Serum Ferritin as a Predictor of Outcomes in Hospitalized Patients with Covid-19 Pneumonia.

Purpose: Elevated ferritin levels are associated with poor outcomes in Covid-19 patients. Optimal timing of ferritin assessment and the merit of longitudinal values remains unclear. Methods: Patients admitted to Henry Ford Hospital with confirmed SARS-CoV-2 were studied. Regression models were used to determine the relation between ferritin and mortality, need for mechanical ventilation, ICU admission, and days on the ventilator. Results: 2265 patients were evaluated. Patients with an initial ferritin of > 490 ng/mL had an increased risk of death (OR 3.4, P < .001), admission to the ICU (OR 2.78, P < .001) and need for mechanical ventilation (OR 3.9, P < .001). There was no difference between admission and Day 1 ICU ferritin levels (611.5 ng/mL vs. 649 ng/mL respectively; P = .07). The decline in ferritin over ICU days 1-4 was similar between survivors and non-survivors. A change in ferritin levels from admission to ICU Day 1 (P = .330), or from ICU Day 1 to 2 (P = .788), did not predict days on the ventilator. Conclusions: Initial Ferritin levels were highly predictive of ICU admission, the need for mechanical ventilation and in-hospital mortality. However, longitudinal measures of ferritin throughout the hospital stay did not provide additional predictive value.

Racial Differences in a Detroit, MI, ICU Population of Coronavirus Disease 2019 Patients.

OBJECTIVES: To investigate the potential influence of racial differences in outcomes of patients infected by coronavirus disease 2019-positive patients who require intensive care in an urban hospital. DESIGN: Retrospective cohort study. SETTING: Henry Ford Health System Multidisciplinary ICU, a total of 156 beds spread throughout the hospital in Detroit, MI. PATIENTS: We obtained data from the electronic medical record of all adult severe acute respiratory syndrome coronavirus-2-positive patients managed in the ICU of Henry Ford Hospital in Detroit, MI, between March 13, 2020, and July 31, 2020. Included patients were divided into two groups: people of color (including Black, Asian, Hispanic/Latino, and Arab) and White. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 365 patients were evaluated: 219 were Black (60.0%), 129 were White (35.3%), two were Asian (0.6%), eight were Hispanic/Latino (2.2%), and seven were Arab (1.9%). People of color were younger (62.8 vs 67.1; p = 0.007), with equal distribution of sex. People of color had less coronary artery disease (34 [14.4%] vs 35 [27.1%]; p =0.003) and less self-reported use of regular alcohol consumption (50 [21.2%] vs 12 [9.3%]; p = 0.004) than Whites, with no differences in diabetes (125 [53.0%] vs 66 [51.2%]; p = 0.742), hypertension (188 [79.7%] vs 99 [76.8%]; p = 0.516), congestive heart failure (41 [17.4%] vs 32 [24.8%]; p = 0.090), or chronic kidney disease (123 [54.1%] vs 55 [42.6%]; p = 0.083).There was no difference in ICU length of stay between people of color (18 d [CI, 7-47 d]) and Whites (18 d [CI, 6-48 d]; p = 0. 0.979). Neither frequency (72.5% vs 71.3%; p = ns) nor median time to mechanical ventilation between people of color (9 d [CI, 6-15 d]) and Whites (10 d [CI, 5-16 d]; p = 0.733) was different. Overall, 188 patients (51.5 %) died in the hospital. The 28-day mortality was lower in people of color (107/236; 45.3%) versus Whites (73/129; 56.6%) (adjusted odds ratio 0.60; p = 0.034), and there was an increased median survival time in people of color (20 d) versus Whites (13.5 d; hazard ratio 0.62; p = 0.002). The inhospital mortality was lower in people of color versus White, but the difference was not statistically significant (113 [47.9%] vs 75 [58.1%], respectively; p = 0.061). Finally, there was no significant difference in days of symptoms prior to admission, frequency of presenting symptoms, or frequency or severity of acute respiratory distress syndrome between the two groups. CONCLUSIONS: In critically ill patients infected with coronavirus disease 2019, people of color had a lower 28-day mortality than Whites with no difference in hospital mortality, ICU length of stay, or rates of intubation. These findings are contrary to previously held beliefs surrounding the pandemic.

Outcomes in Medical Intensive Care Patients Housed in Geographically Distant Units.

