Temporal Trends in Mortality of Critically Ill Patients with Sepsis in the United Kingdom, 1988-2019.

Rationale: Sepsis is a frequent cause of ICU admission and mortality. Objectives: To evaluate temporal trends in the presentation and outcomes of patients admitted to the ICU with sepsis and to assess the contribution of changing case mix to outcomes. Methods: We conducted a retrospective cohort study of patients admitted to 261 ICUs in the United Kingdom during 1988-1990 and 1996-2019 with nonsurgical sepsis. Measurements and Main Results: A total of 426,812 patients met study inclusion criteria. The patients had a median (interquartile range) age of 66 (53-75) years, and 55.6% were male. The most common sites of infection were respiratory (60.9%), genitourinary (11.5%), and gastrointestinal (10.3%). Compared with patients in 1988-1990, patients in 2017-2019 were older (median age, 66 vs. 63 yr), were less acutely ill (median Acute Physiology and Chronic Health Evaluation II acute physiology score, 14 vs. 20), and more often had genitourinary sepsis (13.4% vs. 2.0%). Hospital mortality decreased from 54.6% (95% confidence interval [CI], 51.0-58.1%) in 1988-1990 to 32.4% (95% CI, 32.1-32.7%) in 2017-2019, with an adjusted odds ratio of 0.64 (95% CI, 0.54-0.75). The adjusted absolute hospital mortality reduction from 1988-1990 to 2017-2019 was 8.8% (95% CI, 5.6-12.1). Thus, of the observed 22.2-percentage point reduction in hospital mortality, 13.4 percentage points (60% of total reduction) were explained by case mix changes, whereas 8.8 percentage points (40% of total reduction) were not explained by measured factors and may be a result of improvements in ICU management. Conclusions: Over a 30-year period, mortality for ICU admissions with sepsis decreased substantially. Although changes in case mix accounted for the majority of observed mortality reduction, there was an 8.8-percentage point reduction in mortality not explained by case mix.

Development of a brief core set for knee dysfunction based on the International Classification of Functioning, Disability and Health: assessing construct validity and measurement potential.

BACKGROUND: The comprehensive core set for knee dysfunction was developed to classify the functioning of people with any knee dysfunction. To be used as a clinical instrument to measure the functioning of people with knee dysfunction, the construct validity of the core set still needs to be assessed. The purpose of this study was to analyze the construct validity of the comprehensive core set for knee dysfunction as an instrument to measure functioning. METHODS: A cross-sectional study with 200 participants with knee dysfunction with or without clinical diagnosis of knee pathology, with or without complaint of pain, with or without instability, and/or with or without knee movement restriction of any type. Participants were assessed using the comprehensive core set for knee dysfunction with 25 categories, the subjective form from the International Knee Documentation Committee scale, and measures of self-perceived general health and functioning. The construct validity of the core set was assessed by Rasch analysis, and the external construct validity was assessed by correlation between the score of the brief core set for knee dysfunction with the subjective form from the International Knee Documentation Committee scale, and scores of self-perception of health and functioning. RESULTS: Twelve categories were consistent with a unidimensional construct, with no difference in the response pattern for age, sex, educational level, and time of complaint. These categories were included in the brief core set for knee dysfunction. The mean score of the brief core set was 37 ± 21 points, a value classified as moderate impairment regarding functioning. Correlations with the subjective form from the International Knee Documentation Committee scale and scores of self-perception were adequate (p < 0.01; r > 0.5). CONCLUSION: The brief core set for knee dysfunction, a set with 12 categories, can be used as a clinical instrument to measure and score the functioning of people with knee dysfunction, aged between 18 and 89 years, with adequate construct validity.

Incorporation, adaptation and rejection of obstetric practices during the implementation of the "Adequate Childbirth Program" in Brazilian private hospitals: a qualitative study.

BACKGROUND: The "Adequate Childbirth Program" (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation. METHOD: This study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software. RESULTS: The three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals. CONCLUSIONS: After the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it's harmful.

