Structure, process, and annual ICU mortality across 69 centers: United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study.

OBJECTIVE: Hospital-level variations in structure and process may affect clinical outcomes in ICUs. We sought to characterize the organizational structure, processes of care, use of protocols, and standardized outcomes in a large sample of U.S. ICUs. DESIGN: We surveyed 69 ICUs about organization, size, volume, staffing, processes of care, use of protocols, and annual ICU mortality. SETTING: ICUs participating in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. SUBJECTS: Sixty-nine intensivists completed the survey. MEASUREMENTS AND MAIN RESULTS: We characterized structure and process variables across ICUs, investigated relationships between these variables and annual ICU mortality, and adjusted for illness severity using Acute Physiology and Chronic Health Evaluation II. Ninety-four ICU directors were invited to participate in the study and 69 ICUs (73%) were enrolled, of which 25 (36%) were medical, 24 (35%) were surgical, and 20 (29%) were of mixed type, and 64 (93%) were located in teaching hospitals with a median number of five trainees per ICU. Average annual ICU mortality was 10.8%, average Acute Physiology and Chronic Health Evaluation II score was 19.3, 58% were closed units, and 41% had a 24-hour in-house intensivist. In multivariable linear regression adjusted for Acute Physiology and Chronic Health Evaluation II and multiple ICU structure and process factors, annual ICU mortality was lower in surgical ICUs than in medical ICUs (5.6% lower [95% CI, 2.4-8.8%]) or mixed ICUs (4.5% lower [95% CI, 0.4-8.7%]). We also found a lower annual ICU mortality among ICUs that had a daily plan of care review (5.8% lower [95% CI, 1.6-10.0%]) and a lower bed-to-nurse ratio (1.8% lower when the ratio decreased from 2:1 to 1.5:1 [95% CI, 0.25-3.4%]). In contrast, 24-hour intensivist coverage (p = 0.89) and closed ICU status (p = 0.16) were not associated with a lower annual ICU mortality. CONCLUSIONS: In a sample of 69 ICUs, a daily plan of care review and a lower bed-to-nurse ratio were both associated with a lower annual ICU mortality. In contrast to 24-hour intensivist staffing, improvement in team communication is a low-cost, process-targeted intervention strategy that may improve clinical outcomes in ICU patients.

Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study.

RATIONALE: Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies. OBJECTIVES: To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS). METHODS: In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions. MEASUREMENTS AND MAIN RESULTS: Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1-4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78-0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9-5.7). CONCLUSIONS: ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with www.clinicaltrials.gov (NCT00889772).

Physician alerts to prevent symptomatic venous thromboembolism in hospitalized patients.

BACKGROUND: Venous thromboembolism (VTE) prophylaxis remains underused among hospitalized patients. We designed and carried out a large, multicenter, randomized controlled trial to test the hypothesis that an alert from a hospital staff member to the attending physician will reduce the rate of symptomatic VTE among high-risk patients not receiving prophylaxis. METHODS AND RESULTS: We enrolled patients using a validated point score system to detect hospitalized patients at high risk for symptomatic VTE who were not receiving prophylaxis. We randomized 2493 patients (82% on Medical Services) from 25 study sites to the intervention group (n=1238), in which the responsible physician was alerted by another hospital staff member, or the control group (n=1255), in which no alert was issued. The primary end point was symptomatic, objectively confirmed VTE within 90 days. Patients whose physicians were alerted were more than twice as likely to receive VTE prophylaxis as control subjects (46.0% versus 20.6%; P<0.0001). The symptomatic VTE rate was lower in the intervention group (2.7% versus 3.4%; hazard ratio, 0.79; 95% CI, 0.50 to 1.25), but the difference did not achieve statistical significance. The rate of major bleeding at 30 days in the alert group was similar to that in the control group (2.1% versus 2.3%; P=0.68). CONCLUSIONS: A strategy of direct notification of the physician by a staff member increases prophylaxis use and leads to a reduction in the rate of symptomatic VTE in hospitalized patients. However, VTE prophylaxis continues to be underused even after physician notification, especially among Medical Service patients.

Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial.

BACKGROUND: Recent studies have reported a high prevalence of relative adrenal insufficiency in patients with liver cirrhosis. However, the effect of corticosteroid replacement on mortality in this high-risk group remains unclear. We examined the effect of low-dose hydrocortisone in patients with cirrhosis who presented with septic shock. METHODS: We enrolled patients with cirrhosis and septic shock aged 18 years or older in a randomized double-blind placebo-controlled trial. Relative adrenal insufficiency was defined as a serum cortisol increase of less than 250 nmol/L or 9 µg/dL from baseline after stimulation with 250 µg of intravenous corticotropin. Patients were assigned to receive 50 mg of intravenous hydrocortisone or placebo every six hours until hemodynamic stability was achieved, followed by steroid tapering over eight days. The primary outcome was 28-day all-cause mortality. RESULTS: The trial was stopped for futility at interim analysis after 75 patients were enrolled. Relative adrenal insufficiency was diagnosed in 76% of patients. Compared with the placebo group (n = 36), patients in the hydrocortisone group (n = 39) had a significant reduction in vasopressor doses and higher rates of shock reversal (relative risk [RR] 1.58, 95% confidence interval [CI] 0.98-2.55, p = 0.05). Hydrocortisone use was not associated with a reduction in 28-day mortality (RR 1.17, 95% CI 0.92-1.49, p = 0.19) but was associated with an increase in shock relapse (RR 2.58, 95% CI 1.04-6.45, p = 0.03) and gastrointestinal bleeding (RR 3.00, 95% CI 1.08-8.36, p = 0.02). INTERPRETATION: Relative adrenal insufficiency was very common in patients with cirrhosis presenting with septic shock. Despite initial favourable effects on hemodynamic parameters, hydrocortisone therapy did not reduce mortality and was associated with an increase in adverse effects. (Current Controlled Trials registry no. ISRCTN99675218.).

Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients.

OBJECTIVE: The role of intensive insulin therapy in medical surgical intensive care patients remains unclear. The objective of this study was to examine the effect of intensive insulin therapy on mortality in medical surgical intensive care unit patients. DESIGN: Randomized controlled trial. SETTINGS: Tertiary care intensive care unit. PATIENTS: Medical surgical intensive care unit patients with admission blood glucose of > 6.1 mmol/L or 110 mg/dL. INTERVENTION: A total of 523 patients were randomly assigned to receive intensive insulin therapy (target blood glucose 4.4-6.1 mmol/L or 80-110 mg/dL) or conventional insulin therapy (target blood glucose 10-11.1 mmol/L or 180-200 mg/dL). MEASUREMENTS AND MAIN OUTCOMES: The primary end point was intensive care unit mortality. Secondary end points included hospital mortality, intensive care unit and hospital length of stay, mechanical ventilation duration, the need for renal replacement therapy and packed red blood cells transfusion, and the rates of intensive care unit acquired infections as well as the rate of hypoglycemia (defined as blood glucose < or = 2.2 mmol/L or 40 mg/dL). There was no significant difference in intensive care unit mortality between the intensive insulin therapy and conventional insulin therapy groups (13.5% vs. 17.1%, p = 0.30). After adjustment for baseline characteristics, intensive insulin therapy was not associated with mortality difference (adjusted hazard ratio 1.09, 95% confidence interval 0.70-1.72). Hypoglycemia occurred more frequently with intensive insulin therapy (28.6% vs. 3.1% of patients; p < 0.0001 or 6.8/100 treatment days vs. 0.4/100 treatment days; p < 0.0001). There was no difference between the intensive insulin therapy and conventional insulin therapy in any of the other secondary end points. CONCLUSIONS: Intensive insulin therapy was not associated with improved survival among medical surgical intensive care unit patients and was associated with increased occurrence of hypoglycemia. Based on these results, we do not advocate universal application of intensive insulin therapy in intensive care unit patients. TRIAL REGISTRATION: Current Controlled Trials registry (ISRCTN07413772) http://www.controlled-trials.com/ISRCTN07413772/07413772; 2005.

