Impact of Baseline Characteristics on Future Episodes of Bloodstream Infections: Multistate Model in Septic Patients With Bloodstream Infections.

BACKGROUND: Looking only at the index infection, studies have described risk factors for infections caused by resistant bacteria. We hypothesized that septic patients with bloodstream infections may transition across states characterized by different microbiology and that their trajectory is not uniform. We also hypothesized that baseline risk factors may influence subsequent blood culture results. METHODS: All adult septic patients with positive blood cultures over a 7-year period were included in the study. Baseline risk factors were recorded. We followed all survivors longitudinally and recorded subsequent blood culture results. We separated states into bacteremia caused by gram-positive cocci, susceptible gram-negative bacilli (sGNB), resistant GNB (rGNB), and Candida spp. Detrimental transitions were considered when transitioning to a culture with a higher mortality risk (rGNB and Candida spp.). A multistate Markov-like model was used to determine risk factors associated with detrimental transitions. RESULTS: A total of 990 patients survived and experienced at least 1 transition, with a total of 4282 transitions. Inappropriate antibiotics, previous antibiotic exposure, and index bloodstream infection caused by either rGNB or Candida spp. were associated with detrimental transitions. Double antibiotic therapy (beta-lactam plus either an aminoglycoside or a fluoroquinolone) protected against detrimental transitions. CONCLUSION: Baseline characteristics that include prescribed antibiotics can identify patients at risk for subsequent bloodstream infections caused by resistant bacteria. By altering the initial treatment, we could potentially influence future bacteremic states.

[Ibero-latinamerican clinical practical guidelines on pediatric caustic esophagitis: Physiopathology and clinical-endoscopic diagnosis (1st Part)]. / Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: Fisiopatología y diagnóstico clínico-endoscópico (1a Parte).

Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) successive papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

[Ibero-Latinamerican Clinical Practical Guidelines on pediatric caustic esophagitis: Therapeutical aspects (Part 2)]. / Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: Aspectos terapéuticos (2a. Parte).

Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) separate papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

Host-Pathogen-Treatment Triad: Host Factors Matter Most in Methicillin-Resistant Staphylococcus aureus Bacteremia Outcomes.

Previous studies have separately emphasized the importance of host, pathogen, and treatment characteristics in determining short-term or in-hospital mortality rates for patients with methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections. Less is known about the relative importance of these factors and their interactions in determining short-, medium-, and long-term mortality rates. This is an observational cohort study in which data for all patients admitted to the University of New Mexico (UNM) Health Sciences Center (HSC) between July 2002 and August 2013 with MRSA-positive blood cultures were recorded. We collected patients' demographics and treatment data, as well as data on genetic markers of the MRSA isolates. Outcomes of interest were determinants of short-term (within 30 days), medium-term (30 to 90 days), and long-term (>90 days) mortality rates. This study included 273 patients with MRSA bacteremia. Short-, medium-, and long-term mortality rates were 18.7%, 26.4%, and 48%, respectively. Thirty-day mortality rates were influenced by host variables and host-pathogen interaction characteristics. Pitt bacteremia scores, malignancy, and health care exposure contributed to 30- to 90-day mortality rates, while treatment duration of >4 weeks had a protective effect. Age remained a significant risk factor for death at >90 days, while admission leukocytosis was protective. Infection represented the most frequent cause of death for all three time frames; rates varied from 72.6% in the first 30 days and 60% for 30 to 90 days to 35.7% for >90 days (P = 0.003). Host characteristics affect short-, medium-, and long-term mortality rates for MRSA bloodstream infections more than do pathogen genetic markers and treatment factors.

Predicting Resistance to Piperacillin-Tazobactam, Cefepime and Meropenem in Septic Patients With Bloodstream Infection Due to Gram-Negative Bacteria.

