Annals of the American Thoracic Society最新文献

Rationale: Intrapleural enzyme therapy (IET) with tissue plasminogen activator (tPA) and DNase has been shown to reduce the need for surgical intervention for complicated parapneumonic effusion/empyema (CPPE/empyema). Failure of IET may lead to delayed care and increased length of stay. Objectives: The goal of this study was to identify risk factors for failure of IET. Methods: We performed a multicenter, retrospective study of patients who received IET for the treatment of CPPE/empyema. Clinical and radiological variables at the time of diagnosis were included. We compared four different machine learning classifiers (L1-penalized logistic regression, support vector machine [SVM], extreme gradient boosting [XGBoost], and light gradient-boosting machine [LightGBM]) by multiple bootstrap-validated metrics, including F-β, to demonstrate model performances. Results: A total of 466 participants who received IET for pleural infection were included from five institutions across the United States. Resolution of CPPE/empyema with IET was achieved in 78% (n = 365). SVM performed superiorly, with median F-β of 56%, followed by L1-penalized logistic regression, LightGBM, and XGBoost. Clinical and radiological variables were graded based on their ranked variable importance. The top two significant predictors of IET failure using SVM were the presence of an abscess/necrotizing pneumonia (17%) and pleural thickening (13%). Similarly, LightGBM identified abscess/necrotizing pneumonia (35%) and pleural thickening (26%) and XGBoost indicated pleural thickening (36%) and abscess/necrotizing pneumonia (17%) as the most significant predictors of treatment failure. Predictors identified by the L1-penalized logistic regression model were pleural thickening (18%) and pleural fluid lactate dehydrogenase (LDH) (9%). Conclusions: The presence of abscess/necrotizing pneumonia and pleural thickening consistently ranked among the strongest predictors of IET failure in all machine learning models. The difference in rankings between models may be a consequence of the different algorithms used by each model. These results indicate that the presence of abscess/necrotizing pneumonia and pleural thickening may predict IET failure. These results should be confirmed in larger studies.

Rationale: Propofol is one of the first-line sedative-hypnotic agents for critically ill adults requiring mechanical ventilation. Although propofol can elevate triglyceride levels, and the latter is a risk factor for pancreatitis, the association between propofol and acute pancreatitis is unclear. Objectives: We sought to determine the clinical impact and potential associations between propofol infusion, hypertriglyceridemia, and acute pancreatitis. Methods: This is an observational multicenter study of adults (⩾18 yr old) who were admitted to an intensive care unit, who required mechanical ventilation and received continuous propofol infusion for at least 24 hours. The primary outcomes were the frequency of hypertriglyceridemia (>400 mg/dl) and acute pancreatitis. Further analyses were done to determine the clinical impact of elevated triglyceride levels (i.e., sedation changes) and risk factors for pancreatitis development. Results: Of 11,828 patients included, 33.2% (n = 3,922) had triglyceride levels measured, of whom 21.7% (n = 851) had hypertriglyceridemia at 4.5 days (SD = 6.8) after propofol initiation. Of those still requiring sedation, 70.4% (n = 576/818) received alternative sedatives after developing hypertriglyceridemia. Pancreatitis occurred in 1.2% of patients (n = 47/3,922) and was more frequent in those with hypertriglyceridemia (3.2%, 27/851; vs. 0.7%, 20/3,071; P < 0.001). After adjustment for potential confounding variables, each 100 mg/dl increase in triglyceride levels was associated with an 11% increase in risk of pancreatitis. Propofol dose was not associated with pancreatitis development. Conclusions: Acute pancreatitis is uncommon in patients receiving propofol infusion, and it occurs over a wide range of triglyceride levels, indicating a multifactorial pathophysiology. Hypertriglyceridemia frequently prompts the use of alternative sedatives. Further study is needed to determine how to best monitor and treat hypertriglyceridemia in critically ill patients receiving propofol infusion.

