Acute kidney injury and other factors associated with mortality in hiv-infected patients.

OBJECTIVE: HIV-related mortality is still high, especially in developed countries. The aim of this study is to investigate factors associated to death in HIV-infected patients. METHODS: This is a cross-sectional study with all HIV adult patients admitted to a tertiary infectious diseases hospital in Fortaleza, Northeast Brazil, from January 2013 to December 2014. Patients were divided into two groups: survivors and non-survivors. Demo-graphical, clinical and laboratory data were compared and a logistic regression was performed in order to investigate risk factors for death. P values ≤0.05 were considered statistically significant. RESULTS: A total of 200 patients with mean age of 39 years were including in the study, 69.5% males. Fifteen patients (7.5%) died. Non-survivors presented a higher percentage of males (93.3 vs. 67.3%, p = 0.037). Non-survivors presented AKI (73.3 vs. 10.3%, p < 0.001), liver dysfunction (33.3 vs. 11.5, p = 0.031), dyspnea (73.3 vs. 33.0%, p = 0.002) and disorientation (33.3 vs. 12.4%, p = 0.025) more frequently. Non-survivors also had higher levels of urea (73.8 ± 52.7vs. 36.1 ± 29.1 mg/dL, p < 0.001), creatinine (1.98 ± 1.65 vs. 1.05 ± 1.07 mg/dL, p < 0.001), aspartate aminotransferase (130.8 vs. 84.8 U/L, p = 0.03), alanine aminotransferase (115.6 vs. 85.4 U/L, p = 0.045) and lactate dehydrogenase (LDH) (1208 vs. 608 U/L, p = 0.012), as well as lower levels of bicarbonate (18.0 ± 4.7 vs. 21.6 ± 4.6 mEq/L, p = 0.016) and PCO2 (27.8 ± 7.7 vs. 33.0 ± 9.3 mmHg, p = 0.05). In multivariate analysis, disorientation (p = 0.035, OR = 5.523, 95%CI = 1.130 - 26.998), dyspnoea (p = 0.046, OR = 4.064, 95%CI = 1.028 - 16.073), AKI (p < 0.001, OR = 18.045, 95%CI = 4.308 - 75.596) and disseminated histoplasmosis (p = 0.016, OR = 12.696, 95%CI = 1.618 - 99.646) and LDH > 1000 U/L (p = 0.038, OR = 4.854, 95%CI = 1.093 - 21.739) were risk factors for death.]CONCLUSION: AKI and disseminated histoplasmosis (DH) were the main risk factors for death in the studied population. Neurologic and respiratory impairment as well as higher levels of LDH also increased mortality in HIV-infected patients.

Acute kidney injury and other factors associated with mortality in hiv-infected patients

SUMMARY OBJECTIVE: HIV-related mortality is still high, especially in developed countries. The aim of this study is to investigate factors associated to death in HIV-infected patients. METHODS: This is a cross-sectional study with all HIV adult patients admitted to a tertiary infectious diseases hospital in Fortaleza, Northeast Brazil, from January 2013 to December 2014. Patients were divided into two groups: survivors and non-survivors. Demo-graphical, clinical and laboratory data were compared and a logistic regression was performed in order to investigate risk factors for death. P values ≤0.05 were considered statistically significant. RESULTS: A total of 200 patients with mean age of 39 years were including in the study, 69.5% males. Fifteen patients (7.5%) died. Non-survivors presented a higher percentage of males (93.3 vs. 67.3%, p = 0.037). Non-survivors presented AKI (73.3 vs. 10.3%, p < 0.001), liver dysfunction (33.3 vs. 11.5, p = 0.031), dyspnea (73.3 vs. 33.0%, p = 0.002) and disorientation (33.3 vs. 12.4%, p = 0.025) more frequently. Non-survivors also had higher levels of urea (73.8 ± 52.7vs. 36.1 ± 29.1 mg/dL, p < 0.001), creatinine (1.98 ± 1.65 vs. 1.05 ± 1.07 mg/dL, p < 0.001), aspartate aminotransferase (130.8 vs. 84.8 U/L, p = 0.03), alanine aminotransferase (115.6 vs. 85.4 U/L, p = 0.045) and lactate dehydrogenase (LDH) (1208 vs. 608 U/L, p = 0.012), as well as lower levels of bicarbonate (18.0 ± 4.7 vs. 21.6 ± 4.6 mEq/L, p = 0.016) and PCO2 (27.8 ± 7.7 vs. 33.0 ± 9.3 mmHg, p = 0.05). In multivariate analysis, disorientation (p = 0.035, OR = 5.523, 95%CI = 1.130 - 26.998), dyspnoea (p = 0.046, OR = 4.064, 95%CI = 1.028 - 16.073), AKI (p < 0.001, OR = 18.045, 95%CI = 4.308 - 75.596) and disseminated histoplasmosis (p = 0.016, OR = 12.696, 95%CI = 1.618 - 99.646) and LDH > 1000 U/L (p = 0.038, OR = 4.854, 95%CI = 1.093 - 21.739) were risk factors for death.]CONCLUSION: AKI and disseminated histoplasmosis (DH) were the main risk factors for death in the studied population. Neurologic and respiratory impairment as well as higher levels of LDH also increased mortality in HIV-infected patients.