The safety of percutaneous tracheostomy in patients with coagulopathy or thrombocytopenia.

The safety and complications of percutaneous tracheostomy (PT) without bronchoscopic guidance in a group of ICU patients with thrombocytopenia platelet count of < or = 60.000/mm3) or coagulopathy (INR > or = 1.5 or systemic heparinization), was studied. During the study period (May 2004-June 2005), 190 percutaneous tracheostomies were performed. Of these there were 11 (6%) patients with prolonged INR, 7 (4%) patients with thrombocytopenia and 14 (7%) patients on systemic heparin. There was no evidence of bleeding in patients with prolonged INR. A minor bleeding developed in only one patient with thrombocytopenia, and in two patients receiving systemic heparin. The PT was aborted for one patient with thrombocytopenia and slight increase of INR (1.3) due to major bleeding in spite of transfusion of both platelets and FFP. Our data suggest the incidence of bleeding is low in patients with coagulopathy and or thrombocytopenia-undergoing PT without bronchoscopic guidance.

Magnesium supplementation and the potential association with mortality rates among critically ill non-cardiac patients.

OBJECTIVE: Recent literature showed that development of hypomagnesemia is associated with higher mortality. The objective of this study is to evaluate the impact of magnesium supplementation on mortality rates of critically ill patients. METHODS: All patients admitted to the Intensive Care Unit (ICU) of King Abdul-Aziz Medical City, Riyadh, Saudi Arabia since September 2003 were included. We recorded the demographics data, APACHE score, daily magnesium levels and magnesium supplementation. We collected the data for 30 days or until discharge from ICU. Statistical analysis was performed using the student t-test for continuous data and the Fischers exact test for categorical data. Nothing was carried out to influence the behavior of intensivists in replacing magnesium. RESULTS: During the study period, 71 patients (45 males and 26 females) were admitted to the ICU, the mean age was 54 +/- 18 years for males and 56 +/- 19.2 years for females. The mean magnesium level on admission was 0.78 +/- 0.2 mmol/L and the majority of the patients were medical admissions. Approximately 39.4% had hypomagnesemia on admission and the overall mortality rate was 31%. In able to standardize the supplementation of magnesium among groups, the daily magnesium supplementation index (DMSI = total magnesium supplement in grams/length of stay in days) was calculated. The mortality rates for DMSI with <1 grm/day (low groups) was statistically significant higher than that of DMSI with >or=1 grm/day (high group) (43.5% versus 17%, p=0.035). There was no statistically significant differences between magnesium levels of both groups of DMSI except at admission where DMSI group had higher magnesium levels (<1 grm/day). CONCLUSION: Daily magnesium supplementation index higher than 1 grm/day is associated with lower mortality rates for critically ill patients. This effect was not found to be independent and may be related to severity of illness. Given that magnesium levels were similar between the 2 groups of DMSI at almost all points of the study, magnesium supplementation per se may be beneficial in lowering mortality rates. The exact cause of this effect is unknown. An aggressive magnesium supplementation protocol may be warranted. A larger scale randomized study is necessary to evaluate this effect.

Characteristics and outcomes of patients hospitalized following pulmonary aspiration.

BACKGROUND: Pulmonary aspiration is an important recognized cause of ARDS. Better characterization of patients who aspirate may allow identification of potential risks for aspiration that could be used in future studies to mitigate the occurrence of aspiration and its devastating complications. METHODS: We conducted a secondary analysis of the Lung Injury Prediction Score cohort to better characterize patients with aspiration, including their potential risk factors and related outcomes. RESULTS: Of the 5,584 subjects at risk for ARDS and who required hospitalization, 212 (3.8%) presented with aspiration. Subjects who aspirated were likely to be male (66% vs 56%, P < .007), slightly older (59 years vs 57 years), white (73% vs 61%, P = .0004), admitted from a nursing home (15% vs 5.9%, P < .0001), have a history of alcohol abuse (21% vs 8%, P < .0001), and have lower Glasgow Coma Scale (median, 13 vs 15; P < .0001). Aspiration subjects were sicker (higher APACHE [Acute Physiology and Chronic Health Evaluation] II score), required more mechanical ventilation (54% vs 32%, P < .0001), developed more moderate to severe ARDS (12% vs 3.8%, P < .0001), and were twofold more likely to die in-hospital, even after adjustment for severity of illness (OR = 2.1; 95% CI, 1.2-3.6). Neither obesity nor gastroesophageal reflux was associated with aspiration. CONCLUSIONS: Aspiration was more common in men with alcohol abuse history and a lower Glasgow Coma Scale who were admitted from a nursing home. It is independently associated with a significant increase in the risk for ARDS as well as morbidity and mortality. Findings from this study may facilitate the design of future clinical studies of aspiration-induced lung injury.

