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Min SY, Yong HJ, Kim D. Sex or gender differences in treatment outcomes of sepsis and septic shock. Acute Crit Care 2024; 39:207-213. [PMID: 38863351 PMCID: PMC11167424 DOI: 10.4266/acc.2024.00591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/12/2024] [Accepted: 04/12/2024] [Indexed: 06/13/2024] Open
Abstract
Gender disparities in intensive care unit (ICU) treatment approaches and outcomes are evident. However, clinicians often pay little attention to the importance of biological sex and sociocultural gender in their treatment courses. Previous studies have reported that differences between sexes or genders can significantly affect the manifestation of diseases, diagnosis, clinicians' treatment decisions, scope of treatment, and treatment outcomes in the intensive care field. In addition, numerous reports have suggested that immunomodulatory effects of sex hormones and differences in gene expression from X chromosomes between genders might play a significant role in treatment outcomes of various diseases. However, results from clinical studies are conflicting. Recently, the need for customized treatment based on physical, physiological, and genetic differences between females and males and sociocultural characteristics of society have been increasingly emphasized. However, interest in and research into this field are remarkably lacking in Asian countries, including South Korea. Through this review, we hope to enhance our awareness of the importance of sex and gender in intensive care treatment and research by briefly summarizing several principal issues, mainly focusing on sex and sex hormone-based outcomes in patients admitted to the ICU with sepsis and septic shock.
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Affiliation(s)
- Seung Yeon Min
- Department of Internal Medicine, Dankook University Hospital, Cheonan, Korea
| | - Ho Jin Yong
- Department of Internal Medicine, Dankook University Hospital, Cheonan, Korea
| | - Dohhyung Kim
- Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
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Ahlberg CD, Wallam S, Tirba LA, Itumba SN, Gorman L, Galiatsatos P. Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review. J Crit Care 2023; 77:154324. [PMID: 37159971 DOI: 10.1016/j.jcrc.2023.154324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/11/2023]
Abstract
RATIONALE Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection. Social risk factors including location and poverty are associated with sepsis-related disparities. Understanding the social and biological phenotypes linked with the incidence of sepsis is warranted to identify the most at-risk populations. We aim to examine how factors in disadvantage influence health disparities related to sepsis. METHODS A scoping review was performed for English-language articles published in the United States from 1990 to 2022 on PubMed, Web of Science, and Scopus. Of the 2064 articles found, 139 met eligibility criteria and were included for review. RESULTS There is consistency across the literature of disproportionately higher rates of sepsis incidence, mortality, readmissions, and associated complications, in neighborhoods with socioeconomic disadvantage and significant poverty. Chronic arterial hypertension and diabetes mellitus also occur more frequently in the same geographic distribution as sepsis, suggesting a potential shared pathophysiology. CONCLUSIONS The distribution of chronic arterial hypertension, diabetes mellitus, social risk factors associated with socioeconomic disadvantage, and sepsis incidence, are clustered in specific geographical areas and linked by endothelial dysfunction. Such population factors can be utilized to create equitable interventions aimed at mitigating sepsis incidence and sepsis-related disparities.
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Affiliation(s)
- Caitlyn D Ahlberg
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Sara Wallam
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Lemya A Tirba
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Stephanie N Itumba
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Linda Gorman
- Harrison Medical Library, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Lakbar I, Einav S, Lalevée N, Martin-Loeches I, Pastene B, Leone M. Interactions between Gender and Sepsis—Implications for the Future. Microorganisms 2023; 11:microorganisms11030746. [PMID: 36985319 PMCID: PMC10058943 DOI: 10.3390/microorganisms11030746] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/15/2023] Open
Abstract
Sex and gender dimorphisms are found in a large variety of diseases, including sepsis and septic shock which are more prevalent in men than in women. Animal models show that the host response to pathogens differs in females and males. This difference is partially explained by sex polarization of the intracellular pathways responding to pathogen–cell receptor interactions. Sex hormones seem to be responsible for this polarization, although other factors, such as chromosomal effects, have yet to be investigated. In brief, females are less susceptible to sepsis and seem to recover more effectively than males. Clinical observations produce more nuanced findings, but men consistently have a higher incidence of sepsis, and some reports also claim higher mortality rates. However, variables other than hormonal differences complicate the interaction between sex and sepsis, including comorbidities as well as social and cultural differences between men and women. Conflicting data have also been reported regarding sepsis-attributable mortality rates among pregnant women, compared with non-pregnant females. We believe that unraveling sex differences in the host response to sepsis and its treatment could be the first step in personalized, phenotype-based management of patients with sepsis and septic shock.