BACKGROUND: Predicting antimicrobial resistance in gram-negative bacteria (GNB) could balance the need for administering appropriate empiric antibiotics while also minimizing the use of clinically unwarranted broad-spectrum agents. Our objective was to develop a practical prediction rule able to identify patients with GNB infection at low risk for resistance to piperacillin-tazobactam (PT), cefepime (CE), and meropenem (ME). METHODS: The study included adult patients with sepsis or septic shock due to bloodstream infections caused by GNB admitted between 2008 and 2015 from Barnes-Jewish Hospital. We used multivariable logistic regression analyses to describe risk factors associated with resistance to the antibiotics of interest (PT, CE, and ME). Clinical decision trees were developed using the recursive partitioning algorithm CHAID (χ2 Automatic Interaction Detection). RESULTS: The study included 1618 consecutive patients. Prevalence rates for resistance to PT, CE, and ME were 28.6%, 21.8%, and 8.5%, respectively. Prior antibiotic use, nursing home residence, and transfer from an outside hospital were associated with resistance to all 3 antibiotics. Resistance to ME was specifically linked with infection attributed to Pseudomonas or Acinetobacter spp. Discrimination was similar for the multivariable logistic regression and CHAID tree models, with both being better for ME than for PT and CE. Recursive partitioning algorithms separated out 2 clusters with a low probability of ME resistance and 4 with a high probability of PT, CE, and ME resistance. CONCLUSIONS: With simple variables, clinical decision trees can be used to distinguish patients at low, intermediate, or high risk of resistance to PT, CE, and ME.

Layer 1 NDNF interneurons are specialized top-down master regulators of cortical circuits.

Diverse types of inhibitory interneurons (INs) impart computational power and flexibility to neocortical circuits. Whereas markers for different IN types in cortical layers 2-6 (L2-L6) have been instrumental for generating a wealth of functional insights, only the recent identification of a selective marker (neuron-derived neurotrophic factor [NDNF]) has opened comparable opportunities for INs in L1 (L1INs). However, at present we know very little about the connectivity of NDNF L1INs with other IN types, their input-output conversion, and the existence of potential NDNF L1IN subtypes. Here, we report pervasive inhibition of L2/3 INs (including parvalbumin INs and vasoactive intestinal peptide INs) by NDNF L1INs. Intersectional genetics revealed similar physiology and connectivity in the NDNF L1IN subpopulation co-expressing neuropeptide Y. Finally, NDNF L1INs prominently and selectively engage in persistent firing, a physiological hallmark disconnecting their output from the current input. Collectively, our work therefore identifies NDNF L1INs as specialized master regulators of superficial neocortex according to their pervasive top-down afferents.

Acute kidney injury criteria predict outcomes of critically ill patients.

OBJECTIVE: The Acute Kidney Injury Network's proposed definition for acute kidney injury (increment of serum creatinine > or = 0.3 mg/dL or 50% from baseline within 48 hrs or urine output < 0.5 mL/kg/hr for > 6 hrs despite fluid resuscitation when applicable) predicts meaningful clinical outcomes. DESIGN: Retrospective cohort study. SETTING: A 350-bed community teaching hospital. PATIENTS: The study population consisted of 471 patients with no recent history of renal replacement therapy who were admitted to the medical intensive care unit during 1 yr. INTERVENTIONS: Medical records of all patients were reviewed using a data abstraction tool. Demographic information, diagnoses, risk factors for acute kidney disease, physiologic and laboratory data, and outcomes were recorded. MEASUREMENTS AND MAIN RESULTS: Of 496 patients, 471 were not receiving renal replacement therapy in the weeks before medical intensive care unit admission; 213 had changes > or = .3 mg/dL in serum creatinine within 48 hrs and/or urine output of < or = .5 mL/kg/hr for > 6 hrs. Detailed fluid challenge information was available for only 123 patients, who met acute kidney injury criteria, and three patients reversed after administration of > or = 500 mL of intravenous fluid and/or blood products. All patients whose creatinine increased > or = 50% also had increments > or = 0.3 mg/dL. The 120 patients with acute kidney injury were older (mean +/- SE: 69.3 +/- 1.7 vs. 62.9 +/- 1.3, p < .01), were more ill (Acute Physiology and Chronic Health Evaluation II score 18.7 +/- .6 vs. 13.3 +/- .4, p < .01), and had multiple comorbidities (two or more organs, 65% vs. 51.3%, p < .01) compared with those without acute kidney injury. The mortality rate of patients who met criteria for acute kidney injury was significantly higher than that of patients who did not have acute kidney injury (45.8 vs. 16.4%, p < .01). In multivariate logistic regression analyses, acute kidney injury was an independent predictor of mortality (adjusted odds ratio 3.7, 95% confidence interval 2.2-6.1). Acute kidney injury was a better predictor of in-hospital mortality than was Acute Physiology and Chronic Health Evaluation II score, advanced age, or presence of nonrenal organ failures. Median hospital stay was twice as long in patients with acute kidney injury (14 vs. 7 days, p < .01), and only patients with acute kidney injury required hemodialysis during hospitalization. The oliguria criterion of acute kidney injury did not affect the odds of in-hospital mortality. CONCLUSIONS: The Acute Kidney Injury Network definition of acute kidney injury predicts hospital mortality, need for renal replacement therapy, and prolonged hospital stay in critically ill patients. An increment of serum creatinine > or = 0.3 mg/dL in 48 hrs alone predicts clinical outcomes as well as the full Acute Kidney Injury Network definition.

