Chest最新文献

Background: Quoting patients in electronic medical record (EMR) notes is controversial. Quotations may be used to promote accuracy in documentation. However they also may be used to cast skepticism on patient speech. Little is known about how quotations are used in EMR notes documenting goal of care (GOC) conversations.

Research question: 1) How often are quotations used in GOC notes; 2) what content do clinicians quote; and 3) how does quotation use vary by clinician specialty and patient sociodemographic characteristics?

Study design and methods: This multihospital, cross-sectional study assessed quotation use in GOC notes for seriously ill adult patients hospitalized between July-October 2021. Quotation frequency was evaluated and thematic analysis was used to assess the content of language quoted in GOC notes. The odds of quotation use by clinician specialty and patient sociodemographic group were determined using multivariable logistic regression.

Results: Our review of 1003 GOC notes across fourteen hospitals found quotations were used in 32% of notes and were more often used by palliative clinicians when compared to non-palliative clinicians (38% vs. 21%, unadjusted OR 2.34, 95% CI 1.74-3.14, adjusted OR 2.62, 95% CI 1.66-4.13). Quotations were present more often in notes of Black versus White patients (41% vs. 30%, unadjusted OR 1.61, 95% CI 1.08-2.38, adjusted OR 1.73, 95% CI 1.11-2.71). The content of language included in quotations most often detailed patient feelings, family preferences, and patient discussion about death.

Conclusion: This multicenter study found quotations were used in almost one-third of GOC notes, were used more often used by palliative versus non-palliative clinicians and were present more often in notes for Black versus White patients. Future research must explore clinician intentions in using quotations and identify whether quotation use may contribute to racial disparities in patient care.

Background: Survivorship after coronavirus disease 2019 (COVID-19) critical illness may be associated with important long-term sequelae, but little is known regarding mental health outcomes.

Research question: What is the association between COVID-19 critical illness and new post-discharge mental health diagnoses.

Study design: AND METHODS: We conducted a population-based cohort study in Ontario, Canada (January 1, 2020-March 31, 2022). We included consecutive adult survivors (age ≥ 18 years) of COVID-19 critical illness, and compared them with consecutive adult survivors of critical illness from non-COVID-19 pneumonia. The primary outcome was a new mental health diagnosis (a composite of mood, anxiety, or related disorders; schizophrenia/psychotic disorders; and other mental health disorders) following hospital discharge. We compared patients using overlap propensity score-weighted, cause-specific proportional hazard models.

Results: We included 6,098 survivors of COVID-19 critical illness, and 2,568 adult survivors of critical illness from non-COVID-19 pneumonia at 102 centres. Incidence of new mental health diagnosis among survivors of COVID-19 critical illness was 25.3 per 100-person years (95% confidence interval [CI] 24.0-26.6), and 25.9 per 100-person years (95% CI: 24.0-27.8) among non-COVID-19 pneumonia. Following propensity weighting, COVID-19 critical illness was not associated with increased risk of new mental health diagnosis overall (hazard ratio [HR] 1.08 [95% CI: 0.96-1.23]), but was associated with increased risk in the category of new mood, anxiety, or related disorders (HR 1.21 [95% CI: 1.05-1.40]). No difference was seen in psychotic disorders, other mental health diagnoses, social problems, or deliberate self-harm.

Interpretation: As compared to survival after critical illness from non-COVID-19 pneumonia, survival after COVID-19 critical illness was not associated with increased risk of the composite outcome of new mental health diagnosis, but was associated with elevated risk for new mood, anxiety, or related disorders.

Background: The optimal target for partial pressure of arterial carbon dioxide (PaCO₂) remains uncertain in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) following out-of-hospital cardiac arrest (OHCA).

Research question: Are PaCO₂ levels associated with functional outcomes in patients receiving VA-ECMO after OHCA?

Study design: and Methods: This multicenter, registry-based observational study, conducted from 2014 to 2020, included non-traumatic adult OHCA patients on VA-ECMO with PaCO₂ levels measured within six hours of initiation (initial PaCO₂ set) and at 18-30 hours post-initiation (24-hour PaCO₂ set). PaCO₂ levels were categorized into five groups: hypocapnia (<30 mmHg), low normocapnia (30-<40 mmHg), high normocapnia (40-<50 mmHg), mild hypercapnia (50-<60 mmHg), and moderate to severe hypercapnia (≥60 mmHg). The primary outcome was the favorable functional outcome at 30 days, analyzed using multivariable logistic regression. PaCO₂ trajectories from initial to 24-hour levels were also explored.