Brazil has high Cesarean Section (CS) rates, with rates far from the ideal recommended by the World Health Organization and a model of care that does not favor women's autonomy and empowerment. In 2015, a quality improvement project, called "Projeto Parto Adequado" (PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean section, in addition to encouraging the process of natural and safe childbirth. One of the components of this project was to reorganize the model of care in hospitals to prepare professionals for humanized and safe care. The data were collected in 8 hospitals with interviews with 49 professionals, approximately two years after the beginning of the project in the hospitals. There were changes in the hospital routine and in the care of women after the project. The professionals incorporated practices such as skin-to-skin contact and breastfeeding; diet during labor; non-invasive care technologies, especially to relieve pain during labor; birth plan; pregnancy courses with guided tours in hospitals (for pregnant women and family); and analgesia for vaginal labor. There was adaptation of existing practices in hospitals to reduce CS that had no clinical indication; better monitoring of labor, favoring vaginal delivery. And finally, the professionals rejected the practice that presses the uterine fundus, for not having shown efficacy in recent studies. We can conclude that the hospitals that participated in this study have made an effort to change their obstetric model. However, specific aspects of each hospital, the organization of the health system in Brazil, and the incentive of the local administration influenced the implementation of these changes by professionals in practice.

The Combination of Systemic Immune-Inflammation Index and Serum Procalcitonin has High Auxiliary Predictive Value for Short-Term Adverse Prognosis in Septic Shock Patients.

BACKGROUND: Septic shock is the most serious complication of sepsis, with more secure and efficient biomarkers urgently needed. Systemic immune-inflammation index (SII) and serum procalcitonin (PCT) show involvement in predicting septic shock prognosis. OBJECTIVE: Herein, we explored the clinical value of the SII-PCT combination in the short-term prognosis of septic shock patients. METHODS: Totally 200 septic shock patients were analyzed retrospectively and allocated into the survival and death groups upon 28-day in-hospital outcomes. Correlations of SII, PCT, acute physiology and chronic health evaluation II (APACHE II)/sepsis-related organ failure assessment (SOFA) scores, C-reactive protein (CRP), and serum creatinine (Scr) were analyzed using Spearman. The influencing factors of SII and serum PCT for short-term poor prognosis were analyzed using logistic multivariate regression model. The auxiliary predictive value of SII, PCT, and their combination for short-term adverse septic shock prognosis was evaluated by the receiver operating characteristic curve. Differences in the area under the curve (AUC) were compared using MedCalc. RESULTS: The death group had higher APACHE II/SOFA scores, LYM, CRP, Scr, SII, and PCT levels than the survival group. SII and PCT were positively correlated with APACHE II and SOFA scores, LYM, CRP, and Scr, and were independent risk factors influencing the adverse septic shock prognosis. The AUC of the SII-PCT combination in predicting short-term adverse septic shock prognosis was 0.893 (0.841-0.932), with 76.12% sensitivity and 87.97% specificity, with the combination showing a higher AUC than SII/PCT alone. CONCLUSIONS: The SII-PCT combination helps predict the adverse prognosis of septic shock patients.

Establishing a river health evaluation index system for seven rivers in Jiamusi City of China.

The Jiamusi section of the Songhua River is one of the first 17 model river construction sections in China. The implementation of river health assessments can determine the health dynamics of rivers and test the management's effectiveness. Targeting seven rivers, this study conducted river zoning and monitoring point deployment to conduct sufficient field research and monitoring. The authors selected hydrological and water resources, physical structure, water quality, aquatic life, social service functions, and management as guideline layers and 15 indicator layers. Subsequently, the authors established an evaluation index system to evaluate and analyze the ecological status and social service status of each river. The results showed that the Yindamu, Alingda, and Gejie rivers scored well as healthy rivers, with health evaluation scores of 78.98, 76.06, and 75.83, respectively. The Wangsanwu, Lujiagang, and Lingdangmai rivers are generally sub-healthy rivers with scores of 71.55, 67.97, and 60.7, respectively. The Yinggetu River has a score of 54.52 and is therefore assessed as unhealthy. Based on the scientific evaluation index method, this study analyses the current river health state in Jiamusi City to provide the basis for the evaluation of the river chief's work and future river management.