Sex, race, and the development of acute lung injury.

BACKGROUND: Prior studies suggest that mortality differs by sex and race in patients who develop acute lung injury (ALI). Whether differences in presentation account for these disparities remains unclear. We sought to determine whether sexual and racial differences exist in the rate of ALI development and ALI-related mortality after accounting for differences in clinical presentations. METHODS: This was a multicenter, observational cohort study of 5,201 patients at risk for ALI. Multivariable logistic regression with adjustment for center-level effects was used to adjust for potential covariates. RESULTS: The incidence of ALI development was 5.9%; in-hospital mortality was 5.0% for the entire cohort, and 24.4% for those patients who developed ALI. Men were more likely to develop ALI compared to women (6.9% vs 4.7%, P , .001) and had a nonsignificant increase in mortality when ALI developed (27.6% vs 18.5%, P 5 .08). However, after adjustment for baseline imbalances between sexes these differences were no longer significant. Black patients, compared to white patients, presented more frequently with pneumonia, sepsis, or shock and had higher severity of illness. Black patients were less likely to develop ALI than whites (4.5% vs. 6.5%, P 5 .014), and this association remained statistically significant after adjusting for differences in presentation (OR, 0.66; 95 % CI, 0.45-0.96). CONCLUSIONS: Sex and race differences exist in the clinical presentation of patients at risk of developing ALI. After accounting for differences in presentation, there was no sex difference in ALI development and outcome. Black patients were less likely to develop ALI despite increased severity of illness on presentation.

Contemporary ventilator management in patients with and at risk of ALI/ARDS.

BACKGROUND: Ventilator practices in patients at risk for acute lung injury (ALI) and ARDS are unclear. We examined factors associated with choice of set tidal volumes (VT), and whether VT < 8 mL/kg predicted body weight (PBW) relates to the development of ALI/ARDS. METHODS: We performed a secondary analysis of a multicenter cohort of adult subjects at risk of lung injury with and without ALI/ARDS at onset of invasive ventilation. Descriptive statistics were used to describe ventilator practices in specific settings and ALI/ARDS risk groups. Logistic regression analysis was used to determine the factors associated with the use of VT < 8 mL/kg PBW and the relationship of VT to ALI/ARDS development and outcome. RESULTS: Of 829 mechanically ventilated patients, 107 met the criteria for ALI/ARDS at time of intubation, and 161 developed ALI/ARDS after intubation (post-intubation ALI/ARDS). There was significant intercenter variability in initial ventilator settings, and in the incidence of ALI/ARDS and post-intubation ALI/ARDS. The median VT was 7.96 (IQR 7.14-8.94) mL/kg PBW in ALI/ARDS subjects, and 8.45 (IQR 7.50-9.55) mL/kg PBW in subjects without ALI/ARDS (P = .004). VT decreased from 8.40 (IQR 7.38-9.37) mL/kg PBW to 7.97 (IQR 6.90-9.23) mL/kg PBW (P < .001) in those developing post-intubation ALI/ARDS. Among subjects without ALI/ARDS, VT ≥ 8 mL/kg PBW was associated with shorter height and higher body mass index, while subjects with pneumonia were less likely to get ≥ 8 mL/kg PBW. Initial VT ≥ 8 mL/kg PBW was not associated with the post-intubation ALI/ARDS (adjusted odds ratio 1.30, 95% CI 0.74-2.29) or worse outcomes. Post-intubation ALI/ARDS subjects had mortality similar to subjects intubated with ALI/ARDS. CONCLUSIONS: Clinicians seem to respond to ALI/ARDS with lower initial VT. Initial VT, however, was not associated with the development of post-intubation ALI/ARDS or other outcomes.