RESUMO INTRODUÇÃO: A mortalidade relacionada ao HIV ainda é alta, especialmente nos países em desenvolvimento. O objetivo deste estudo é investigar os fatores associados ao óbito em pacientes com HIV. MÉTODOS: Trata-se de um estudo transversal com todos os pacientes com HIV admitidos consecutivamente em um hospital terciário de doenças infecciosas em Fortaleza, Nordeste do Brasil, entre janeiro de 2013 e dezembro de 2014. Os pacientes foram divididos em dois grupos: sobreviventes e não sobreviventes. Dados demográficos, clínicos e laboratoriais foram comparados e análise de regressão logística foi feita para investigação dos fatores de risco para óbito. RESULTADOS: Um total de 200 pacientes, com média de idade de 39 anos, foi incluído no estudo, sendo 69,5% do sexo masculino. Óbito ocorreu em 15 pacientes (7,5%). Os não sobreviventes apresentaram maior percentual de homens (93,3 vs. 67,3%, p = 0,037) e um menor tempo de internação (8 ± 6 vs. 18 ± 15 dias, p = 0,005). Na análise multivariada, desorientação (p = 0,035, OR = 5,523), dispneia (p = 0,046, OR = 4,064), LRA (p < 0,001, OR = 18,045), histoplasmose disseminada (p = 0,016, OR = 12,696) e desidrogenase lática (LDH) > 1.000 U/L (p = 0,038, OR = 4,854) foram fatores de risco para óbito. CONCLUSÕES: LRA e histoplasmose disseminada foram os principais fatores de risco para óbito na população estudada. Distúrbios neurológicos e respiratórios, bem como níveis elevados de LDH, também estiveram associados com o aumento da mortalidade em pacientes com HIV.

Gabapentin dose and the 30-day risk of altered mental status in older adults: A retrospective population-based study.

Gabapentin is an effective treatment for chronic neuropathic pain but may cause dizziness, drowsiness, and confusion in some older adults. The goal of this study was to assess the association between gabapentin dosing and adverse outcomes by obtaining estimates of the 30-day risk of hospitalization with altered mental status and mortality in older adults (mean age 76 years) in Ontario, Canada initiated on high dose (>600 mg/day; n = 34,159) compared to low dose (≤600 mg/day; n = 76,025) oral gabapentin in routine outpatient care. A population-based, retrospective cohort study assessing new gabapentin use between 2002 to 2014 was conducted. The primary outcome was 30-day hospitalization with an urgent head computed tomography (CT) scan in the absence of evidence of stroke (a proxy for altered mental status). The secondary outcome was 30-day all-cause mortality. The baseline characteristics measured in the two dose groups were similar. Initiation of a high versus low dose of gabapentin was associated with a higher risk of hospitalization with head CT scan (1.27% vs. 1.06%, absolute risk difference 0.21%, adjusted relative risk 1.29 [95% CI 1.14 to 1.46], number needed to treat 477) but not a statistically significant higher risk of mortality (1.25% vs. 1.16%, absolute risk difference of 0.09%, adjusted relative risk of 1.01 [95% CI 0.89 to 1.14]). Overall, the risk of being hospitalized with altered mental status after initiating gabapentin remains low, but may be reduced through the judicious use of gabapentin, use of the lowest dose to control pain, and vigilance for early signs of altered mental status.