[Level and health evaluation of rare earth elements in human blood and hair in the mining areas in Northwest Hubei].

OBJECTIVE: To investigate the content of rare earth elements(REs)in blood and hair of residents in a RE mining area in Northwest Hubei, and evaluate the impact of REs on the health status of local residents. METHODS: A total of 191 residents from the core area of RE mining areas and 186 residents from non RE mining areas, aged 20-69, were selected. The content of REs in the blood and hair of the survey subjects was measured using inductively coupled plasma mass spectrometry, and compared with existing literature values. At the same time, blood tests and questionnaire surveys will be conducted on the health status of residents to examine whether human RE enrichment can lead to endemic diseases. RESULTS: The average total content of REs in the blood of residents in the mining area was 60.22 ng/mL, which was 3.35 times that of the control area; The average total content of REs in hair was 1197.91 ng/g, which was 6.32 times higher than the control area. As age increasing, the abundance of REs in the blood and hair of both men and women in mining areas increased. The proportion of Yttrium and Scandium in the blood and hair were much higher than that in the soil. Compared to hair, Yttrium and Scandium were more easily enriched in the blood. There was no significant difference in the probability of fatty liver, hepatitis B, hypoglycemia, hypotension, hypertension and heart disease and the average life span between residents in RE mining areas and those in the control area. CONCLUSION: The high daily average dietary intake of REs in residents leads to a relatively large accumulation of REs in human blood and hair, but no significant and substantial human health damage has been found at present.

Impact of Iron Profile and Vitamin D Levels on Clinical Outcomes in Patients with Sepsis and Septic Shock: A Cross-sectional Analysis at a Tertiary Care Center.

Aim and background: Sepsis is a major global health affecting millions worldwide, hence understanding its contributing factors becomes paramount. This cross-sectional study at a tertiary care center explores the relationship between iron profile, vitamin D levels, and outcomes in sepsis and septic shock patients. The primary objective was to explore the prevalence of iron profile and vitamin D parameters during early intensive care unit (ICU) admission and their association with 28-day mortality. Materials and methods: Spanning 18 months, the study enrolled adult patients meeting sepsis or septic shock criteria at the ICU. Data collection included demographic information, clinical characteristics, and blood samples for iron profile and vitamin D levels at admission. Disease severity was assessed using sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) scores, and treatment was administered as per surviving sepsis-3 guidelines. Results: The research involved 142 participants, uncovering prevalent organisms such as Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Noteworthy connections to mortality were identified for factors including vasopressor support, ICU stay duration, SOFA score, and APACHE-II score. Interestingly, age, gender, and vitamin D levels showed no significant associations. However, the study did reveal a significant association between iron, ferritin, and transferrin saturation levels with increased 28-day mortality. Conclusion: Our study concluded that low Iron, elevated ferritin, and decreased transferrin saturation levels maintained associations with the outcome of interest. While no such relationship was established with vitamin D levels. These results suggest potential implications for patient management and prognosis, warranting further exploration in future research. How to cite this article: Bairwa M, Jatteppanavar B, Kant R, Singh M, Choudhury A. Impact of Iron Profile and Vitamin D Levels on Clinical Outcomes in Patients with Sepsis and Septic Shock: A Cross-sectional Analysis at a Tertiary Care Center. Indian J Crit Care Med 2024;28(6):569-574.

mNUTRIC Score in ICU Mortality Prediction: An Emerging Frontier or Yet Another Transient Trend?

How to cite this article: Arunachala S, Kumar J. mNUTRIC Score in ICU Mortality Prediction: An Emerging Frontier or Yet Another Transient Trend? Indian J Crit Care Med 2024;28(5):422-423.

Interleukin-6 in Sepsis-Promising but Yet to Be Proven.

How to cite this article: Sinha S. Interleukin-6 in Sepsis-Promising but Yet to Be Proven. Indian J Crit Care Med 2024;28(7):629-631.

