This is a secondary analysis of PROTECT focusing on the patientsadmitted to ICU with a primary diagnosis of pneumonia, including hospital-acquired and community- acquired pneumonia. PROTECT was a multicenter RCT conducted in 67 ICUs in Canada, Australia, Brazil, Saudi Arabia, the United States and United Kingdom from 2006 to 2010, to investigate the efficacy of unfractionated heparin (UFH) versus dalteparin (a low–molecular weight heparin) for prevention of venous thromboembolism (VTE) (ClinicalTrials.gov Identifier: NCT00182143) [23, 24]. Inclusion criteria were age ≥ 18 years, weight ≥ 45 kg and expected ICU stay ≥ 3 days. Exclusion criteria were an admission diagnosis of trauma, orthopedic surgery, uncontrolled hypertension or neurosurgery, major hemorrhage within the previous week, pregnancy, stroke, thrombocytopenia, coagulopathy, and limitation of life- support. If patients needed anticoagulant therapy, had a contraindication to heparin or blood products, or were already enrolled in a related trial, then they were also excluded. Written informed consent was obtained from
To determine the frequency, riskfactors and mortality of nosocomial pneumonia a prospective study was conducted in the intensivecareunits. In the study period, 2402 patients were included. The nosocomial pneumonia was defined according to the Centers for Disease Control Criteria. Overall, 163 (6.8%) of the patients developed nosocomial pneumonia and 75.5% (n = 123) of all patients with nosocomial pneumonia were ventilator-associated pneumonia. 163 patients who were admitted to the intensivecare unit during the same period but had no bacteriologic or histologic evidence of pneumonia were used as a control group. The APACHE II score, coma, hypoalbuminemia, mechanical ventilation, tracheotomy, presence of nasogastric tube were found as independent riskfactors. Crude and attributable mortality were 65% and 52.6%, respectively. The mortality rate was five times greater in the cases (OR: 5.2; CI 95%: 3.2–8.3). The mean length of stay in the intensivecare unit and hospital in the cases were longer than controls (p < 0.0001). Patients requiring mechanical ventilation have a high frequency of nosocomial pneumonia.
In model 1, we studied riskfactors for NP acquisition as well as the competing risk 'discharge (dead or alive without prior NP)' (Figure 1). After admission to the ICU (event 0) the patient may (event 1) or may not (event 2) acquire NP. The impact of the following baseline riskfactors were investigated: age, gender, simplified acute physiology score (SAPS) II, intu- bation at ICU admission, infection present already at the time point of ICU admission (pneumonia, urinary tract infection and other infections), hospitalization prior to ICU admission, elec- tive or emergency surgery before ICU admission (for example, head trauma, multiple trauma, vascular surgery and neurosur- gery), underlying diseases (cardial/pulmonal, gastrointestinal, neurological, and metabolic/renal) and other underlying dis- eases (including sepsis, malignancies or alcoholism). The impact of the following time-dependent riskfactors were inves-
Heart Failure is a disease with a high global burden, the prevalence of which is increasing. Most of the data in heart failure are from the west. There is a lacuna in our knowledge of incidence, prevalence, riskfactors and outcome of heart failure in Indian population. Generating this data will help us plan early interventions to tackle riskfactors so that heart failure can be prevented in the community. Data on the patient outcome will help us know if interventions in the future are actually reducing the burden of the disease. We also need to know if the outcome prediction models developed using western data holds true in our Indian population. Last, but not least, in a resource-poor country like India it is important to gauge the economic impact of this disease.
INTRODUCTION. The improvement in the treatment of critical patholo- gies has increased the survival of patientsadmitted to intensivecareunits. Secondarily, some of these patients present psychic and emo- tional physical alterations encompassed in Post Uci syndrome (PICS) OBJECTIVES. To know the quality of life of patients who survive an ICU admission nine months after discharge through the SF-36 survey to es- tablish the incidence of the post-ICU syndrome in our intensivecare unit.Relate these values with the pre-existing clinical situation to obtain riskfactors associated with this syndrome.To assess if there are intra-ICU interventions that favour the appearance of the Post-ICU Syndrome. METHODS. Prospective and longitudinal observational study of a co- hort of patients during the months of March and April 2018 in a polyvalent ICU.We recorded demographic data (sex, age, weight), co- morbidity (Barthel, Charlson), psychopathology (psychiatric history, psychotropic, treatment and toxic habits), as well as the reason for admission to our unit and associated severity (APACHE II and SAPS II).The days of admission to the ICU, death in ICU or hospital, the need for mechanical ventilation and complications (pneumonia asso- ciated with mechanical ventilation, cognitive impairment and pain at discharge) were documented.We recorded interventions performed intra-ICU such as treatment with benzodiazepines and its maximum dose, corticosteroids, muscle relaxants or anxiolytics by nasogastric tube.In a second phase, 9 months after discharge, patients who could be contacted by telephone were evaluated,discarding the de- ceased patients and those residing abroad, and SF-36 survey was conducted for the evaluation of the quality of life (by pone) RESULTS. Out of a total of 50 patients, the survey could be per- formed on 29, of which 24 answered it. The overall results of the SF- 36 survey showed that 95% of our patients obtained values between 56.10 and 75.40, so our patients nine months after discharge had a positive state of health. No intra-ICU intervention was associated with a worse SF-36 score. The only item prior to admission that is related in a statistically significant way to a worse score of SF 36 is previous psychiatric treatment.