OBJECTIVE: The purpose of this study is to determine whether in patients admitted to a medical intensive care unit (ICU) service there are outcome differences between those in a medical ICU bed ("home") and a geographically distant subspecialty ICU bed ("overflow"). METHODS: We performed a retrospective cohort study of 4091 patients admitted to a medical ICU of a large tertiary-care urban teaching hospital. Depending on bed availability, some patients were housed in surgical or cardiac subspecialty ICUs while still being cared for by the primary medical ICU service. We assessed the association of these overflow patients with readmission rates and ICU and hospital length of stay (LOS). Potential differences in care was assessed by measuring the number of central line days, urinary catheter days, and ventilator days. RESULTS: Of the 4091 consecutive patients admitted to the medical ICU, 362 (9%) were housed in an overflow ICU and 3729 (91%) were home patients. There was no difference in demographics, patient characteristics, ICU admission diagnosis, or risk of mortality between the 2 groups. Compared to home patients, overflow patients had a higher rate of readmission to the ICU (10.5% vs 6.63% respectively P = .006), a slightly shorter ICU LOS (median 2 [interquartile range, IQR: 1-4] days versus home group of 2 [IQR: 1-5] days; P = .001), and a slightly longer hospital LOS (overflow 7 [IQR: 4-17] days vs home 7 [IQR: 4-13] days, P = .001). There was no differences in number of central venous catheter days, urinary catheter days, ventilator days, or mortality. CONCLUSIONS: Medical ICU patients who are housed in ICUs geographically distant from the primary team's location have increased morbidity when compared to patients admitted to the home ICU. However, there are no differences in number of central venous catheter days, urinary catheter days, ventilator days, or mortality.

Anaerobic antibiotic usage for pneumonia in the medical intensive care unit.

BACKGROUND AND OBJECTIVE: Pneumonia is a common admitting diagnosis in the intensive care unit (ICU). When aspiration is suspected, antibiotics to cover anaerobes are frequently used, but in the absence of clear risk factors, current guidelines have questioned their role. It is unknown how frequently these guidelines are followed. METHODS: We conducted a single-centre observational study on practice patterns of anaerobic antibiotic use in consecutive patients admitted to the ICU with aspiration pneumonia (Asp), community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP). RESULTS: A total of 192 patients were studied (Asp: 20, HCAP: 107, CAP: 65). Overall, 59 patients received anaerobic antibiotics (Asp: 90%, HCAP: 28%, CAP 17%) but a significant proportion of these patients did not meet criteria to receive them. Inappropriate anaerobic antibiotic use was 12/20 for Asp, 27/107 for HCAP and 9/65 for CAP. Mortality probability model III at zero hours (MPM0) score and a diagnosis of Asp were predictors of receiving inappropriate anaerobic antibiotics. Receiving inappropriate anaerobic antibiotics was associated with a longer ICU length of stay (LOS; 7 days (interquartile range (IQR): 7-21) vs 4 days (IQR:2-9), P = 0.017). CONCLUSION: For patients in the ICU admitted with pneumonia, there is a high occurrence of inappropriately prescribed anaerobic antibiotics, the use of which was associated with a longer ICU LOS.

The association between depressive symptoms and acute exacerbations of COPD.

BACKGROUND: Depression is an important comorbidity for patients with chronic obstructive pulmonary disease (COPD). The association between depression and acute exacerbations of COPD is unknown. This study was designed to determine the frequency of COPD exacerbations in outpatients with and without depressive symptoms. METHODS: In this retrospective cohort study, patients with a primary diagnosis of COPD were followed for 1 year after discharge from a pulmonary rehabilitation program and the frequency of exacerbations was recorded. Upon completion of the program, all patients were administered the Short-Form 36 Health Survey (SF-36), which contains a mental health domain. Patients were classified as having depressive symptoms based on their domain score, which was separately validated in a second population of patients. RESULTS: Of the 194 patients with COPD who completed the pulmonary rehabilitation program, 32 (16.5%) had depressive symptoms. There were no differences in terms of age, race, pack-years, forced expiratory volume in 1 second (FEV(1)), 6-minute walk distance, body mass index, use of supplemental oxygen, use of inhaled steroids, or the Charlson Comorbidity Index between patients with and without depressive symptoms. Patients with depressive symptoms had more exacerbations in the following year (1.91 vs. 1.36; p = 0.02), were 2.8 times more likely to have ever had an exacerbation (95% confidence interval (CI), 1.1-7.3; p = 0.03), and suffered a first exacerbation earlier (148 days compared with 266 days; p = 0.04) than nondepressed patients. CONCLUSIONS: COPD patients with depressive symptoms have a significantly higher risk for exacerbations. Early screening for depression in patients with COPD may help identify those patients at higher risk for subsequent exacerbations.