HPRT deficiency in a two-month-old child presenting acute renal failure and gout with a new deletion of two bases in exon 3 of the HPRT gene.

We describe an HPRT deficiency in a 2-month-old child who presented acute renal failure and gout with normal mental and motor development for age. The patient was diagnosed with Lesch-Nyhan disease and showed a new mutation, a deletion of two bases in exon 3 of the HPRT gene (c.269-270delAT).

A cohort study of bacteremic pneumonia: The importance of antibiotic resistance and appropriate initial therapy?

Bacteremic pneumonia is usually associated with greater mortality. However, risk factors associated with hospital mortality in bacteremic pneumonia are inadequately described.The study was a retrospective cohort study, conducted in Barnes-Jewish Hospital (2008-2015). For purposes of this investigation, antibiotic susceptibility was determined according to ceftriaxone susceptibility, as ceftriaxone represents the antimicrobial agent most frequently recommended for hospitalized patients with community-acquired pneumonia as opposed to nosocomial pneumonia. Two multivariable analyses were planned: the first model included resistance to ceftriaxone as a variable, whereas the second model included the various antibiotic-resistant species (methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae).In all, 1031 consecutive patients with bacteremic pneumonia (mortality 37.1%) were included. The most common pathogens associated with infection were S aureus (34.1%; methicillin resistance 54.0%), Enterobacteriaceae (28.0%), P aeruginosa (10.6%), anaerobic bacteria (7.3%), and Streptococcus pneumoniae (5.6%). Compared with ceftriaxone-susceptible pathogens (46.8%), ceftriaxone-resistant pathogens (53.2%) were significantly more likely to receive inappropriate initial antibiotic treatment (IIAT) (27.9% vs 7.1%; P < 0.001) and to die during hospitalization (41.5% vs 32.0%; P = 0.001). The first logistic regression analysis identified IIAT with the greatest odds ratio (OR) for mortality (OR 2.2, 95% confidence interval [CI] 1.5-3.2, P < 0.001). Other independent predictors of mortality included age, mechanical ventilation, immune suppression, prior hospitalization, prior antibiotic administration, septic shock, comorbid conditions, and severity of illness. In the second multivariable analysis that included the antibiotic-resistant species, IIAT was still associated with excess mortality, and P aeruginosa infection was identified as an independent predictor of mortality (OR 1.6, 95% CI 1.1-2.2, P = 0.047), whereas infection with ceftriaxone-resistant Enterobacteriaceae (OR 0.6, 95% CI 0.4-1.0, P = 0.050) was associated with lower mortality.More than one-third of our patients hospitalized with bacteremic pneumonia died. IIAT was identified as the most important risk factor for hospital mortality and the only risk factor amenable to potential intervention. Specific antibiotic-resistant pathogen species were also associated with mortality.