Functional status and mortality prediction in community-acquired pneumonia.

BACKGROUND AND OBJECTIVE: Poor functional status (FS) has been suggested as a poor prognostic factor in both pneumonia and severe pneumonia in elderly patients. However, it is still unclear whether FS is associated with outcomes and improves survival prediction in community-acquired pneumonia (CAP) in the general population. METHODS: Data on hospitalized patients with CAP and FS, assessed by the Eastern Cooperative Oncology Group (ECOG) scale were prospectively collected between January 2008 and December 2012. The independent association of FS with 30-day mortality in CAP patients was evaluated using multivariable logistic regression. Improvement in mortality prediction when FS was added to the CRB-65 (confusion, respiratory rate, blood pressure and age 65) score was evaluated for discrimination, reclassification and calibration. RESULTS: The 30-day mortality of study participants (n = 1526) was 10%. Mortality significantly increased with higher ECOG score (P for trend <0.001). In multivariable analysis, ECOG ≥3 was strongly associated with 30-day mortality (adjusted OR: 5.70; 95% CI: 3.82-8.50). Adding ECOG ≥3 significantly improved the discriminatory power of CRB-65. Reclassification indices also confirmed the improvement in discrimination ability when FS was combined with the CRB-65, with a categorized net reclassification index (NRI) of 0.561 (0.437-0.686), a continuous NRI of 0.858 (0.696-1.019) and a relative integrated discrimination improvement in the discrimination slope of 139.8 % (110.8-154.6). CONCLUSION: FS predicted 30-day mortality and improved discrimination and reclassification in consecutive CAP patients. Assessment of premorbid FS should be considered in mortality prediction in patients with CAP.

[Characteristics of Patients with Breathlessness]. / Charakteristika von Palliativpatienten mit Atemnot.

Background Breathlessness is a common and distressing symptom in patients with advanced life-limiting disease. The aim of this study was to describe demographical and clinical characteristics of patients with breathlessness in Germany. Methods We conducted a secondary analysis of hospice and palliative care inpatient data from 2006 to 2008. The Hospice and Palliative Care Evaluation (HOPE) is an annual prospective German survey, that includes a validated 16-item symptom-and-problem checklist (severity score 0 - 3). Characteristics of patients with or without breathlessness were compared in a pure descriptive manner. Interpretation of given p-values takes the error inflation due to multiple testing into account. Results Breathlessness was recorded in 2860/5320 (53.8 %) patients (mean age 67.2 years (SD 12.4), 51.4 % female, 93.6 % malignant disease (female/male lung cancer 15.7/29.5 %, breast cancer 20.3/0.3 %, colon 10.3/8.7 %). Breathless patients compared with those without breathless ness had a significantly worse functional status (ECOG 3 - 4: 78.4 % vs. 70.8 %, p < 0.001), suffered from a larger number (11.1 vs. 9.5, p < 0.001) of symptoms and the symptoms were of higher intensity (except confusion). Breathless patients had a higher risk to die during inpatient stay (43.5 % vs. 32.4 %, p < 0.001). Conclusion Based on this large sample of hospice and palliative care inpatients, breathlessness is associated with a high symptom burden and shortened survival. Breathless patients need more attention in health care.

Use of CRB-65 and quick Sepsis-related Organ Failure Assessment to predict site of care and mortality in pneumonia patients in the emergency department: a retrospective study.