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Affiliation(s)
- Ines Lakbar
- Department of Anesthesiology and Intensive Care Unit, Assistance Publique Hôpitaux Universitaires de Marseille, Aix-Marseille University, Hospital Nord, 13015 Marseille, France
- CEReSS, Health Service Research and Quality of Life Centre, School of Medicine-La Timone Medical, Aix-Marseille University, 13015 Marseille, France
| | - Sharon Einav
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem 23456, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 23456, Israel
| | - Nathalie Lalevée
- INSERM, INRAE, Centre for Nutrition and Cardiovascular Disease (C2VN), Aix-Marseille University, 13005 Marseille, France
| | - Ignacio Martin-Loeches
- Intensive Care Unit, Trinity Centre for Health Science HRB-Wellcome Trust, St James’s Hospital, D08 NHY1 Dublin, Ireland
| | - Bruno Pastene
- Department of Anesthesiology and Intensive Care Unit, Assistance Publique Hôpitaux Universitaires de Marseille, Aix-Marseille University, Hospital Nord, 13015 Marseille, France
- INSERM, INRAE, Centre for Nutrition and Cardiovascular Disease (C2VN), Aix-Marseille University, 13005 Marseille, France
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Assistance Publique Hôpitaux Universitaires de Marseille, Aix-Marseille University, Hospital Nord, 13015 Marseille, France
- INSERM, INRAE, Centre for Nutrition and Cardiovascular Disease (C2VN), Aix-Marseille University, 13005 Marseille, France
- Correspondence:
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Brinkworth JF, Shaw JG. On race, human variation, and who gets and dies of sepsis. AMERICAN JOURNAL OF BIOLOGICAL ANTHROPOLOGY 2022. [PMCID: PMC9544695 DOI: 10.1002/ajpa.24527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jessica F. Brinkworth
- Department of Anthropology University of Illinois Urbana‐Champaign Urbana Illinois USA
- Carl R. Woese Institute for Genomic Biology University of Illinois at Urbana‐Champaign Urbana Illinois USA
- Department of Evolution, Ecology and Behavior University of Illinois Urbana‐Champaign Urbana Illinois USA
| | - J. Grace Shaw
- Department of Anthropology University of Illinois Urbana‐Champaign Urbana Illinois USA
- Carl R. Woese Institute for Genomic Biology University of Illinois at Urbana‐Champaign Urbana Illinois USA
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Alrawashdeh M, Klompas M, Simpson SQ, Kadri SS, Poland R, Guy JS, Perlin JB, Rhee C. Prevalence and Outcomes of Previously Healthy Adults Among Patients Hospitalized With Community-Onset Sepsis. Chest 2022; 162:101-110. [PMID: 35065940 PMCID: PMC9271603 DOI: 10.1016/j.chest.2022.01.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/29/2021] [Accepted: 01/08/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Devastating cases of sepsis in previously healthy patients have received widespread attention and have helped to catalyze state and national mandates to improve sepsis detection and care. However, it is unclear what proportion of patients hospitalized with sepsis previously were healthy and how their outcomes compare with those of patients with comorbidities. RESEARCH QUESTION Among adults hospitalized with community-onset sepsis, how many previously were healthy and how do their outcomes compare with those of patients with comorbidities? STUDY DESIGN AND METHODS We retrospectively identified all adults with community-onset sepsis hospitalized in 373 US hospitals from 2009 through 2015 using clinical indicators of presumed infection and organ dysfunction (Centers for Disease Control and Prevention's Adult Sepsis Event criteria). Comorbidities were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We applied generalized linear mixed models to measure the associations between the presence or absence of comorbidities and short-term mortality (in-hospital death or discharge to hospice), adjusting for severity of illness on admission. RESULTS Of 6,715,286 hospitalized patients, 337,983 (5.0%) were hospitalized with community-onset sepsis. Most patients with sepsis (329,052 [97.4%]) had received a diagnosis of at least one comorbidity; only 2.6% previously were healthy. Patients with sepsis who previously were healthy were younger than those with comorbidities (mean age, 58.0 ± 19.8 years vs 67.0 ± 16.5 years), were less likely to require ICU care on admission (37.9% vs 50.5%), and were more likely to be discharged home (57.9% vs 45.6%), rather than to subacute facilities (16.3% vs 30.8%), but showed higher short-term mortality rates (22.8% vs 20.8%; P < .001 for all). The association between previously healthy status and higher short-term mortality persisted after risk adjustment (adjusted OR, 1.99; 95% CI, 1.87-2.13). INTERPRETATION The vast majority of patients hospitalized with community-onset sepsis harbor pre-existing comorbidities. However, previously healthy patients may be more likely to die when they seek treatment at the hospital with sepsis compared with patients with comorbidities. These findings underscore the importance of early sepsis recognition and treatment for all patients.