Development and validation of a clinical prediction rule for candidemia in hospitalized patients with severe sepsis and septic shock.

OBJECTIVE: To develop and internally validate a prediction rule for the presence of candidemia in patients with severe sepsis and septic shock (candidemia rule) that will fill the gap left by previous rules. To compare the accuracy of the available Candida prediction models. DESIGN: Retrospective cohort study. SETTING: Barnes-Jewish Hospital, St. Louis, Missouri. PATIENTS/SUBJECTS: Two thousand five hundred ninety-seven consecutive patients with a positive blood culture and severe sepsis or septic shock. INTERVENTIONS: Logistic regression and a bootstrap resampling procedure were employed for model development and internal validation. MEASUREMENTS AND MAIN RESULTS: Two hundred sixty-six (10.2%) had blood cultures positive for Candida spp. Mortality was significantly higher in patients with candidemia than in patients with bacteremia (47.0% versus 28.4%; P<.001). Administration of total parenteral nutrition, prior antibiotic exposure, transfer from an outside hospital or admission from a nursing home, mechanical ventilation and presence of a central vein catheter were independent predictors of candidemia while the lung as a source for infection was protective. The prediction rule had an area under the receiver operating characteristic curve of 0.798 (95% CI 0.77-0.82). Internal validation using bootstrapping technique with 1000 repetitions produced a similar area under the receiver operating characteristic curve of 0.797 (bias, -0.037; root mean square error 0.039). Our prediction rule outperformed previous rules with a better calibration slope of 0.96 and Brier score of 0.08. CONCLUSIONS: We developed and internally validated a prediction rule for candidemia in hospitalized patients with severe sepsis and septic shock that outperformed previous prediction rules. Our study suggests that locally derived prediction models may be superior by accounting for local case mix and risk factor distribution.

Detection of anti-tissue transglutaminase IgA antibodies (tTG IgA) in children with type 1 diabetes mellitus / Detección de anticuerpos IgA antitransglutaminasa tisular (IgA-TGT) en niños con diabetes mellitus tipo 1

Abstract Introduction: Children with type 1 diabetes mellitus (DM1) are more likely to develop celiac disease (CD), which is an underdiagnosed condition due to its variable clinical presentation. Therefore, children with DM1 require periodic monitoring to achieve an early diagnosis of CD. Objectives: To identify positivity for the detection of anti-tissue transglutaminase IgA antibodies (tTG-IgA) in children with DM1, as well as to describe gastrointestinal (GI) symptoms, anthropometric status indicators and gluten intake levels. Materials and methods: Descriptive cross-sectional study. The population was composed of children with DM1 who attended the outpatient service of two pediatric endocrinology centers in Bogotá, Colombia. The Biocard-Celiac® test was used to detect the presence of tTG-IgA. In addition, participants were asked about their GI symptoms and underwent an anthropometric nutritional assessment. Gluten intake was assessed by recording dietary intake for 72 hours. A statistical data analysis was performed using the SPSS software version 22.0. Results: The final sample included 45 children with an average age of 10.6±4.1 years, of which 53% were males. None of the participants had a positive result in the tTG-IgA test. The most frequent GI symptoms were flatulence (48.9%) and abdominal pain (28.9%). Only 3 children (6.7%) were below the height-for-age standard. The average gluten intake was 5.29±3.02 g/day. Conclusions: Although children with DM1 are at increased risk of developing CD, none of the participants tested positive for tTG-IgA.