Randomized trial of physician alerts for thromboprophylaxis after discharge.

BACKGROUND: Many hospitalized Medical Service patients are at risk for venous thromboembolism in the months after discharge. We conducted a multicenter randomized controlled trial to test whether a hospital staff member's thromboprophylaxis alert to an Attending Physician before discharge will increase the rate of extended out-of-hospital prophylaxis and, in turn, reduce the incidence of symptomatic venous thromboembolism at 90 days. METHODS: From April 2009 to January 2010, we enrolled hospitalized Medical Service patients using the point score system developed by Kucher et al to identify those at high risk for venous thromboembolism who were not ordered to receive thromboprophylaxis after discharge. There were 2513 eligible patients from 18 study sites randomized by computer in a 1:1 ratio to the alert group or the control group. RESULTS: Patients in the alert group were more than twice as likely to receive thromboprophylaxis at discharge as controls (22.0% vs 9.7%, P <.0001). Based on an intention-to-treat analysis, symptomatic venous thromboembolism at 90 days (99.9% follow-up) occurred in 4.5% of patients in the alert group, compared with 4.0% of controls (hazard ratio 1.12; 95% confidence interval, 0.74-1.69). The rate of major bleeding at 30 days in the alert group was similar to that of the control group (1.2% vs 1.2%, hazard ratio 0.94; 95% confidence interval, 0.44-2.01). CONCLUSIONS: Alerting providers to extend thromboprophylaxis after hospital discharge in Medical Service patients increased the rate of prophylaxis but did not decrease the rate of symptomatic venous thromboembolism.

Hypokalaemia and refractory asystole complicating diabetic ketoacidosis, lessons for prevention.

We report a unique case of diabetic ketoacidosis in which a relatively low potassium level on admission was associated with consequent life-threatening and refractory arrhythmia secondary to inappropriate use of intravenous insulin and bicarbonate therapy. The latter was reversed by rapid bolus potassium injection. Although we do not advocate this approach in every case, we emphasise that a bolus injection of potassium may be life saving in such cases. The lessons from this case have led to multidisciplinary meetings and modification of the institute's diabetic ketoacidosis clinical pathway.

Status epilepticus and cardiopulmonary arrest in a patient with carbon monoxide poisoning with full recovery after using a neuroprotective strategy: a case report.

INTRODUCTION: Carbon monoxide poisoning can be associated with life-threatening complications, including significant and disabling cardiovascular and neurological sequelae. CASE PRESENTATION: We report a case of carbon monoxide poisoning in a 25-year-old Saudi woman who presented to our facility with status epilepticus and cardiopulmonary arrest. Her carboxyhemoglobin level was 21.4 percent. She made a full recovery after we utilized a neuroprotective strategy and normobaric oxygen therapy, with no delayed neurological sequelae. CONCLUSIONS: Brain protective modalities are very important for the treatment of complicated cases of carbon monoxide poisoning when they present with neurological toxicities or cardiac arrest. They can be adjunctive to normobaric oxygen therapy when the use of hyperbaric oxygen is not feasible.

Warfarin Use During Fecal Occult Blood Testing: A Meta-Analysis.