Leprosy and tuberculosis control scenario of the national program for the improvement of access and quality of primary care in Brazil.

BACKGROUND: In Brazil, despite advances in public health policies aimed at eliminating and controlling infectious and parasitic diseases, the incidence of neglected diseases is still high. The epidemiological scenario in Brazil of diseases such as tuberculosis and leprosy evidences a public policy agenda that has not been resolute in terms of control, nor in terms of elimination. OBJECTIVE: To analyze the actions of diagnosis and treatment of leprosy and tuberculosis in the context of primary health care. METHODS: In this ecological study, data from the third cycle of the Program for the Improvement of Access and Quality of Primary Care were extracted from electronic address of the Primary Health Care Secretariat of Brazil in the area of Actions, Programs and Strategies. A total of 37,350 primary health care teams were that answered the questionnaire were eligible, with variables extracted from leprosy and tuberculosis control actions. The municipalities were grouped according to the characteristic of the Brazilian municipality. The partition chi-square and the Residuals Test were used to assess whether there was a difference in the proportion of tuberculosis and leprosy actions between types of municipalities. Statistics were carried out using Minitab 20 and Bioestat 5.3. RESULTS: Regarding the leprosy treatment location, there is a higher proportion of people referred to be treated at the reference in adjacent rural (p = 0.0097) and urban (p < 0.0001) municipalities; monitoring of people with leprosy referred to the service network (p. = 0.0057) in remote rural areas. Lower proportion of teams requesting bacilloscopy in remote rural areas (p = 0.0019). Rural areas have a higher proportion of teams that diagnose new cases (p = 0.0004). Regarding the actions of diagnosis and treatment of tuberculosis. There is a higher proportion of teams that carry out consultations at the unit itself in rural areas when compared to adjacent intermediaries (p = 0.0099) and urban (p < 0.0001); who requested sputum smear microscopy in adjacent intermediaries (p = 0.0021); X-ray in adjacent intermediaries (p < 0.0001) and urban (p < 0.0001); collection of the first sputum sample in urban (p < 0.0001) and adjacent rural areas (p < 0.0001); directly observed treatment (p < 0.0001) in adjacent rural municipalities. CONCLUSION: There are inequalities in the diagnosis and treatment of leprosy and tuberculosis among the types of municipalities.

Care at the first postnatal hour in two hospitals of the Adequate Birth Project: qualitative analysis of experiences in two stages of the Healthy Birth research.

BACKGROUND:  The Adequate Childbirth Project (PPA) is a quality improvement project that aims to enhance normal delivery and reduce cesarean sections with no clinical indication in the Brazilian supplementary health care system. This study aims to analyze the care model of the first postpartum hour in hospitals that participated in the PPA. METHODS: Qualitative analysis based on the narrative of 102 women attended at two hospitals participating in the evaluative "Healthy Birth" research that analyzed the degree of implementation and the effects of the PPA. We assessed three practices within the first hour after delivery: skin-to-skin contact, breastfeeding and appropriate clamping of the umbilical cord. Data was collected through semi-structured interviews by telephone and submitted to thematic content analysis. RESULTS: The categories that emerged from the analysis of the results were "Dimension of time and care expressed in the lived experience" and "Interferences in care in the first hour of life". In the first category, women reported that in the first hour after delivery the newborn was placed on the mother's chest, but the length of time of the newborn's stay in skin-to-skin contact was less than one hour. This experience, even in a shorter period of time, was said to be positive by the women interviewed. Two barriers were observed: interruption of skin-to-skin contact for neonatal care and the transfer to the recovery room, both separating baby from mother without observing the duration of the "golden hour". It was identified that a process of improvement of the quality of care for childbirth is underway, with a gradual incorporation of recommended practices for care in newborn's first hour of life. CONCLUSIONS: Women reported access to the three care practices at two hospitals participating in the PPA quality improvement project. All practices were valued by women as a positive experience and should be promoted. Information during antenatal care to increase women´s autonomy, review of hospital practices to reduce barriers, and support from health care providers during the first hour after birth are needed to improve the implementation of these practices and access to their health benefits.