Results: A total of 1,454 and 572 patients were analyzed in the initial and 24-hour PaCO₂ sets, respectively. Compared to high normocapnia, low normocapnia was associated with worse functional outcomes in both initial and 24-hour PaCO₂ analyses, with adjusted odds ratios of 0.59 (95% CI, 0.38-0.89) for initial low normocapnia and 0.56 (95% CI, 0.33-0.95) for 24-hour low normocapnia. Other categories were similarly associated with worse functional outcomes in both PaCO₂ analyses. In exploratory analyses, trajectories ending in high normocapnia demonstrated higher proportions of the favorable functional outcome than those ending in low normocapnia, regardless of initial PaCO₂ levels.

Interpretation: In non-traumatic adult OHCA patients on VA-ECMO, high normocapnia was associated with better functional outcomes than low normocapnia in both initial and 24-hour PaCO₂ analyses. These findings suggest a hypothesis that maintaining high normocapnia levels, irrespective of initial PaCO₂, may improve functional outcomes for patients on VA-ECMO after OHCA.

Background: Ventilator-associated pneumonia (VAP) rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).

Research question: Could differences in ventilator bundle adherence, ventilation practices, and critical care staffing be driving variations in VAP risk between LMICs and HICs?

Study design and methods: This secondary analysis of the multicenter, international CERTAIN study included mechanically ventilated patients at risk for VAP from eleven LMICs and five HICs. We included oral care, head-of-bed elevation, spontaneous breathing assessments, and sedation breaks in the ventilator bundle. Staffing was assessed by the number of physicians and nurses per bed. Multivariable analyses were adjusted for severity, baseline characteristics, and checklist implementation. The primary outcome was VAP development.

Results: Among 2,253 patients, 1,755 were from LMICs and 498 from HICs. Compared to HICs, patients from LMICs were younger, had lower comorbidity burden, and were less severely ill. Lower country income level was independently associated with VAP development (aOR 2.11; 95% C.I., 1.37-3.24). Ventilator bundle adherence was not significantly associated with VAP. Increased total duration of ventilation was associated with an increased risk of VAP (aOR 1.04; 95% C.I., 1.03-1.05), while higher nursing (aOR 0.88; 95CI 0.79-0.98) and physician staffing ratios (aOR 0.69; 95% C.I., 0.50-0.87) were associated with lower VAP rates.

Interpretation: Patients in LMICs have a twofold higher risk of VAP, independent of bundle adherence. Prolonged mechanical ventilation was an independent predictor of VAP, while higher staffing ratios were associated with decreased risk for VAP development. Unmeasured factors like infrastructure and infection control practices may explain the higher VAP rates in LMICs.

Background: Pulmonary rehabilitation (PR) is a beneficial intervention for people with interstitial lung disease (ILD), however the effect of PR on survival is unclear. This study compared the survival outcomes in people with ILD who were allocated to PR versus those who were allocated to control in two published randomised controlled trials (RCTs).

Research question: Does participation in PR impact survival among people with ILD?

Study design and methods: The combined data from the two previous RCTs of PR in ILD were included. Time from start of PR until date of death, lung transplantation or censoring was calculated. Kaplan-Meir and Cox proportional hazard regression analysis were used to assess the impact of PR on survival. Baseline variables of age at time of PR, gender, FVC, 6-minute walk distance (6MWD), exertional nadir SpO₂ and diagnosis of idiopathic pulmonary fibrosis (IPF) were included as covariates.

Results: Of the 182 participants with ILD (87 IPF, 109 males, mean (SD) age 69(10), FVC%pred 76(19), TLCO%pred 48(16)), death occurred in 62%, 6% were transplanted, 20% were alive and 12% were lost to follow-up. Median survival for those who completed PR was 6.1 years (95% CI 4.4 to 7.9) compared to 4.7 years (95%CI 3.4 to 6.0) for those in the control group, however this was not significantly different (log rank p=0.7). After adjusting for baseline variables, at 5 years, completion of PR was associated a 44% lower risk of mortality (HR 0.56 (0.36-0.88), p=0.01). At 10 years, no difference in survival was observed between the PR and control group.

Interpretation: Participation in PR among people with ILD may impact survival at 5 years. Along with clinical improvements following PR, the potential for a survival benefit further strengthens the importance of PR in the standard care of people with ILD.