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Affiliation(s)
- Mohammad Alrawashdeh
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA; Jordan University of Science and Technology, Jordan.
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA; Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Steven Q Simpson
- Department of Internal Medicine, University of Kansas, Kansas City, KS
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | | | | | | | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA; Department of Medicine, Brigham and Women's Hospital, Boston, MA
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Huang D, Siddiqui S, Slocum CS, Goldstein R, Zafonte RD, Schneider JC. Assessing the Ability of Comorbidity Indexes to Capture Comorbid Disease in the Inpatient Rehabilitation Spinal Cord Injury Population. Arch Phys Med Rehabil 2020; 101:1731-1738. [PMID: 32473110 DOI: 10.1016/j.apmr.2020.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/15/2020] [Accepted: 04/19/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine whether commonly used comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, the Centers for Medicare and Medicaid Services [CMS] comorbidity tiers) capture comorbidities in the acute traumatic and nontraumatic SCI inpatient rehabilitation population. DESIGN Retrospective cross-sectional study. PARTICIPANTS Data were obtained from the Uniform Data System for Medical Rehabilitation from October 1, 2015 to December 31, 2017 for adults with spinal cord injury (SCI) (Medicare-established Impairment Group Codes 04.110-04.230, 14.1, 14.3). This study included SCI discharges (N=66,235) from 833 inpatient rehabilitation facilities. MAIN OUTCOME MEASURES International Classification of Diseases-10th Revision-Clinical Modifications (ICD-10-CM) codes were used to assess 3 comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, CMS comorbidity tiers). The comorbidity codes that occurred with >1% frequency were reported. The percentages of discharges for which no comorbidities were captured by each comorbidity index were calculated. RESULTS Of the total study population, 39,285 (59.3%) were men and 11,476 (17.3%) were tetraplegic. The mean number of comorbidities was 14.7. There were 13,939 distinct ICD-10-CM comorbidity codes. There were 237 comorbidities that occurred with >1% frequency. The Deyo-Charlson comorbidity index, Elixhauser comorbidity index, and the CMS tiers did not capture comorbidities of 58.4% (95% confidence interval, 58.08%-58.84%), 29.4% (29.07%-29.76%), and 66.1% (65.73%-66.46%) of the discharges in our study, respectively, and 28.8% (28.42%-29.11%) of the discharges did not have any comorbidities captured by any of the comorbidity indexes. CONCLUSION Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the SCI rehabilitation population. This work suggests that alternative measures may be needed to capture the complexity of this population.
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Affiliation(s)
- Donna Huang
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Spinal Cord Injury Service, Department of Physical Medicine and Rehabilitation, VA Boston Healthcare System, Boston, MA; Harvard Medical School, Boston, MA.