This study aims to analyze the care model of the first postpartum hour offered by two hospitals participating in the Adequate Childbirth Project (PPA), a quality improvement project to enhance normal delivery and reduce unnecessary cesarean sections in Brazilian private hospital. It is a qualitative analysis, based on the narrative of 102 women attended at two hospitals participating in the PPA. Categories that emerged from the analysis: "First hour; dimension of time and care expressed in the lived experience" and "Interferences in care in the first hour of life". Most women expressed a chronological time of skin-to-skin contact far from the ideal recommended in the first postpartum hour; however, they valued the experience and its meaning. Two barriers were observed in this care process: the interruption of skin-to-skin contact for neonatal care and the transfer to the recovery room, without observing the duration of the "golden hour". We can conclude that women evaluated the service positively, with indications that point to the sustainability of the PPA. Information during antenatal care to increase women´s autonomy are needed to improve the implementation of these practices and access to their health benefits.

Evaluation of labor and childbirth care by nurse-midwives in Brazilian private hospitals: results of a quality improvement project.

BACKGROUND: In 2015, a quality improvement project-the "Adequate Childbirth Project" (Projeto Parto Adequado, or PPA)-was implemented in Brazilian private hospitals with the goal of reducing unnecessary cesarean sections. One of the strategies adopted by the PPA was the implementation of labor and childbirth care by nurse-midwives. The objective of this study is to evaluate the results of the PPA in the implementation and adequacy of labor and childbirth care by nurse-midwives in Brazilian private hospitals. METHODS: Cross-sectional, hospital-based study, carried out in 2017, in 12 hospitals participating in the PPA. We assessed the proportion of women assisted by nurse-midwives during labor and childbirth care and the adequacy of 13 care practices following parameters of the World Health Organization. Women assisted in the PPA model of care and in the standard of care model were compared using the chi-square statistical test. RESULTS: 4798 women were interviewed. Women in the PPA model of care had a higher proportion of labor (53% × 24.2%, p value < 0.001) and vaginal birth (32.7% × 11.3%, p value < 0.001), but no significant differences were observed in the proportion of women assisted by nurse-midwives during labor (54.8% × 50.1%, p value = 0.191) and vaginal birth (2.2% × 0.7%, p value = 0.142). The implementation of recommended practices was adequate, except the use of epidural analgesia for pain relief, which was intermediate. There was a greater use of recommended practices including "oral fluid and food", "maternal mobility and position", "monitoring of labor", "use of non-pharmacological methods for pain relief" and "epidural analgesia for pain relief" in women assisted by nurse-midwives in relation to those assisted only by doctors. Many non-recommended practices were frequently used during labor by nurse-midwives and doctors. CONCLUSIONS: There was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and an appropriate use of recommended practices in women assisted by nurse-midwives. However, there was no difference in the proportion of women assisted by nurse-midwives in the two models of care. The expansion of nursing participation and the reduction of overused practices remain challenges.

Brazil has a high rate of cesarean sections with low participation of nurse-midwives in childbirth care. Nurse-midwife care is associated with less use of interventions, lower proportions of cesarean sections and greater women's satisfaction. In 2015, a quality improvement project, called the "Adequate Childbirth Project" (Projeto Parto Adequado, PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean sections. One of its components is the expansion of nurse-midwives in labor and childbirth care. In this study, we evaluated the results of PPA on childbirth care by nurse-midwives. Data were collected in 12 hospitals with interviews with 4798 women. Women assisted in the PPA model of care had a higher proportion of labor and vaginal birth, but there was no increase in the proportion of women assisted by nurse-midwives, neither during labor nor vaginal birth. The use of recommended practices was adequate, except for the use of epidural analgesia, with greater use of some recommended practices in women assisted by nurse-midwives compared to those seen only by doctors. However, we observed excessive use of non-recommended practices during labor, both by doctors and nurses. We can conclude that there was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and a greater use of recommended practices in women assisted by nurse-midwives, but without an increase in the proportion of women assisted by nurses. The expansion of nurse-midwives' participation in childbirth care and the reduction of non-recommended practices therefore continue to be challenges.