BACKGROUND: Fecal occult blood testing (FOBT) is a widely used screening test for colorectal cancer (CRC). Given the limited data about the effects of warfarin on FOBT are inconclusive, current screening guidelines for CRC do not address whether warfarin should be discontinued before FOBT. Therefore, we conducted a meta-analysis to evaluate the influence of warfarin on the yield of FOBT. METHODS: Multiple medical databases were searched (April 2011). Studies examining the use of warfarin versus no warfarin for FOBT were included. Meta-analysis for the effect of warfarin or no warfarin for FOBT was performed by calculating pooled estimates of colonoscopy findings and detection of neoplasia, any adenoma, advanced adenoma, or colon cancer by odds ratio (OR) with fixed and random effects model. RevMan 5.1 was utilized for statistical analysis. RESULTS: Five studies (N = 11,244) met the inclusion criteria. No statistically significant difference was noted between FOBT with or without warfarin for colonoscopy findings (OR 0.88; 95% CI: 0.48 - 1.62, P = 0.67) or detection of neoplasia (OR 0.88; 95% CI: 0.58 - 1.35, P = 0.57), any adenoma (OR 1.08; 95% CI: 0.73 - 1.58, P = 0.71), advanced adenoma (OR 1.07; 95% CI: 0.69 - 1.65, P = 0.78), and colon cancer (OR 0.69; 95% CI: 0.38 - 1.23, P = 0.21). CONCLUSIONS: Among patients with positive FOBT, the yield of colonoscopy appears not to be altered by warfarin use.

Morbidity and mortality characteristics of morbidly obese patients admitted to hospital and intensive care units.

BACKGROUND: The purpose of this study is to evaluate the outcomes of hospitalized morbidly obese inpatients. METHODS: In this retrospective cohort study, we reviewed the records of all adult morbidly obese patients (defined as body mass index [BM]) >40 kg/m(2) upon admission) admitted to tertiary university hospital from 2000 to 2008. Primary outcome was hospital mortality. Secondary outcomes were hospital and intensive care unit (ICU) length of stay (LOS), need for and duration of mechanical ventilation (MV), and tracheostomy rates. We divided patients into quartiles based on their admission BMI. Baseline characteristics and outcomes were reported for each quartile. RESULTS: Over the 8-year period, we reviewed 897 admissions for 545 patients. The median number of admissions was 1 per patient (mean, 2.44 ± 2.9), with a range of 1 to 20. A total of 40.9% had more than one admission. Morbidly obese patients were more likely to be admitted to a medical service. Higher BMI quartiles had higher rates of ICU admission, MV, and rate of tracheostomy. Although the higher BMI quartiles had longer hospital LOS, hospital mortality did not significantly differ. CONCLUSIONS: As BMI increases, utilization of medical resources also increases such as ICU admission, MV, longer hospital LOS, and tracheostomy. Although overall BMI interquartile mortality rates do not differ significantly in our study, utilization of valuable and costly hospital resources is a major challenge facing health care delivery. Our findings indicate the need for increased efforts and novel strategies for treatment, prevention, and resource allocation to deal with this emerging challenge.

Patients with venous thromboembolism appear to have higher prevalence of obstructive sleep apnea than the general population.

INTRODUCTION: The link between obstructive sleep apnea (OSA) and venous thromboembolism (VTE) remains unclear. We sought to study a possible association between VTE and OSA. METHODS: We retrospectively collected data on patients with VTE between 1999 and 2009. Data on demographics and comorbidities were recorded as well as body mass index was calculated. Primary outcome was prevalence of OSA defined as an apnea-hypopnea index (AHI) ≥5. The study was registered at clinicaltrials.gov (NCT01051297). RESULTS: We identified 840 patients with VTE. Obstructive sleep apnea was confirmed in 130 (15.5% [13%-17.9%]). Compared to the control group (no OSA), those who had OSA were more obese (83.8% vs 43.8%) and had statistically higher prevalence of diabetes, coronary artery disease, and congestive heart failure. CONCLUSIONS: The prevalence of OSA 15.5% (13%-17.9%) appears to be higher than that of the general population among patients with VTE. Our findings suggest a possible link between OSA and VTE.

Does reduced lung diffusing capacity for carbon monoxide predict the presence of pulmonary hypertension?