| | - Sameer Siddiqui
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Spinal Cord Injury Service, Department of Physical Medicine and Rehabilitation, VA Boston Healthcare System, Boston, MA; Harvard Medical School, Boston, MA
| | - Chloe S Slocum
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Richard Goldstein
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Tektonidou MG, Dasgupta A, Ward MM. Interhospital variation in mortality among patients with systemic lupus erythematosus and sepsis in the USA. Rheumatology (Oxford) 2020; 58:1794-1801. [PMID: 31323667 DOI: 10.1093/rheumatology/kez103] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/25/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To determine whether the risk of mortality in patients with SLE hospitalized with sepsis varies among hospitals in the USA. METHODS We used the National Inpatient Sample (2002-2011) to obtain national population-based data on outcomes for adults with SLE admitted with sepsis, and compared it with that for patients without SLE admitted with sepsis at the same hospital. We computed expected mortality based on patient demographic characteristics, comorbidities and major organ dysfunction, and calculated observed/expected (O/E) mortality ratios separately for patients with SLE and without SLE for each hospital. We then computed the ratio of these O/E ratios within hospitals to assess relative SLE mortality. We considered hospitals with a risk ratio (RR) of ⩾2.0 as having high relative SLE mortality. RESULTS Among 424 hospitals that treated a total of 4024 patients with SLE and sepsis, the risk of in-hospital mortality varied from 0% to 60% (median 11.1%). The RR ranged from 0 to 9.75, with a median of 0.84, indicating that O/E mortality was similar in patients with and without SLE at the average hospital. Sixty-one hospitals (14.4%) had a RR of ⩾2.0, indicating higher mortality among patients with SLE. Hospitals that on average treated ⩾3.9 patients with SLE and sepsis annually were less likely to have a RR of ⩾2.0 than hospitals that treated fewer patients (10% vs 17%; P = 0.004). CONCLUSION Mortality among patients with SLE and sepsis varied widely between hospitals, and was lower at hospitals that treated more of these patients.
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Affiliation(s)
- Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Abhijit Dasgupta
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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Bachler M, Hell T, Schausberger L, Schlömmer C, Schäfer V, Liebensteiner M, Schäffler K, Schenk B, Fries D, Innerhofer P, Niederwanger C. Response patterns of routinely measured inflammatory and coagulatory parameters in sepsis. PeerJ 2019; 7:e7147. [PMID: 31275752 PMCID: PMC6590445 DOI: 10.7717/peerj.7147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 05/19/2019] [Indexed: 12/13/2022] Open
Abstract
Background Sepsis is characterized by a pro-inflammatory and pro-coagulatory shift which can induce life-threatening complications. Close monitoring and risk stratification of sepsis patients is crucial for proper treatment and consequently patient outcome. Therefore, this study focuses on the response patterns of inflammatory and coagulatory parameters used in clinical routines to estimate the course of sepsis. Methods A total of 1,110 patients diagnosed with sepsis were retrospectively analyzed to identify response patterns for risk stratification of routine parameters measured at the peak level of C-reactive protein. Cluster analysis was used and the differences in the patient characteristics and 28-day survival were assessed. Cox proportional hazards regression model for survival stratified by the clusters was performed. Results The analyses revealed the parameters to have five distinct response patterns. These clusters reflect the etiology as well as the course of sepsis associated with different mortalities. Here, impairment of the liver plays a crucial role in the ability to appropriately respond to sepsis. Of the routinely measured parameters, C-reactive protein and antithrombin seem to be unspecific for stratification of septic patients. Adjusted for the individual clusters, survival was associated with an increase in fibrinogen (p = 0.0042), platelets (p = 0.0003) and PT (p = 0.001) as well as a decrease in leukocytes (p = 0.034). Conclusions This study reveals that patients have distinct response patterns of inflammatory and coagulatory parameters depending on disease etiology. These patterns are associated with different mortalities although the patients have similar levels of C-reactive protein. Independently of the type of response, good coagulatory capacity seems to be crucial for patient survival.
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Affiliation(s)
- Mirjam Bachler
- University for Health Sciences, Medical Informatics and Technology, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Hall, Austria
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Innsbruck, Austria
| | - Lukas Schausberger
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christine Schlömmer
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Volker Schäfer
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Marlies Liebensteiner
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Katharina Schäffler
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Schenk
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Fries
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Petra Innerhofer
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics, Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
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Factors Underlying Racial Disparities in Sepsis Management. Healthcare (Basel) 2018; 6:healthcare6040133. [PMID: 30463180 PMCID: PMC6315577 DOI: 10.3390/healthcare6040133] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 11/10/2018] [Accepted: 11/14/2018] [Indexed: 12/13/2022] Open
Abstract
Sepsis, a syndrome characterized by systemic inflammation during infection, continues to be one of the most common causes of patient mortality in hospitals across the United States. While standardized treatment protocols have been implemented, a wide variability in clinical outcomes persists across racial groups. Specifically, black and Hispanic populations are frequently associated with higher rates of morbidity and mortality in sepsis compared to the white population. While this is often attributed to systemic bias against minority groups, a growing body of literature has found patient, community, and hospital-based factors to be driving racial differences. In this article, we provide a focused review on some of the factors driving racial disparities in sepsis. We also suggest potential interventions aimed at reducing health disparities in the prevention, early identification, and clinical management of sepsis.