Clinical outcomes after tracheostomy in patients with coronavirus disease 2019: a single-center experience in Japan.

PURPOSE: Many patients with coronavirus disease 2019 require mechanical ventilation and tracheostomy. However, the timing and indications for tracheostomy are controversial. This study assessed 11 patients with coronavirus disease 2019 who underwent tracheostomy with clinical information and retrospective analyses. METHODS: A single-center retrospective observational study was performed on patients with coronavirus disease 2019 who underwent tracheostomy between 2020 and 2021. RESULTS: Failure to wean was the most common indication for tracheostomy, followed by extracorporeal membrane oxygenation decannulation and the need for secretion management. After tracheostomy, six patients (54.5%) were liberated from the ventilator. The time from intubation to tracheostomy (21.1 ± 9.14 days) was correlated with the duration of ventilator dependency (36.83 ± 20.45 days, r2 = 0.792, p = 0.018). The mean Acute Physiological and Chronic Health Evaluation II score was significantly lower in the ventilator-liberated group (23 ± 2.77) than in the non-ventilator-liberated group (31 ± 6.13, p = 0.0292). Furthermore, patients with Acute Physiological and Chronic Health Evaluation II scores of < 27 points achieved ventilator liberation and a long-term survival (p = 0.0006). CONCLUSIONS: This study describes the outcomes of a cohort of patients who underwent tracheostomy after intubation for coronavirus disease 2019. The Acute Physiological and Chronic Health Evaluation II score predicted whether or not the patient could achieve ventilator liberation.

Do Functional Tests Estimate Physical Activity in COPD?

The association between physical activity in daily life (PADL) and simple functional tests is not yet clearly understood in subjects with chronic obstructive pulmonary disease (COPD). Therefore, the aim of this study was to investigate the association of two functional tests (Sit-to-Stand test [STS] and the 4-Metre Gait Speed test [4MGS]) with PADL, as well as to identify whether these tests can discriminate those subjects who are physically inactive. In this cross-sectional study, 28 subjects with COPD performed the five repetitions Sit-to-Stand (STS5r), the 4MGS and used the DynaPort activity monitor for 7 days in order to assess PADL. Walking time, movement intensity while walking (MI) and Physical Activity Level index (PAL) were considered as PADL outcomes. STS5r and 4MGS, respectively, were significantly associated with walking time (R2 = 0.16; p = 0.024 and R2 = 0.25; p = 0.006) and PAL index (R2 = 0.17; p = 0.002 and R2 = 0.30; p = 0.003), whereas movement intensity was associated only with the 4MGS (R2 = 0.23; p = 0.009). Additionally, both tests were able to discriminate physically inactive subjects (cutoffs: STS5r = 11.48s [AUC = 0.73]; 4MGS = 1.09m/s [AUC = 0.88]). In conclusion, STS5r and 4MGS can predict up to 30% of PADL in subjects with COPD. Both tests are related to PADL duration (e.g. time spent walking), while only the 4MGS reflects movement intensity. Both tests presented discriminative capacity to identify subjects with worse PADL pattern.

Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score!

How to cite this article: Kannan A, Jindal A. Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score! Indian J Crit Care Med 2023;27(2):150.

Elderly in the ICU.

How to cite this article: Jagathkar G. Elderly in the ICU. Indian J Crit Care Med 2023;27(3):157-158.

ADMA and homoarginine independently predict mortality in critically ill patients.