A number of studies have documented mortality rates for patients with CAP admitted to ICU [5-7,9-22]. The considerable heterogeneity in admission policies, study design, guidelines compliance , and severity scoring in these studies probably accounts for the wide range of reported mortality rates and makes meaningful com- parisons difficult. Most of these studies have used ICU admission rather than severity scores to indicate severe disease. Only three studies [12,18,21] defined censor points for death, which is important as in-hospital mortality increases following ICU discharge by between 15 and 27% . Admission practices in different countries may also lead to large ranges in mortality. Take for instance one study of 395 patientsadmitted to a Spanish respira- tory ICU in the 1990s the mortality rate was 5% but with rates of mechanical ventilation and septic shock of 9% and 2% respectively , whereas in a UK study published in 1997 the mortality rate was 58%, with mechanical venti- lation and septic shock rates of 96% and 16% respectively . The mortality rates reported here are more in keep- ing with other recent, large cohorts. The CAPUCI group analysed 529 patientsadmitted to over 30 Spanish ICUs between 2000 and 2002 and found ICU mortality rates of 28% with associated APACHE II scores of 19 . They included both immunocompetent and immunosuppressed patients. In the 459 immunocompetent individuals the rate of death at ICU discharge was slightly lower at 25%, a figure that is closer to the 19% seen in the GenOSept cohort, (in which immunocompromised patients were Table 3 Mortality rates in a cohort of 1,166 patients with
Although the precise pathophysiological mechanism of the correlation between higher RDW and mortality is vague, it seems that chronic subclinical inflammation affects iron metabolism as well as bone marrow function and its response to erythropoietin. On the other hand, erythrocyte maturation is suppressed by the inflammatory cytokines and high oxidative stress leading to the entry of newer, larger reticulocytes into the circulation and elevation of RDW. 10 Additionally, RBC
scored based on the Likert scale of 1-4, with 4 being very important and 1 not important. The questionnaire has 5 factors and the total scores range from 45 to 180. The aspects are support (15 items), comfort (6 items), information (8 items), proximity (9 items), and assurance (7 items). In the study by Bandari et al, the Cronbach alpha coefficient was 0.926 for the total scale, and >0.7 for 3 factors of support, comfort, and proximity; it was also 0.6-0.7 for the 2 factors of information and assurance. Results of the current study also indicated face, structural, and differential validities, in addition to internal consistency of the questionnaire. The use of CCFNI has been recommended in the studies. 11 To
The independent predictors of mortality in this study were serum lactate, bilirubin, PT ratio and age. Increased lactate and bilirubin have both been widely found to predict short-term mortality in critically ill cir- rhotic patients [5, 11, 12, 14, 16, 21, 23], but this is the first time they have been associated with poor long- term outcome. Whilst the odds ratio of 4.82 for PT ratio appears large, this ratio represents the increased risk of mortality associated with an increase in the PT ratio of 1, a significant clinical deterioration. Surprisingly, neither alcohol-related disease nor the presence of social depri- vation was found to be associated with poorer outcome, although we may have underestimated a true population effect as the vast majority of the cohort had one or both of these riskfactors. In contrast to a number of previ- ous studies [2, 14, 15, 18], mechanical ventilation at ICU admission was not found to be associated with increased mortality. Notably, readmission to ICU was a significant predictor of survival, although this may reflect a bias where patients who were readmitted to ICU were those with the highest chance of survival.