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O'Brien Z, Cass A, Cole L, Finfer S, Gallagher M, McArthur C, McGuiness S, Myburgh J, Bellomo R, Mårtensson J. Sex and mortality in septic severe acute kidney injury. J Crit Care 2018; 49:70-76. [PMID: 30388491 DOI: 10.1016/j.jcrc.2018.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 10/08/2018] [Accepted: 10/20/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate the relationship between sex and mortality and whether menopause or the intensity of renal replacement therapy (RRT) modify this relationship in patients with severe septic acute kidney injury (AKI). MATERIALS AND METHODS Post-hoc analysis of patients with sepsis included in the Randomized Evaluation of Normal versus Augmented Level renal replacement therapy (RENAL) trial. RESULTS Of 724 patients, 458 (63.3%) were male and 266 (36.7%) were female. The mean delivered effluent flow rate was 25.6 ± 7.4 ml/kg/h (80 ± 15% of prescribed dose) in males and 27.4 ± 7.6 ml/kg/h (83 ± 15% of prescribed dose) in females (p = .01). A total of 237 (51.7%) males and 118 (44.5%) females died within 90 days of randomization (p = .06). The adjusted hazard ratio (HR) for 90-day mortality was significantly decreased in females as compared with males (HR 0.74, 95% CI 0.57 to 0.96, p = .02). The relationship between sex and mortality was not significantly altered by menopausal status (adjusted P value for interaction 0.99) or by RRT intensity allocation (adjusted P value for interaction 0.27). CONCLUSIONS In a cohort of patients with sepsis and severe AKI, female sex was associated with improved survival. The relationship between sex and survival was not altered by menopausal status or RRT intensity.
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Affiliation(s)
- Zachary O'Brien
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Winnellie, NT, Australia
| | - Louise Cole
- Department of Intensive Care, Nepean Hospital, Sydney, Australia
| | - Simon Finfer
- The George Institute for Global Health, University of Sydney, Level 13, Sydney, NSW, Australia
| | - Martin Gallagher
- The George Institute for Global Health, University of Sydney, Level 13, Sydney, NSW, Australia
| | - Colin McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Shay McGuiness
- Cardiovascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - John Myburgh
- The George Institute for Global Health, University of Sydney, Level 13, Sydney, NSW, Australia; St George Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Johan Mårtensson
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
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A systematic review on risk factors associated with sepsis in patients admitted to intensive care units. Aust Crit Care 2018; 32:155-164. [PMID: 29574007 DOI: 10.1016/j.aucc.2018.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/29/2018] [Accepted: 02/05/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE We sought to systematically review data on the risk factors influencing the incidence of sepsis in patients admitted to intensive care units (ICUs). REVIEW METHODS An electronic search was undertaken in PubMed, MEDLINE, Scopus, and the Cochrane Library for studies reporting the risk factors of sepsis from the earliest available date up to December 30, 2016. RESULTS Among the 2978 articles, 14 studies met the inclusion criteria with a total of 56 164 participants from nine countries. The extracted risk factors were from the following categories: demographic, critical care interventions, surgery-related factors, pre-existing comorbidities, severity of organ injury, and biomarkers and biochemical and molecular indicators. From demographic factors, older age and male gender were associated with an increased risk of sepsis among ICU-admitted patients. CONCLUSION Our analysis comprehensively summarised the risk factors of sepsis in patients admitted to medical, surgical, neurologic, trauma, and general ICUs. Age, sex, and comorbidities were non-modifiable risk factors; however, critical care interventions and surgery-related factors were modifiable factors and suggest that improving the care of surgical patients and effective management of critical care interventions may play a key role in decreasing the development of sepsis in patients admitted to the ICUs.