BACKGROUND: Arginine metabolites are associated with cardiovascular and all-cause mortality in several patient groups. We investigated whether arginine metabolites are associated with mortality in patients with critical illness and whether associations are independent of other factors affecting prognosis in an Intensive Care Unit (ICU). METHODS: 1155 acutely unwell adult patients admitted to a mixed medical-surgical ICU were studied. Arginine, asymmetric dimethyl-l-arginine (ADMA), monomethyl-l-arginine (MMA), symmetric dimethyl-l-arginine (SDMA) and l-homoarginine were measured in a plasma sample collected at admission to ICU by liquid chromatography tandem mass spectrometry. Risk of death score was calculated using data submitted to the Australia and New Zealand Intensive Care Society. RESULTS: In this cohort, 163 patients (14.1%) died. ADMA (odds ratio = 1.159 (1.033-1.300) per 0.1 µmol/L increment, p = 0.012), homoarginine (odds ratio = 0.963 (0.934-0.992), p = 0.013) and risk of death score (odds ratio = 1.045 (1.037-1.053) per 1% increment, p < 0.001) were independently associated with mortality in ICU patients. The area under the receiver operator characteristic curve for risk of death score, ADMA and homoarginine combined for mortality was greater than for risk of death score alone (0.815 (95% CI 0.790-0.837) vs 0.796 (95% CI 0.781-0.820), p = 0.019). Other arginine metabolites were not independently associated with mortality. CONCLUSIONS: ADMA is positively and homoarginine negatively associated with mortality in ICU patients, independent of other clinical factors. Measuring ADMA and homoarginine may refine models to predict ICU mortality. Reducing ADMA and increasing homoarginine are potential therapeutic targets to reduce mortality in critically ill patients.

Critical Care Utilization and Outcomes of Interhospital Medical Transfers at Lower Risk of Death.

PURPOSE: To evaluate utilization and mortality outcomes of interhospital transferred critically-ill medical patients with lower predicted risk of hospital mortality. MATERIALS & METHODS: Multisite retrospective cohort analysis of patients with Acute Physiology and Chronic Health Evaluation (APACHE) IV-a predicted mortality of ≤20% from 335 ICUs in 208 hospitals in the Philips eICU database between 2014-2015. Differences in length-of-stay (LOS) and mortality between transferred and local patients were evaluated using negative binomial logistic regression and logistic regression, respectively. Stratified analyses were conducted for subgroups of predicted mortality: 0%-5%, 6%-10%, 11%-15%, and 16%-20%. RESULTS: Transfers had a higher risk of longer ICU and hospital LOS across all risk strata (IRR 1.12; 95% CI 1.09-1.16, P < 0.001 and IRR 1.11; 95% CI 1.07-1.14, P < 0.001 respectively). Mortality was higher among transfers, largely driven by the 6%-10% mortality risk strata (OR 1.30; 95% CI 1.09-1.54, P = 0.003). CONCLUSIONS: Interhospital transfer of critically-ill medical patients with lower illness severity is associated with higher ICU and hospital utilization and increased mortality. Better understanding of factors driving patient selection for and characteristics of interhospital transfer for this population will have an impact on ICU resource utilization, care efficiency, and hospital quality.

[Factors associated with hospitalizations for primary care-sensitive conditions in Brazil: an ecological studyFactores asociados a las hospitalizaciones infantiles por afecciones que podrían tratarse en la atención primaria en Brasil: estudio ecológico]. / Fatores associados às internações infantis por condições sensíveis à atenção primária no Brasil: estudo ecológico.

Objective: To investigate whether structural aspects of primary care units (PCUs) and the work processes of primary care teams are associated with the rate of hospitalizations for primary care-sensitive conditions (HPCSC) in children younger than 5 years of age in Brazil. Method: For this longitudinal ecological study, secondary data were obtained from the Brazilian Hospital Information System and from three cycles of the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB) (2012, 2014, 2017/2018). The analysis included 42 916 PCUs. A multilevel random intercept model with fixed slope was used. In the first level, the outcome (HPCSC rates) and explanatory variables (structure and process indicators) aggregated by PCU were analyzed. Social determinants (represented by a stratification criterion combining municipality population and health care management indicators) were entered in the second level. The t test with Bonferroni correction was used to compare indicator means between regions, and multilevel linear regression was used to estimate the correlation coefficients. Results: The HPCSC rate in children younger than 5 years was 62.78/100 thousand population per estimated PCU coverage area. A direct association with the outcome was observed for: participation in one or more PMAQ-AB cycles; team planning; special hours; dedicated pediatric care area; and availability of vaccines. Equipment, materials, supplies, and being a small or medium-size municipality were inversely associated with HPCSC. Conclusions: HPCSC rates in children below 5 years of age may potentially be reduced through improvements in PCU structure and process indicators and in municipal social determinants.