Ventilator associated pneumonia (VAP) is defined as nosocomial pneumonia developing in a patient 48 hours after the initiation of mechanical ventilator support (by endotracheal tube (ETT) or tracheostomy tube). 1 Despite major advances in the techniques for the management of ventilator dependent patients, VAP continues to complicate the course of 8-28% of the patients receiving mechanical ventilation (MV). 1-5 Rates of pneumonia are considerably higher among patients hospitalized in intensivecareunits (ICUs) compared with those in the hospital wards. The risk of pneumonia is increased 3 to 10 folds for the intubated patient receiving mechanical ventilation. 1 The mortality with VAP is considerably high, varying from 24 to 50% and can reach as high as 76% in some specific settings or when lung infection is caused by high risk pathogens. 2
In both hospitals, age was higher and serum albumin levels lower in patients that died in hospital than those discharged. An observa- tional study by Jinwoo et al.  showed that older-age of patientsadmitted to medical inten- sive care unit, and to a lower extent, heart and respiratory failure are the common riskfactors for venous thromboembolism. Shirakabe et al.  found that lower serum albumin is associ- ated with alkalosis in AHF, which is linked to higher hospital mortality, compared to acid- base balance in AHF. Poor serum albumin lev- els indicated malnutrition and those patients had experienced HF for a period of time. Serum albumin could be used for prognosis of hospital mortality to a certain extent. Metabolic alkalo- sis is a common complication of diuretic thera- py in patients with HF. Severe metabolic alkalo- sis has been associated with adverse effects, and shown to contribute to increased mortality . However, lower normal pH was statistically associated with hospital mortality in BIDMC in this study.
Approximately 49% of the study participants had an AVF. Ongoing community health promotion, education and empowerment of women are probable measures that will prevent the identified patient-related AVFs. To prevent the health-worker-related AVFs, continuing training and retraining of healthcare personnel, particularly on fluid balance management, should be strengthened by emergency obstetric simulation training. Administrative AVFs may be prevented by promoting donation of blood in the SA population to ensure a regular supply of blood/blood products. Lastly, studies such as ours must be brought to the attention of the National Department of Health so that sufficient ICU beds and well- trained health professionals are made available to reduce maternal morbidity and mortality.
organs . Studies in human demonstrated that hyper- oxia could impair the responsiveness of host defense to infections . Hyperoxia may affect a variety of patients ’ biological systems, such as antioxidant enzymes  and cytokine production  through excessive production of reactive oxygen species. Exaggerated apoptosis, in part through the death receptor-mediated signals, accelerates hyperoxia-induced acute lung injury . However, clin- ical studies testing the relationship between hyperoxia and mortality in critically ill patients have yielded conflicting results. For example, in a study of 36,307 patientsadmitted to the intensivecareunits (ICU), no difference in mortality was noted between the patients exposed to hyperoxia and those who did not . In contrast, Page et al. found that there was an association between hyperxia and increased mortality (adjusted odds ratio[aOR] 1.95, 95% confidence interval[CI] 1.34 – 2.85) . These conflicts were also seen in some specified diseases such as 1) patients with cardiac arrest, in which Elmer et al. showed a decreased survival (aOR 0.83, 95%
performed by the multivariable analysis has strongly moved the crude effect of a higher mortality for ICUs with an IMCU in an opposite direction. In non-randomised studies the case-mix adjustment is problematical but necessary . In our study the adjustment was based on patient factors - including SAPS II, admission for ‘basic observation’, presence of infection, more than seven days in hospital before ICU admission and unplanned ICU admission. Besides the patients’ characteristics, we adjusted for countries because we suspected that mortality and health care management vary across countries. Add- itionally, some ICU and hospital characteristics have been introduced in the multivariate model to capture the hos- pital/ICU size (adjusted number of ICU beds, number of hospital beds). The organization of ICU was captured by the following factors: possibility of allocating extra beds inside the ICU, having intermediate care beds inside the ICU and ICU nurse to patient ratio during daytime hours. The size of the hospitals with and without an IMCU is different, being the former larger than the latter (median number of beds 665 vs. 294). A relationship between high volume and better outcome was reported in the EURICUS I database , for some high-risk surgical patients  and ICU cancer patients with septic shock , and a systematic review  confirmed this finding. Neverthe- less, the volume-outcome relationship has been ques- tioned  and a recent study found no correlation between standardized mortality ratio and ICU volume with only mechanically ventilated patients in very low-volume centres . However, in our study we ad- justed hospital mortality also for the size of the hospitals, which was strongly related to the volume of activity. Therefore, we have reason to believe that our finding is not due to the volume-outcome relationship.
Ventilator-Associated Pneumonia (VAP) refers to nosocomial pneumonia occurring 48 hours or more after initiation of mechanical ventilation (MV) . VAP is the most common Hospital- Associated Infection (HAI) among adult patients in IntensiveCareUnits (ICUs), with frequencies ranging from 15-45% . Moreover, it is the second most common HAI after blood stream infection in the paediatric age group, accounting for about 20% of all HAIs in the paediatric intensivecareunits (PICUs) and has a rate of 2.9- 21.6 per 1000 ventilator days . VAP is associated with increased hospital morbidity; mortality; duration of hospitalization by an average of 7-9 days per patient; and health care costs [4-7]. The incidence rates of VAP are higher in developing countries with limited resources . In Egypt, a study of device-associated infection rates in the PICUs in a number of hospitals has showed that the overall rate of HAIs was 24.5% and that of VAP was 31.8 per 1000 ventilator days .