OBJECTIVE: The objective of this study was to determine whether reduced lung diffusing capacity for carbon monoxide (DLCO) predicts the presence of pulmonary hypertension (PH) in heterogeneous group of patients. METHODS: Consecutive patients who underwent pulmonary function and transthoracic echocardiographic testing within a 6-month period were retrospectively identified by chart review. Right ventricular systolic pressure (RVSP) was measured using Doppler echocardiography. PH was defined as a RVSP >30 mm Hg. Patients were divided into 2 major groups: those whose RVSP was < or =30 mm Hg and those whose RVSP was >30 mm Hg. PH was classified as mild (RVSP = 31-40 mm Hg), moderate (RSVP = 41-60 mm Hg) and severe (RVSP >60 mm Hg). RESULTS: A total of 398 patients were entered into the study: 264 (66.3%) with PH and 134 (33.7%) without PH. Patients with PH were older, had a lower mean percentage of predicted values for forced vital capacity (%FVC), for DLCO (%DLCO) and for DLCO corrected for alveolar volume (%DLCO/VA) than those without PH. Multivariate analysis identified age and %FVC as independent predictors of PH [odds ratios and 95% confidence intervals of 1.038 (1.020-1.056) and 0.972 (0.955-0.988), respectively]. There was a weak, but significant negative correlation between RVSP and %DLCO (r = -0.205, P = 0.001), but there was no correlation between RVSP and %DLCO/VA. Neither %DLCO nor %DLCO/VA was found to be independent predictors of PH. CONCLUSION: In a heterogeneous group of patients, %DLCO and %DLCO/VA do not independently predict the presence of PH.

Retrievable inferior vena cava filters are not getting retrieved: where is the gap?

OBJECTIVE: The purpose of this study is to assess the retrieval rate and the predictors of successful retrieval of Retrievable Inferior Vena Cava (RIVC) filters. METHODS: We retrospectively reviewed the medical records of adult patients who had RIVC filter placements from 2004-2008. We excluded patients who died or were lost to follow-up and those who refused or had unsuccessful retrieval. We collected demographic and clinical data including indications for placement and follow-up. Successful retrieval was defined as objective evidence of retrieval by medical records. RESULTS: Over a 4 year period, we identified 351 patients who had RIVC filter placements. We excluded 99 patients (65 died, 24 decided to leave filter in place, 7 had unsuccessful retrieval and 3 lost follow-up). Majority of the filters were placed for surgical patients (161, 63.9%). Of 252 eligible patients for retrieval, only 47 filters were successfully retrieved yielding a retrieval rate of 18.7%. We identified three predictors for successful retrieval: Male gender, home discharge and follow up with procedural service. CONCLUSION: In this large cohort we found that the retrieval rate of retrievable IVCF is extremely low consistent with national statistics. Male patients, patients who were discharged home and patients who were followed by the procedural service had higher chance of successful retrieval. We recommend that procedural service placing the filter should ascertain adequate follow-up. We are not certain why more males had successful retrieval than females. Further studies are necessary to investigate this finding.

Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease.

BACKGROUND: It is uncertain whether pathologically prolonged international normalized ratio (INR) seen in chronic liver disease (CLD) protects against venous thromboembolism (VTE). Previous studies reported VTE incidence of 0.5% to 1.9% in patients with CLD. We sought to evaluate VTE incidence among hospitalized patients with CLD according to INR levels. METHODS: This was a retrospective cohort study performed at a tertiary university hospital. We included all adult patients admitted with a primary diagnosis of CLD over a 7-year period. The primary outcome was the development of VTE during hospital stay. Patients were divided into quartiles according to their highest admission INR. VTE events and prophylaxis rates were compared among INR quartiles. RESULTS: During the allotted 7-year period, we included 190 patients. Of these, 12 developed VTE events, yielding a VTE incidence of 6.3%. There was no significant difference in the incidence of VTE between INR quartiles. Hospital mortality rates were higher in the higher INR quartiles than in the lower ones (P < .001), but hospital length of stay was not significantly different. Of the patients with documented VTE, one (4.2%) was Child-Pugh stage A, three (4.6%) were stage B, and eight (8.0%) were stage C (P = .602). VTE prophylaxis was not used in 75% of patients. CONCLUSIONS: An elevated INR in the setting of CLD does not appear to protect against the development of hospital-acquired VTE. The notion that "auto-anticoagulation" protects against VTE is unfounded. Use of DVT prophylaxis was extremely low in this population.