Objetivo: Determinar la asociación de la estructura de las unidades básicas de salud (UBS) y del proceso de trabajo de los equipos de atención primaria con los determinantes sociales y las tasas de hospitalización por afecciones que podrían tratarse en la atención primaria en menores de 5 años en Brasil. Métodos: Estudio longitudinal ecológico, con datos secundarios del Sistema de Informaciones Hospitalarias y los tres ciclos del Programa Nacional de Mejora del Acceso y de la Calidad de la Atención Básica (PMAQ-AB) (2012, 2014, 2017-2018). Se analizaron 42.916 UBS. Se aplicó un modelo multinivel con pendiente fija e intercepción aleatoria. En el primer nivel, se analizaron el desenlace (tasas de hospitalización por afecciones que podrían tratarse en los servicios de atención primaria) y las variables explicativas (indicadores estructurales y procedimentales) consolidados por UBS. En el segundo nivel, se incluyeron determinantes sociales municipales (representados por un criterio de estratificación que combina el tamaño del municipio con indicadores que influyen en la gestión de salud). Se utilizó la prueba de la t con la corrección de Bonferroni para comparar las medias de los indicadores entre las regiones y la regresión lineal multinivel para estimar los coeficientes de correlación. Resultados: La tasa de hospitalización por afecciones que podrían tratarse en los servicios de atención primaria en menores de 5 años fue de 62,78/100 mil habitantes por área estimada de cobertura de UBS. Los siguientes factores presentaron una asociación directa con el desenlace: participación en uno o más ciclos del PMAQ-AB; planificación del equipo; horario especial; dependencias de atención infantil en la unidad; y disponibilidad de vacunas. La variable relativa a equipos, materiales e insumos y la clasificación como municipio pequeño o mediano se asociaron inversamente con las hospitalizaciones por afecciones que podrían tratarse en los servicios de atención primaria. Conclusiones: Las hospitalizaciones de menores de 5 años por afecciones que podrían tratarse en los servicios de atención primaria pueden reducirse mejorando los indicadores estructurales y procedimentales de las UBS y los determinantes sociales municipales.

A Non-Destructive Health Evaluation Method for Wooden Utility Poles with Frequency-Modulated Empirical Mode Decomposition and Laplace Wavelet Correlation Filtering.

Wooden utility poles are one of the most commonly used utility carriers in North America. Even though they are given different protection treatments, wooden utility poles are prone to have defects that are mainly caused by temperature, oxygen, moisture, and high potential hydrogen levels after decades of being exposed in open-air areas. In order to meet the growing demand regarding their maintenance and replacement, an effective health evaluation technology for wooden utility poles is essential to ensure normal power supply and safety. However, the commonly used hole-drilling inspection method always causes extra damage to wooden utility poles and the precision of health evaluation highly relies on technician experience at present. Therefore, a non-destructive health evaluation method with frequency-modulated empirical mode decomposition (FM-EMD) and Laplace wavelet correlation filtering based on dynamic responses of wooden utility poles was proposed in this work. Specifically, FM-EMD was used to separate multiple confusing closely-spaced vibration modes due to nonlinear properties of wooden utility poles into several single modes. The instantaneous frequency and damping factor of the decomposed signal of each single mode of the dynamic response of a wooden utility pole could be determined using Laplace wavelet correlation filtering with high precision. The health status of a wooden utility pole could then be estimated according to the extracted instantaneous frequency and damping factor of the decomposed signal of each single mode. The proposed non-destructive health evaluation method for wooden utility poles was tested in the field and achieved successful results.