BACKGROUND: The quick Sepsis-related Organ Failure Assessment (qSOFA) is a new screening system for sepsis that has prognostic performance equal to the full SOFA for patients with suspected infection outside the intensive care unit (ICU). The predictive value of qSOFA for mortality and site of care in patients with pneumonia is not clear. The present study was designed to investigate the predictive performance of qSOFA, CRB-65 (confusion, respiratory rate ≥30/minute, systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg, age ≥65 years) and CRB (confusion, respiratory rate ≥30/minute, systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg) for mortality, hospitalisation and ICU admission in patients with pneumonia in the emergency department (ED). METHODS: Retrospective analyses of published data on adult patients with pneumonia presenting between January 2012 and May 2014 were undertaken. The prevalence of 28-day mortality, hospitalisation and ICU admission were compared with regard to qSOFA, CRB and CRB-65 scores. The performance of these three systems for predicting outcomes was compared. RESULTS: Of 1641 patients, 861 (53 %) were hospitalised (38 % in a general ward, 15 % in the ICU), and the remaining 780 (47 %) were treated as outpatients or were observed in the ED. Within 28 days, 547 (33 %) of 1641 patients died. CRB-65, CRB and qSOFA scores of patients who died, were hospitalised and admitted to the ICU than those who survived and were not hospitalised or admitted to the ICU (P < 0.001). AUC values of qSOFA for prediction of 28-day mortality, hospitalisation and ICU admission were similar to those for CRB-65 and CRB. Patients with qSOFA scores of 0, 1, 2 and 3 were associated with, respectively, mortality of 16.3 %, 24.4 %, 48.2 % and 68.4 %; prevalence of hospitalisation of 37.2 %, 47.4 %, 61.6 % and 73.7 %; and prevalence of ICU admission of 9.3 %, 9.1 %, 22.4 % and 45.3 %. Patients with qSOFA scores of 2 and 3 had a significantly higher prevalence of mortality and ICU admission than patients with identical CRB-65 scores. CONCLUSIONS: qSOFA is better than CRB-65 for identification of a high risk of mortality and requirement of ICU admission.

The confusion assessment method for the intensive care unit in patients with cirrhosis.

In the intensive care unit (ICU), delirium is routinely measured with the widely-used, validated Confusion Assessment Method for the ICU (CAM-ICU), but CAM-ICU has not been studied in patients with cirrhosis. We studied a group of patients with cirrhosis to determine the relationship between delirium measured by CAM-ICU and clinical outcomes. Consecutive patients with cirrhosis admitted to the ICU from 2009 to 2012 were included in a retrospective cohort study. Patients were screened twice daily for coma and delirium during their ICU stay using the Richmond Agitation Sedation Scale (RASS) and CAM-ICU. The association between delirium/coma and mortality was determined using multiple logistic regression. RASS and CAM-ICU were also compared to a retrospective assessment of hepatic encephalopathy (HE). Of 91 patients with cirrhosis, 26 (28.6 %) developed delirium/coma. RASS/CAM-ICU had fair agreement with the HE assessment (κ 0.38). Patients with delirium/coma had numerically greater mortality in-hospital (23.1 vs. 7.7 %, p = 0.07) and at 90 days (30.8 vs. 18.5 %, p = 0.26), and they also had longer hospital length of stay (median 19.5 vs. 6 days, p < 0.001). Delirium/coma was associated with increased inpatient mortality, independent of disease severity (unadjusted OR 3.6; 95 % CI, 0.99-13.1; MELD-adjusted OR 5.4; 95 % CI, 1.3-23.8; acute physiology score-adjusted OR 2.2; 95 % CI, 0.53-8.9). Delirium/coma was also associated with longer length of stay after adjusting for disease severity. In critically ill patients with cirrhosis, delirium/coma as measured by the RASS and CAM-ICU is associated with increased mortality and hospital length of stay. For these patients, these measures provide valuable information and may be useful tools for clinical care. RASS and CAM-ICU need to be compared to HE-specific measures in future studies.

CURB-65 as an initial prognostic score in Internal Medicine patients.