Recent studies suggest that the infection due to MRSA is not only hospital-acquired but community acquired as well . Some large outbreaks have been reported from different parts of the world, where it had caused severe infections including septicemia, endocarditis and menin- gitis . A study by Dickinson in England and Wales has concluded an increase in the trend of death due to MRSA infection . Infections caused by MRSA can be expensive in terms of antibiotic therapy, isolation fa- cilities and materials and length of hospital stay. Ac- cording to a World Health Organization literature, the global financial burden because of MRSA infection has been worked out to be $20,000 to $114,000 for outbreaks and from $28,000 to $1600,000 for endemic infections per year. The common sources of these infections are human patients and carriers . The riskfactors that contribute to MRSA are antibiotics abuse, prolonged hospitalization, intravascular instrumentation and hospi- talization in an intensivecare unit . There is consid- erable variation in numbers of clinical infections among units, hospitals and countries.
Introduction: Thyroid hormones play a key role in the maintenance of body growthby modulating metabolism and the immune system. In the 20th century,researchers found that thyroid dysfunction is associated with theincreased mortality of patientsadmitted to the intensivecareunits (ICU).This study was conducted to evaluate the prognostic value of the thyroid functions; free triiodothyronine(FT3), total triiodothyronine (TT3), free thyroxin (FT4), total thyroxine (TT4) and thyroid-stimulating hormone (TSH) in unselected ICU patients.
The present study describes the characteristics of all the ad- missions to the ICU of patients in a reference center for RD. As expected, there is a predominance of women of re- productive age typical of the behavior of the disease [1, 12, 15]. Compared with different series, both the age and the predominance of the female sex are similar; this is import- ant because although the SLE tends to be thought of as a single entity, its behavior varies significantly according to sex, race, and age . This is evidenced, for example, in Abramovich’s study  that evaluated the mortality of pa- tients with SLE who were admitted to the ICU due to sep- sis. In this study, the average age of admission was 55 years with an accumulated damage scale in SLICC lupus [18, 19] between 5 and 7, which is a high value and with cardiovas- cular comorbidity in 27%. The mortality found was 31%, with the main risk factor being cardiovascular dysfunction due to sepsis, a finding that is not found in other series and was expected considering their baseline characteristics.
Methods: We assessed associations between race and outcomes (IntensiveCare Unit [ICU] variables, LOS, 30-day mortality) for African-American or Caucasian patients over 65 years hospitalized in the Veterans Health Administration (VHA) with CAP (2002-2007). Patientsadmitted to the ICU were analyzed separately from those not admitted to the ICU. VHA patients who died within 30 days of discharge were excluded from all LOS analyses. We used chi-square and Fisher’s exact statistics to compare dichotomous variables, the Wilcoxon Rank Sum test to compare age by race, and Cox Proportional Hazards Regression to analyze hospital LOS. We used separate generalized linear mixed-effect models, with admitting hospital as a random effect, to examine associations between patient race and the receipt of guideline-concordant antibiotics, ICU admission, use of mechanical ventilation, use of vasopressors, LOS, and 30-day mortality. We defined statistical significance as a two-tailed p ≤ 0.0001.
microbiological criteria for diagnosis of VAP. The overall incidence of VAP rate was 46.6 per 1000 ventilation days. The incidence of VAP reported in different studies conducted at various centers varies from 24% to 67%. (Fagon et al., 1988; Kerver et al., 1987; Torres et al., 1990; Mukhopadhyay et al., 2003; Kanafani, 2003; Rakshit et al., 2005; Ranjan et al., 2014; Dominic et al., 2012) This variation in the incidence of VAP as observed above is probably related to factors like differences in patient populations, hospital infection control and critical care practices and variability in data collection methods as well as variability in the definition of VAP. A study conducted in Pondicherry, India, showed a incidence rate of 22.94 per 1,000 ventilator days. (Joseph et al., 2009) In other Asian countries, the incidence rate is relatively less, ranging from 9 to 12 per 1,000 ventilator days. (Aly et al., 2008; Suka et al., 2007) The higher incidence of VAP in our study could be attributed to a lower number of cases and lack of adequate nursing staff which may have adversely affected the quality of care given to the patients. The health-seeking behavior of our patients is different compared with that in developed world. Patients seek medical help only when it is absolutely inevitable. By the time patient is referred to the tertiary-care centre, his underlying condition is well advanced and may be irreversible. This may necessitate longer duration of MV, which is directly proportional to development of VAP. The other most important factor in our set-up the number of cases of poisoning that predominated requiring prolonged ventilation, which is proved to be a risk factor.