this PC to azole therapy.

Pulmonary cytolytic thrombi: unusual complication of hematopoietic stem cell transplantation.

Pulmonary complications of hematopoietic stem cell transplantation (HSCT), including peripheral blood stem cell transplantation (PBSCT) and bone marrow transplantation, are frequent and often life-threatening. Differentiating acute infectious from noninfectious pulmonary complications is difficult but critical for proper treatment. The authors describe an 11-year-old boy who developed a sudden fever and cough associated with a normal chest radiograph 2 months after successful haploidentical PBSCT for severe aplastic anemia. High-resolution chest computed tomography revealed numerous tiny peripheral pulmonary nodules. Lung biopsy demonstrated an unusual occlusive thrombotic vascular lesion associated with hemorrhagic infarction without evidence of infection. The thrombi were composed of intensely basophilic granular material recently described as "cytolytic" thrombi. Symptoms and chest computed tomography improved rapidly following intravenous corticosteroids and cyclosporin. However, the patient subsequently died of rapidly progressive pulmonary hypertension. Our patient illustrates the importance of considering this noninfectious complication in the acute pulmonary disorders associated with HSCT as this condition may represent a pulmonary manifestation of acute graft-versus-host disease.

Prognostic factors, clinical course, and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure.

OBJECTIVE: To describe prognostic factors, clinical course, and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure. DESIGN: Analysis of prospectively collected data. SETTING: A multidisciplinary intensive care unit of an inner-city university hospital. PATIENTS: Patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure from August 1995 through July 1998. MEASUREMENTS AND MAIN RESULTS: Data were obtained concerning demographics, arterial blood gas, Acute Physiology and Chronic Health Evaluation (APACHE) II score, sepsis, mechanical ventilation, organ failure, complications, and hospital mortality rate. Fifty-nine percent of patients were male, 63% white, and 36% African-American; the mean age was 63.1 +/- 8.9 yrs. Noninvasive mechanical ventilation was tried in 40% of patients and was successful in 54% of them. Invasive mechanical ventilation was required in 61% of the 250 admissions. Sepsis developed in 31% of patients, nonpulmonary organ failure in 20%, pneumothorax in 3%, and acute respiratory distress syndrome in 2%. Multiple organ failure developed in 31% of patients with sepsis compared with 3% without sepsis (p <.0001). Predicted and observed hospital mortality rates were 30% and 15%, respectively. Differences in age and arterial carbon dioxide and oxygen tensions between survivors and nonsurvivors were not significant. Arterial pH was lower in nonsurvivors than in survivors (7.21 vs. 7.25, p =.0408). The APACHE II-predicted mortality rate (p =.0001; odds ratio, 1.046; 95% confidence interval, 1.022-1.070) and number of organ failures (p <.0001; odds ratio, 5.524; 95% confidence interval, 3.041-10.031) were independent predictors of hospital outcome; invasive mechanical ventilation was not an independent predictor. CONCLUSIONS: Physiologic abnormalities at admission to an intensive care unit and development of nonrespiratory organ failure are important predictors of hospital outcome for critically ill patients with chronic obstructive pulmonary disease who have acute respiratory failure. Improved outcome would require prevention and appropriate treatment of sepsis and multiple organ failure.

Respiratory complications of poliomyelitis and multiple sclerosis.

Years after suffering from poliomyelitis and completely recuperating from any of its acute complications, patients can develop postpolio syndrome (PPS), thought to be caused by progressive neuronal loss. The symptoms and manifestations of PPS vary in intensity and distribution, but many patients have respiratory involvement and will require a pulmonary evaluation for new or increased dyspnea, fatigue, or symptoms suggestive of sleep-related disordered breathing. The diagnosis, evaluation, and management of this complex problem are discussed in the first part of this article. In the second part, pulmonary complications of multiple sclerosis are described. This common neurological disease affects young adults and often requires evaluation by a pulmonologist. This review centers on the acute respiratory manifestations of multiple sclerosis and also describes the chronic effects.