Resumen Introducción. Los niños con diabetes mellitus tipo 1 (DM1) tienen mayor probabilidad de desarrollar enfermedad celiaca (EC), la cual es una condición subdiagnosticada debido a que su presentación clínica varía; por lo tanto, es necesario monitorear periódicamente a esta población con el objetivo de diagnosticar a tiempo la EC. Objetivos. Identificar la positividad para la detección de anticuerpos IgA antitransglutaminasa tisular (IgA-TGT) en población pediátrica con DM1, así como describir los síntomas gastrointestinales (SGI), los indicadores antropométricos y los niveles de ingesta de gluten. Materiales y métodos. Estudio descriptivo de corte transversal. La población estuvo compuesta por niños con DM1 que asistieron al servicio de consulta externa en dos centros de endocrinología pediátrica en Bogotá D.C., Colombia. Para detectar la presencia de IgA-TGT se aplicó el test Biocar-dTM Celiac®. Además, se indagó sobre los SGI y se realizó valoración nutricional antropométrica de los participantes. Para evaluar la ingesta de gluten se llevó a cabo un registro dietético de 72 horas. El análisis estadístico de los datos se realizó con el programa SPSS versión 22.0. Resultados. La muestra final estuvo compuesta por 45 niños con una edad promedio de 10.6±4.1 años, de los cuales 53% eran varones. Ninguno de los pacientes presentó positividad cualitativa en el test aplicado para detección de IgA-TGT. Los SGI más frecuentes fueron flatulencias (48.9%) y dolor abdominal (28.9%). Solo en 3 niños (6.7%) se observó talla baja con respecto a su edad. La ingesta promedio de gluten fue 5.29±3.02 g/día. Conclusiones. Pese a que los niños con DM1 tienen mayor riesgo de desarrollar EC, ninguno de los participantes presentó positividad para IgA-TGT.

Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: fisiopatología y diagnóstico clínico-endoscópico (1a Parte) / Ibero-latinamerican clinical practical guidelines on pediatric caustic esophagitis: physiopathology and clinical-endoscopic diagnosis (1st Part)

Resumen: La ingestión de cáusticos representa un grave problema médico-social por las consecuencias devastadoras e irreversibles que puede producir en el tracto digestivo superior. En Iberoamérica no se han publicado datos fidedignos sobre la incidencia o la prevalencia de lesiones inducidas por cáusticos. La información disponible sobre la presentación clínica, diagnóstico, tratamiento y pronóstico se basa en series retrospectivas de casos y, de hecho, su manejo clínico se sustenta en muchos casos fundamentalmente en la opinión de expertos. Recientemente como una iniciativa de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP) y con la co laboración de colegas de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediá trica (SEGHNP), hemos diseñado una Guía de Práctica Clínica (GPC) la cual incluye una serie de enunciados y recomendaciones dirigidos a optimizar la atención a los pacientes y que se basan en la revisión sistemática de la evidencia. En dos (2) manuscritos sucesivos nos hemos enfocado primero, en los aspectos fisiopatológicos y de diagnóstico clínico-endoscópico de la esofagitis cáustica en niños (1a. Parte) y en segundo lugar, en los aspectos más relevantes del tratamiento (2a. Parte). Esperamos esta guía se convierta en una herramienta útil para el clínico en el difícil proceso de toma de decisio nes a la hora de evaluar un paciente posterior a la ingesta de una sustancia cáustica.

Abstract: Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) successive papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: aspectos terapéuticos (2a. Parte) / Ibero-Latinamerican Clinical Practical Guidelines on pediatric caustic esophagitis: therapeutical aspects (Part 2)

Resumen: La ingestión de cáusticos representa un grave problema médico-social por las consecuencias devastadoras e irreversibles que puede producir en el tracto digestivo superior. En Iberoamérica no se han publicado datos fidedignos sobre la incidencia o la prevalencia de lesiones inducidas por cáusticos. La información disponible sobre la presentación clínica, diagnóstico, tratamiento y pronóstico se basa en series retrospectivas de casos y, de hecho, su manejo clínico se sustenta en muchos casos fundamentalmente en la opinión de expertos. Recientemente como una iniciativa de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP) y con la co laboración de colegas de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediá trica (SEGHNP), hemos diseñado una Guía de Práctica Clínica (GPC) la cual incluye una serie de enunciados y recomendaciones dirigidos a optimizar la atención a los pacientes y que se basan en la revisión sistemática de la evidencia. En dos (2) manuscritos sucesivos nos hemos enfocado primero, en los aspectos fisiopatológicos y de diagnóstico clínico-endoscópico de la esofagitis cáustica en niños (1a. Parte) y en segundo lugar, en los aspectos más relevantes del tratamiento (2a. Parte). Esperamos esta guía se convierta en una herramienta útil para el clínico en el difícil proceso de toma de decisio nes a la hora de evaluar un paciente posterior a la ingesta de una sustancia cáustica.