BACKGROUND: There are few validated tools to assess severity in patients admitted to an Internal Medicine service. The aim of this study was to evaluate if CURB-65 score, previously validated as mortality index in community acquired pneumonia, could also be used in those patients. METHODS: We analyzed prospectively all patients admitted to Hospital Sierrallana (Spain) from 1 March to 31 October 2010. Variables of the CURB-65 score (confusion, serum urea>7mmol/L (42mg/dl), respiratory rate≥30/min, systolic blood pressure<90mmHg and/or diastolic blood pressure≤60mmHg, and age≥65) and other clinical and epidemiological data and laboratory findings were recorded. Charlson comorbidity index was also estimated. Prognostic variables were identified using multiple logistic regression with 30days mortality as the outcome measure. RESULTS: 539 patients were studied (51% males; mean age: 78±14years; mortality 12%). A high CURB-65 score was a significant predictor of 30day mortality (p<0.001). Eighty-six percent of the patients who died had high CURB-65 score at admission, and none of them had low score. Sensitivity and specificity for high CURB-65 score were 86% and 70%, respectively, and negative predictive value was 97%. Receiver-operator characteristic curve showed an area under curve of 0.79 for CURB 65-score. Charlson index also correlated with mortality, but its performance was worse than that of CURB-65. CONCLUSION: Our findings suggest that CURB-65 score may be a simple and useful tool to help clinicians in establishing the prognosis of patients admitted to general Internal Medicine wards.

Confusion, Urea, Respiratory Rate and Shock Index or Adjusted Shock Index (CURSI or CURASI) criteria predict mortality in community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is common and associated with a significant mortality. Shock index, heart rate divided by systolic blood pressure, has been shown to be associated with outcome in sepsis. OBJECTIVE: To examine the usefulness of two new criteria CURSI (confusion, urea, respiratory rate and shock index), and CURASI where shock index is replaced by temperature adjusted shock index in mortality assessment of CAP. METHODS: A prospective study was conducted in Norfolk and Suffolk, UK. We explored the usefulness of CURSI and CURASI which we derived and performed mapping exercise using a different cohort. In this study we compared these new indices with the CURB-65 criteria in correctly predicting mortality in CAP. RESULTS: A total of 190 patients were included (males=53%). The age range was 18-101 years (median=76 years). There were a total of 54 deaths during a six-week follow-up. All died within 30-days. Sixty-five (34%) had severe pneumonia by CURB-65. Using CURSI and CURASI, 71(37%) and 69(36%) had severe pneumonia, respectively. The sensitivity, specificity, positive and negative predictive values in predicting death during six-week follow-up were comparable among three indices examined. The Receiver Operating Characteristic curve values (95%CI) for the criteria were 0.67(0.60-0.75) for CURB-65, 0.67(0.59-0.74) for CURSI and 0.66(0.58-0.74) for CURASI (p>0.05). There were strong agreements between these three indices (Kappa values > or =0.75 for all). Repeating analyses in those who were aged 65years and over (n=135) did not alter the results. CONCLUSIONS: Both CURSI and CURASI are similarly useful to CURB-65 in predicting deaths associated with CAP including older patients.

Symptoms experienced by intensive care unit patients at high risk of dying.

OBJECTIVE: To provide a focused, detailed assessment of the symptom experiences of intensive care unit patients at high risk of dying and to evaluate the relationship between delirium and patients' symptom reports. DESIGN: Prospective, observational study of patients' symptoms. SETTING: Two intensive care units in a tertiary medical center in the western United States. PATIENTS: One hundred seventy-one intensive care unit patients at high risk of dying. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were interviewed every other day for up to 14 days. Patients rated the presence, intensity (1 = mild; 2 = moderate; 3 = severe), and distress (1 = not very distressing; 2 = moderately distressing; 3 = very distressing) of ten symptoms (that is, pain, tired, short of breath, restless, anxious, sad, hungry, scared, thirsty, confused). The Confusion Assessment Method-Intensive Care Unit was used to ascertain the presence of delirium. A total of 405 symptom assessments were completed by 171 patients. Patients' average age was 58 ± 15 yrs; 64% were males. Patients were mechanically ventilated during 34% of the 405 assessments, and 22% died in the hospital. Symptom prevalence ranged from 75% (tired) to 27% (confused). Thirst was moderately intense, and shortness of breath, scared, confusion, and pain were moderately distressful. Delirium was found in 34.2% of the 152 patients who could be evaluated. Delirious patients were more acutely ill and received significantly higher doses of opioids. Delirious patients were significantly more likely to report feeling confused (43% vs. 22%, p = .004) and sad (46% vs. 31%, p = .04) and less likely to report being tired (57% vs. 77%, p = .006) than nondelirious patients. CONCLUSIONS: Study findings suggest that unrelieved and distressing symptoms are present for the majority of intensive care unit patients, including those with delirium. Symptom assessment in high-risk intensive care unit patients may lead to more focused interventions to avoid or minimize unnecessary suffering.