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Association of Gender With Outcome and Host Response in Critically Ill Sepsis Patients. Crit Care Med 2017; 45:1854-1862. [PMID: 28806220 DOI: 10.1097/ccm.0000000000002649] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine the association of gender with the presentation, outcome, and host response in critically ill patients with sepsis. DESIGN AND SETTING A prospective observational cohort study in the ICU of two tertiary hospitals between January 2011 and January 2014. PATIENTS All consecutive critically ill patients admitted with sepsis, involving 1,815 admissions (1,533 patients). INTERVENTIONS The host response was evaluated on ICU admission by measuring 19 plasma biomarkers reflecting organ systems implicated in sepsis pathogenesis (1,205 admissions) and by applying genome-wide blood gene expression profiling (582 admissions). MEASUREMENTS AND MAIN RESULTS Sepsis patients admitted to the ICU were more frequently males (61.0%; p < 0.0001 vs females). Baseline characteristics were not different between genders. Urosepsis was more common in females; endocarditis and mediastinitis in men. Disease severity was similar throughout ICU stay. Mortality was similar up to 1 year after ICU admission, and gender was not associated with 90-day mortality in multivariate analyses in a variety of subgroups. Although plasma proteome analyses (including systemic inflammatory and cytokine responses, and activation of coagulation) were largely similar between genders, females showed enhanced endothelial cell activation; this difference was virtually absent in patients more than 55 years old. More than 80% of the leukocyte blood gene expression response was similar in male and female patients. CONCLUSIONS The host response and outcome in male and female sepsis patients requiring ICU admission are largely similar.
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Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, Lemeshow S, Osborn T, Terry KM, Levy MM. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med 2017; 376:2235-2244. [PMID: 28528569 PMCID: PMC5538258 DOI: 10.1056/nejmoa1703058] [Citation(s) in RCA: 1225] [Impact Index Per Article: 175.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. METHODS We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care for patients with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid. RESULTS Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours. The median time to completion of the 3-hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk-adjusted in-hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21). CONCLUSIONS More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality. (Funded by the National Institutes of Health and others.).
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Affiliation(s)
- Christopher W Seymour
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Foster Gesten
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Hallie C Prescott
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Marcus E Friedrich
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Theodore J Iwashyna
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Gary S Phillips
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Stanley Lemeshow
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Tiffany Osborn
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Kathleen M Terry
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Mitchell M Levy
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
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15
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Abstract
OBJECTIVE To evaluate the association between total medical contact, prehospital, and emergency department delays in antibiotic administration and in-hospital mortality among patient encounters with community-acquired sepsis. DESIGN Retrospective cohort study. SETTING Nine hospitals served by 21 emergency medical services agencies in southwestern Pennsylvania from 2010 through 2012. PATIENTS All emergency medical services encounters with community acquired sepsis transported to the hospital. MEASUREMENTS AND MAIN RESULTS Among 58,934 prehospital encounters, 2,683 had community-acquired sepsis, with an in-hospital mortality of 11%. Median time from first medical contact to antibiotic administration (total medical contact delay) was 4.2 hours (interquartile range, 2.7-8.0 hr), divided into a median prehospital delay of 0.52 hours (interquartile range, 0.40-0.66 hr) and a median emergency department delay of 3.6 hours (interquartile range, 2.1-7.5 hr). In a multivariable analysis controlling for other risk factors, total medical contact delay was associated with increased in-hospital mortality (adjusted odds ratio for death, 1.03 [95% CI, 1.00-1.05] per 1-hr delay; p < 0.01), as was emergency department delay (p = 0.04) but not prehospital delay (p = 0.61). CONCLUSIONS Both total medical contact and emergency department delay in antibiotic administration are associated with in-hospital mortality in community-acquired sepsis.
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16
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Anti-inflammatory mechanism of ulinastatin: Inhibiting the hyperpermeability of vascular endothelial cells induced by TNF-α via the RhoA/ROCK signal pathway. Int Immunopharmacol 2017; 46:220-227. [DOI: 10.1016/j.intimp.2017.03.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022]
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17
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Suarez De La Rica A, Gilsanz F, Maseda E. Epidemiologic trends of sepsis in western countries. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:325. [PMID: 27713883 DOI: 10.21037/atm.2016.08.59] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Since the American College of Chest Physicians (ACCP) and the Society of Critical care Medicine (SCCM) published the first consensus definition of syndromes related to sepsis in 1992, the knowledge of epidemiology of sepsis has clearly improved, although no prospective studies have been performed to analyse the incidence of sepsis in general population. There are differences in epidemiologic trends in sepsis between western countries and low-income and middle-income countries. In the United States (US), most of epidemiologic studies have been based on large, administrative databases, reporting an increase in the incidence of severe sepsis over years. In general, studies describing epidemiology of sepsis outside the US use clinical definitions and intensive care unit (ICU) observational cohort designs instead of administrative databases and definitions. Incidence of sepsis has increased over years, probably due to progressive aging of population, the existence of more comorbidities and maybe the liberal use of sepsis codification, by including patients with less severity. Notwithstanding, mortality due to sepsis is clearly decreasing over years, probably to improvement in ICU care, although absolute mortality is growing on account of the raise in incidence. Risk factors for sepsis are the two ends of life, male sex, US black race, presence of comorbidities and certain genetic variants. Respiratory tract infections are the most common source of sepsis, and, nowadays, Gram-positive infections are more frequent that Gram-negative sepsis in most prospective studies.