Abstract: Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) separate papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

Elders' environs and their end-of-life preferences.

HYPOTHESIS: Elders' predilections regarding end-of-life interventions vary with their living environs. METHODS: Patients in 3 settings--assisted living/outpatient, skilled nursing facility (SNF), and acute hospitalization--were asked to complete a brief questionnaire. RESULTS: A total of 269 patients who averaged 80.0 ± (SD) 8.1 years, 44% male, 70% white were studied. Eighty-five patients were outpatient elderly, 101 were hospitalized for acute illnesses, and 83 were interviewed in SNFs. Outpatients (44/85; 52%) and acutely ill inpatients (40/101; 40%) were more likely than patients residing in SNFs (19/81; 23%) to choose comfort care only (P = .047) for acute pneumonia requiring endotracheal intubation (ETI). Overall, 32% changed their choice for ETI, opting for comfort care only if acute pneumonia was followed by disposition to an SNF. However, ambulatory and acutely ill elderly patients were 3 times as likely as SNF patients to change from aggressive to comfort care if the most likely outcome was disposition to an SNF (P < .001). In multivariate regression models, age (>80), gender, number of lost ADLs (>2), and self-described quality of life were not associated with choosing comfort care instead of ETI, whereas place of residence (SNF versus home) was independently associated with choosing ETI (odds ratio = 3.5; 95%CI = 1.9-6.4). Similarly, those already living in an SNF were more likely to opt for remaining there for advancing dementia (odds ratio = 7.7; 95%CI = 3.8-15.8). However, choices for ETI did not coincide with choosing an SNF for advancing dementia. CONCLUSIONS: Elders residing in nursing homes were more likely than ambulatory patients to request invasive end-of-life care, a difference that was more pronounced when outcome required disposition to an SNF. These preferences were not dependent on patients' self-described disability or quality of life. This study suggests that qualitative outcomes matter to patients and their choices are associated with their place of residence.

Accuracy of bedside physical examination in distinguishing categories of shock: a pilot study.

HYPOTHESIS: Selected elements of a simple physical examination algorithm accurately predict categories of shock. SETTING: A 350-bed community teaching hospital. METHODS: Resident trainees who manage all critically ill and medically unstable patients were instructed to document capillary refill, (palpated) pulse volume, skin temperature, jugular venous pressure (JVP) and lung examination in all patients with prolonged (>30 minutes hypotension <90 mmHg). Treatment was determined by house officers guided by attending physicians of record. All cases were retrospectively reviewed by a senior clinician who applied consensus criteria/definitions to categorize shock as septic, cardiogenic or hypovolemic. Operating characteristics of examination findings for predicting categories of shock were computed. RESULTS: A total of 68 patients, averaging 71 ± 16 years, were studied. A total of 37 patients were diagnosed with septic shock, 18 with cardiogenic shock of and 13 with hypovolemic shock. Capillary refill and skin temperature predicted septic shock with sensitivity of 89%, specificity of 68%, positive predictive value (PPV) of 77%, negative predictive value (NPV) of 84%, and overall accuracy of 79%. Presence of JVP >7 cmH(2)O was more accurate than bilateral pulmonary crackles (>1/3 from bases) in predicting cardiogenic shock for low-output patients with sensitivity of 82%, specificity of 79%, PPV of 75%, NPV of 85%, and overall accuracy of 80%. Using just skin temperature and JVP, the bedside approach correctly diagnosed 52/68 cases (overall accuracy = 76%). CONCLUSIONS: Simple bedside clinical examination findings correctly predict categories of shock in a majority of cases.