Identifying risk factors for an abnormal computed tomographic scan of the head among patients with altered mental status in the Emergency Department.

AIMS: The aims of our study are to evaluate the use of computed tomographic scan of the head (CT-head) in patients with altered mental status (AMS) presenting to the Emergency Department (ED) and to identify clinical features associated with an abnormal CT-head result. METHODS: In this prospective observational study, we recruited consecutive adult patients with undifferentiated AMS and no major trauma at a busy urban ED over 11 months. Demographical, clinical, radiological and laboratory data were collected prospectively. The primary outcome measure was an abnormal CT-head result. Secondary outcome measures were the distribution of aetiologies of AMS with age, mortality rate and length of hospital stay. Logistic regression was applied to identify variables associated with an abnormal CT-head result. RESULTS: Nine hundred and sixty-seven patients were recruited. The rate of CT-head use in the ED was 41%, with 45% of the scans being abnormal. We identified eight clinical factors associated with an abnormal CT-head result. Odds ratios (95% confidence intervals) for diastolic blood pressure greater than 80 mmHg, focal weakness, Glasgow Coma Score less than 15, antiplatelet use, upgoing plantar response, presence of headache, anticoagulant use and dilated pupils were 1.016 (1.003-1.029), 1.816 (1.063-3.103), 1.899 (1.113-3.242), 2.203 (1.146-4.234), 2.680 (1.623-4.427), 3.369 (1.449-7.830), 3.589 (1.253-10.283) and 5.212 (1.153-23.558), respectively. CONCLUSION: Our study identified important risk factors for an abnormal CT-head result which can be used in future research to establish a guideline for rational ordering of the test in AMS patients.

Confusion, a rather serious adverse drug reaction with valproic acid: a review of the French Pharmacovigilance database.

INTRODUCTION: Confusion is an adverse drug reaction frequently observed with valproic acid. Some case reports are published in the literature but no systematic study from a sample of patients has been published. We performed this study in order to describe the main characteristics of this adverse drug reaction. METHODS: Using the French Pharmacovigilance database, we selected the cases of confusion reported since 1985 with valproic acid. RESULTS: 272 cases of confusion were reported with valproic acid: 153 women and 119 men. Confusion mostly occurred during the two first weeks following valproic acid exposure (39.7%). It was "serious" for almost 2/3 of the patients (62.5%) and its outcome favourable in most of the cases (82%). The occurrence of this ADR was more frequent in patients aged between 61 and 80 years. CONCLUSION: This work shows that confusion with valproic acid is a serious, rather frequent but reversible adverse drug reaction. It occurs especially in older patients and during the first two weeks of treatment.

[Delirium and intensive care unit syndrome]. / Delir und Durchgangssyndrom.

Delirium and intensive care unit (ICU) syndrome are frequently seen postoperatively, especially in intensive care. Hospital mortality and complication rates are higher in patients with these disorders. Delirium is characterized by disturbance of consciousness and cognition and short development time. Drugs, drug withdrawal, and manifold metabolic syndromes may be causative. Knowledge of differential diagnosis and causality is essential for curative therapy. Drug therapy is recommended for the treatment of psychotic symptoms and vegetative disorders.

Behaviors and outcomes of acute confusion in hospitalized patients.

The purpose of this study was to describe behaviors associated with acute confusion (AC) in hospitalized patients and to determine whether acutely confused patients experience more adverse outcomes compared with their nonconfused counterparts. Using a prospective design, 117 subjects were followed throughout hospital stay. Subjects who developed AC were more likely to fall, be incontinent, have a urinary catheter, and experience functional decline. Mortality was higher in subjects with AC. Contrary to popular belief, acutely confused patients exhibited decreased psychomotor activity. Nurses can be trained to recognize AC using a standardized protocol to improve outcomes for this vulnerable population.