Rationale: Despite functional impairments, intensive care unit (ICU) survivors can perceive their quality of life as acceptable. Objectives: To investigate discrepancies between calculated health, based on self-reported physical, mental, and cognitive functioning and perceived health, 1 year after ICU admission. Methods: Data from an ongoing prospective multicenter cohort study, MONITOR-IC, were used. Patient-reported physical, mental, and cognitive functioning and perceived health (EuroQol visual analog scale; range, 0-100) 1 year post-ICU of patients admitted to 1 of 11 participating ICUs between July 2016 and September 2021 were analyzed. The relationship between functional outcomes and perceived health was modeled using linear regression. Calculated health for each patient was estimated using this model and compared with patients' perceived health, the difference reflecting a discrepancy. On the basis of a minimal clinically important difference of 8 points, three groups were defined: patients who rated their health better than calculated (positive discrepancy), patients who rated their health worse than calculated (negative discrepancy), and patients whose perceived health was concordant with their calculated health. Results: A total of 2,545 patients were analyzed, of whom 45.0% (n = 1,146) showed a discrepancy between calculated and perceived health. Patients with a negative discrepancy rated their health significantly lower (median, 50; interquartile range, 36-66) than patients with a positive discrepancy (median, 84; interquartile range, 75-90). Importantly, there were no significant differences in physical, mental, and cognitive functioning between patients with a negative versus positive discrepancy. Patients with a negative discrepancy had a higher education level and were more often unemployed. Conclusions: One year post-ICU, almost half of ICU survivors showed a discrepancy between calculated health and perceived health.

Rationale: Understanding the health risks associated with extreme weather events is needed to inform policies to protect vulnerable populations. Objectives: To estimate heat and cold wave-related mortality risks in a cohort of veteran patients with chronic obstructive pulmonary disease (COPD) and explore disparities among strata of comorbidities, tobacco exposure, and urbanicity. Methods: We designed a time-stratified case-crossover study among deceased patients with COPD between 2016 and 2021 in the Veterans Health Administration system. Distributed lag models with conditional logistic regression estimated incidence rate ratios of heat and cold wave-associated mortality risk from lag days 0 to 3 for heatwaves and lag days 0 to 7 for cold waves. Attributable risks (ARs) per 100,000 patients were also calculated. Results: Of the 377,545 deceased patients with COPD, the largest heatwave-related mortality risk was in patients with COPD and asthma (AR, 14,016; 95% confidence interval [CI], -326, 30,706) across lag days 0 to 3. The largest cold wave-related mortality burden was in patients with COPD with no other reported comorbidities (AR, 1,704; 95% CI, 759, 2,686) across lag days 0 to 7. Patients residing in urban settings had the greatest heatwave-related (AR, 1,062; 95% CI, 576, 1,559) and cold wave-related (AR, 1,261; 95% CI, 440, 2,105) mortality risk (across lag days 0 to 1 and 0 to 7, respectively). There were no differences in mortality risk by tobacco exposure. Conclusions: Our findings show that individuals with COPD are susceptible to heat and cold waves. This information can inform clinical practice and public health policy about the mortality risk vulnerable populations experience with respect to extreme weather conditions. Furthermore, our results may be used in the development and refinement of future extreme weather warning systems designed for public health purposes.

Rationale: Early identification of intensive care unit (ICU) patients likely to benefit from specialist palliative care could reduce the time such patients spend in the ICU receiving care inconsistent with their goals. Objectives: To evaluate the real-world effects of early screening for palliative care criteria in a medical ICU. Methods: We performed a retrospective cohort study in adults admitted to the ICU using a causal inference approach with instrumental variable analysis. The intervention consisted of screening ICU admissions for palliative care trigger conditions and, if present, offering specialist palliative care consultation, which could be accepted or declined by the ICU. We evaluated specialist palliative care use in pre and postimplementation cohorts from the year before and after screening implementation began (October 2022). In the postimplementation cohort, we compared use of specialist palliative care in those who received early screening versus not. We then estimated the effect of early screening on the primary outcome of days to do-not-resuscitate (DNR) code status or ICU discharge, with death without a DNR order placed at the 99th percentile of the days to DNR or ICU discharge distribution. Secondary outcomes included: DNR order, ICU and hospital lengths of stay, hospice discharge, and mortality metrics. To address unmeasured confounding, we used two-stage least-squares instrumental variables analysis. The instrument, which predicts early screening, comprised weekend versus weekday admission and number of patients meeting palliative care criteria on a patient's ICU Days 1 and 2. Results: Among 1,282 postimplementation admissions, 626 (45%) received early screening, and 398 (28%) received specialty palliative consultation. Early receipt of specialist palliative care was higher in patients who received early screening versus not (17% vs. 1%; P < 0.001), and overall use of specialty palliative care was higher after versus before screening implementation (28% vs. 15%; P < 0.001). In the postimplementation cohort, there were no statistically significant effects of early screening on the primary outcome of days to DNR or ICU discharge (15% relative increase; 95% confidence interval, -11% to +48%) or other secondary outcomes. Conclusions: Despite significantly increased specialty palliative care consultation, there was no evidence that early screening for palliative care criteria affected time to DNR/ICU discharge or other secondary outcomes.