Low Rate of Adverse Events Associated With Inpatient Parenteral Prostacyclins.

Parenteral prostacyclin is the most-effective therapy for patients with pulmonary arterial hypertension. Administration is complex, and administration errors are potentially life threatening. Hospital policies to minimize the risk to patients are necessary, but their effectiveness has not been well studied. We quantified the adverse event incident rate per at-risk patient day in a tertiary care hospital with an established parenteral prostacyclin policy. Patients on parenteral prostacyclin including new initiations from January 2003 to January 2013 were identified, encompassing 386 discrete admissions. Reports of adverse events were obtained from the inpatient risk feedback-reporting process and detailed chart review. Policy-divergent events were analyzed both categorically and by the degree of severity. Overall, 153 total policy-divergent events were identified. Data analysis indicated an incident rate of 45.9 per 1,000 patient days. In total, 21 of 153 potential errors reached the patient, translating to an incident rate of 6.3 per 1,000 patient days. Incident rate for "serious symptomatic" or "catastrophic" policy-divergent events was 3.3 per 1,000 patient days. Even with specific prostacyclin training and administration policy, there remains a small risk of adverse events in hospitalized pulmonary hypertension patients receiving parenteral prostacyclin.

Removal of Self-Expanding Metallic Stents.

BACKGROUND: Despite their safety profile, self-expanding metallic stents (SEMS) have been difficult to remove. We aim to describe our experience in removal of SEMS at Henry Ford Hospital with a specific emphasis on safety. METHODS: We reviewed the charts of all patients who underwent removal of a SEMS at Henry Ford Hospital between 2003 and 2013. We recorded demographic information, indication for initial stent placement, indication for stent removal, time to stent removal, procedure of removal, and any complications. RESULTS: In all, 19 stents were removed in 16 separate procedures in 14 patients. The median age was 62 years, and 50% of the patients were female. Stents were removed at a median of 35 days (range, 2 to 595 d). No complications occurred in 10/16 (62.5%) procedures. In the remaining 5 patients, complications were not directly related to the stent removal, and serious complications were mostly related to severity of underlying lung disease. Of the 10 procedures done as outpatients, 70% were discharged immediately after the procedure. CONCLUSIONS: Removal of SEMS can be done safely. Routine postoperative ventilation and intensive care unit monitoring is not required. In the absence of severe underlying lung disease, patients can safely be discharged if there are no immediate postprocedure complications.

Predischarge bundle for patients with acute exacerbations of COPD to reduce readmissions and ED visits: a randomized controlled trial.

BACKGROUND: Hospital readmissions for acute exacerbations of COPD (AECOPDs) pose burdens to the health-care system and patients. A current gap in knowledge is whether a predischarge screening and educational tool administered to patients with COPD reduces readmissions and ED visits. METHODS: A single-center, randomized trial of admitted patients with AECOPDs was conducted at Henry Ford Hospital between February 2010 and April 2013. One hundred seventy-two patients were randomized to either the control (standard care) or the bundle group in which patients received smoking cessation counseling, screening for gastroesophageal reflux disease and depression or anxiety, standardized inhaler education, and a 48-h postdischarge telephone call. The primary end point was the difference in the composite risk of hospitalizations or ED visits for AECOPD between the two groups in the 30 days following discharge. A secondary end point was 90-day readmission rate. RESULTS: Of the 172 patients, 18 of 79 in the control group (22.78%) and 18 of 93 in the bundle group (19.35%) were readmitted within 30 days. The risk of ED visits or hospitalizations within 30 days was not different between the groups (risk difference, -3.43%; 95% CI, -15.68% to 8.82%; P = .58). Overall, the time to readmission in 30 and 90 days was similar between groups (log-rank test P = .71 and .88, respectively). CONCLUSIONS: A predischarge bundle intervention in AECOPD is not sufficient to reduce the 30-day risk of hospitalizations or ED visits. More resources may be needed to generate a measurable effect on readmission rates. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02135744; URL: www.clinicaltrials.gov.

Dedicated multidisciplinary ventilator bundle team and compliance with sedation vacation.