Gurgling breath sounds may predict hospital-acquired pneumonia.

OBJECTIVES: To determine whether gurgling sounds heard during speech or quiet breathing, with or without a stethoscope over the glottis, predict hospital-acquired pneumonia (HAP). METHODS: All patients admitted to the respiratory or general medicine ward of a 350-bed community teaching hospital were eligible. Patients were examined each day, and those who had upper airway gurgling, heard with or without the stethoscope, during breathing or speech at any point during admission were noted. Assuming an overall incidence of HAP (>48 h after admission) of 5% to 10% and estimated incidence of 30% to 50% in patients with gurgle, 20 patients with gurgle and 60 patients without gurgle, matched on the same day and ward of admission, were included in the study. Demographic, physiologic, and outcome variables were compared using univariate and multivariate techniques to ascertain whether gurgling is independently associated with HAP, rate of transfer to ICU, and inhospital mortality. RESULTS: Twenty patients with gurgle were compared with 60 patients without gurgle. Patients with gurgle were older (78.5 vs 65.2 y; P < .001), more likely to reside in nursing homes (75% vs 6%; P < .001), and were more likely to have dementia (70% vs 13%; P < .001). In multivariate analysis, dementia (odds ratio [OR] = 23.4; 95% CI, 4.2-131.9) and recent (within 24 h) treatment with opiates (OR = 14.7; 95% CI, 2.2-97.5) emerged as the only statistically significant independent predictors of gurgling. HAP occurred in 55% of patients with gurgle compared with 1.7% of patients without gurgle (P < .001), and 50% of patients with vs 3.3% of patients without gurgle required transfer to ICU (P < .001). After adjustment for age, Charlson score, dementia, opiate administration, and stroke, gurgling emerged as the sole independent predictor of HAP (OR = 140.1; 95% CI, 5.6-3,529.4) and ICU transfer (OR = 35.1; 95% CI, 4.1-303.7). Gurgling did not predict mortality; the Charlson comorbidity index was the only significant predictor of inhospital death. CONCLUSIONS: Gurgling sounds heard during quiet breathing or speech are independently associated with HAP.

Outcomes of cardiopulmonary resuscitation for patients on vasopressors or inotropes: a pilot study.

HYPOTHESIS: Outcomes of critically ill patients who receive cardiopulmonary resuscitation (CPR) are poor, and the subgroup on vasopressors or inotropes before cardiopulmonary arrest (CPA) rarely survives. SETTING: The setting of the study was a critical care unit of a 350-bed community teaching hospital. STUDY DESIGN: This was a retrospective, cohort study. METHODS: A retrospective review was performed of medical records of all patients, identified through medical billing and hospital committee records, who received CPR for CPA in a critical care unit. RESULTS: Of 83 patients, with an average age of 66 years, 14 (17%) survived to hospital discharge. Patients with pulseless electrical activity and asystole were significantly less likely to survive (9% and none, respectively; P = .0001). Only 2 (4%) of 55 critically ill patients receiving vasopressors before CPR survived, whereas 12 of 28 patients not on vasopressors survived (P < .0001). Although mechanical ventilation just before CPR was highly associated with administration of vasopressors, ventilation was not significantly associated with mortality (P = .13). Mortality of patients on vasopressors was higher for both mechanically ventilated (95% vs 33%, P < .001) and spontaneously breathing (100% vs 64%, P = .02) patients. In multiple logistic regression analyses, administration of vasopressors was the only variable independently associated with in-hospital mortality (odds ratio, 35.1; 95% confidence interval = 4.1-304.3). CONCLUSIONS: Survival of patients requiring CPR during critical care admission was 17%. Very few patients survived who required vasopressors or inotropes immediately before CPA. This study is limited significantly by its retrospective design and small cohort, and so this question should be reexamined in a larger study.