BACKGROUND: How compliance with a ventilator bundle is monitored varies from institution to institution. Some institutions rely on the primary intensive care unit team to review the bundle during their rounds; others rely on a separate team of health care personnel that may include representatives from disciplines such as nursing, respiratory therapy, and pharmacy. OBJECTIVES: To compare rates of compliance with ventilator bundle components between a dedicated ventilator bundle rounding team and the primary intensive care unit rounding team in a 68-bed medical intensive care unit. METHODS: A query of the medical intensive care unit's database was used to retrospectively determine rates of compliance with specific ventilator bundle components at a tertiary care hospital in an urban community for 1 year. RESULTS: Compared with the intensive care unit rounding team, the ventilator bundle rounding team had better compliance with sedation vacation (61.7% vs 54.0%, P < .001). Rates of compliance with spontaneous breathing trials and prophylaxis of peptic ulcer disease were similar in both study groups. CONCLUSIONS: A dedicated ventilator bundle rounding team improves compliance with sedation vacation, but not with spontaneous breathing trials and prophylaxis of peptic ulcer disease. In a large-volume tertiary center, a dedicated ventilator bundle rounding team may be more effective than the primary rounding team in achieving compliance with some bundle components.

A welder with pneumosiderosis: a case report.

Pneumosiderosis or Welder's lung is an occupational lung disease which is usually seen after chronic exposure to iron dust. We present a case of a 64-year-old welder in whom the diagnosis of pneumosiderosis was made by lung biopsies. We also briefly review the literature regarding the disease, its prognosis and association with development of lung cancer. Avoidance of iron dust exposure and implementing prevention strategies in people at risk are the mainstay of therapy.

Monocytes recruited to the lungs of mice during immune inflammation ingest apoptotic cells poorly.

Apoptotic cells must be cleared to resolve inflammation, but few resident alveolar macrophages (AMo) from normal lungs ingest apoptotic cells. We examined how Mo ingestion of apoptotic cells is altered during immune inflammation induced by intratracheal challenge of primed C57BL/6 mice using sheep red blood cells. Resident AMo were labeled in situ before challenge using intravenous PKH26 to distinguish them from recruited monocytes. Using flow cytometry, we identified phagocytosis of fluorescently-labeled apoptotic thymocytes by alveolar mononuclear phagocytes in vitro and in vivo, and measured surface molecule expression. Intratracheal challenge induced rapid recruitment of monocytes, peaking at Day 3 and decreasing thereafter, whereas numbers of resident AMo did not change significantly. At all times, the percentage of phagocytes ingesting apoptotic thymocytes in vitro was greater among resident AMo (28-45%) than among recruited monocytes (9-19%), but was low in both cell types relative to ingestion of immunoglobulin-opsonized targets. There was also a nonsignificant trend toward lower ingestion by monocytes in vivo. MerTK, a receptor tyrosine kinase crucial for apoptotic cell phagocytosis, was expressed by resident AMo, but not by recruited monocytes. Relative to resident AMo, monocytes recruited to the alveolus ingest apoptotic cells meagerly, possibly due to absence of MerTK expression.

Resident murine alveolar and peritoneal macrophages differ in adhesion of apoptotic thymocytes.

Apoptotic cells must be cleared efficiently by macrophages (Mø) to prevent autoimmunity, yet their ingestion impairs Mø microbicidal function. The principal murine resident lung phagocyte, the alveolar Mø (AMø), is specifically deficient at apoptotic cell ingestion, both in vitro and in vivo, compared with resident peritoneal Mø (PMø). To further characterize this deficiency, we assayed static adhesion in vitro using apoptotic thymocytes and resident AMø and PMø from normal C57BL/6 mice. Adhesion of apoptotic thymocytes by both types of Mø was rapid, specific, and cold-sensitive. Antibody against the receptor tyrosine kinase MerTK (Tyro12) blocked phagocytosis but not adhesion in both types of Mø. Surfactant protein A increased adhesion and phagocytosis by AMø, but not to the levels seen using PMø. Adhesion was largely cation-independent for PMø and calcium-dependent for AMø. Adhesion was not inhibited in either Mø type by mAbs against beta1 or beta3 integrins or scavenger receptor I/II (CD204), but AMø adhesion was inhibited by specific mAbs against CD11c/CD18. Thus, resident murine tissue Mø from different tissues depend on qualitatively disparate receptor systems to bind apoptotic cells. The decreased capacity of murine AMø to ingest apoptotic cells is only partially explained by reduced initial adhesion.