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Affiliation(s)
- Alejandro Suarez De La Rica
- Department of Anesthesiology and Surgical Critical Care, Surgical Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Fernando Gilsanz
- Department of Anesthesiology and Surgical Critical Care, Surgical Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Emilio Maseda
- Department of Anesthesiology and Surgical Critical Care, Surgical Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
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18
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Analysis of Race and Time to Antibiotics Among Patients with Severe Sepsis or Septic Shock. J Racial Ethn Health Disparities 2016; 4:680-686. [PMID: 27553054 DOI: 10.1007/s40615-016-0271-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/07/2016] [Accepted: 07/22/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND/OBJECTIVES The objective of this study is to investigate potential racial disparities in time to antibiotics among patients presenting to the emergency department (ED) with severe sepsis or septic shock. METHODS This was a retrospective observational study of adults >18 years with severe sepsis or septic shock presenting to a large, urban, academic ED and admitted to the ICU from 10/2005 to 2/2012. Time to antibiotic data was abstracted by ICU research staff; other data were abstracted by blinded trained research assistants using standardized abstraction forms. Time from ED arrival to antibiotics was compared in white vs. non-white patients using cumulative events curves followed by Cox proportional hazards regression, controlling for age, gender, ethnicity, source of infection, and SOFA score. RESULTS Seven hundred sixty-eight patients were included; 19.5 % (n = 150) were non-white. Median minutes to antibiotics was 131 in white patients vs. 158 in non-white patients (p = 0.03, log-rank test). The unadjusted hazard ratio for non-white patients was 0.82 (95 %CI 0.58-0.98). After adjustment, the hazard ratio for race was not significant (0.90, 95 %CI 0.73-1.10). CONCLUSIONS In a single-center sample of patients with severe sepsis or septic shock, adjustment for factors including age and infectious source eliminated the difference in time to antibiotics by race. Further research should investigate disparities in sepsis care between hospitals with differing patient populations.
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19
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Abstract
Abstract
Background
The relationship between annualized case volume and mortality in patients with sepsis is not fully understood. The authors performed a dose–response meta-analysis to assess the effect of annualized case volume on mortality among patients with sepsis in the intensive care unit, emergency department, or hospital, hypothesizing that higher annualized case volume may lead to lower mortality.
Methods
The authors searched PubMed and Embase through July 2015 to identify observational studies that examined the relationship between annualized case volume and mortality in sepsis. The predefined outcome was mortality. Odds ratios with 95% CIs were pooled using a random-effects model.
Results
Ten studies involving 3,495,921 participants and 834,009 deaths were included. The pooled estimate suggested that annualized case volume was inversely associated with mortality (odds ratio, 0.76; 95% CI, 0.65 to 0.89; P = 0.001), with high heterogeneity (I2 = 96.6%). The relationship was consistent in most subgroup analyses and robust in sensitivity analysis. Dose–response analysis identified a nonlinear relationship between annualized case volume and mortality (P for nonlinearity less than 0.001).
Conclusions
This meta-analysis confirmed the study hypothesis and provided strong evidence for an inverse and a nonlinear dose–response relationship between annualized case volume and mortality in patients with sepsis. Variations in cutoff values of category for annualized case volume across studies may mainly result in the overall heterogeneity. Future studies should uncover the mechanism of volume–mortality relationship and standardize the cutoff values of category for annualized case volume in patients with sepsis.
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20
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Banta JE, McKinney O. Faith-Based Hospitals and Variation in Psychiatric Inpatient Length of Stay in California, 2002-2011. JOURNAL OF RELIGION AND HEALTH 2016; 55:787-802. [PMID: 26718346 DOI: 10.1007/s10943-015-0175-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We examined current treatment patterns at faith-based hospitals. Psychiatric discharges from all community-based hospitals in California were obtained for 2002-2011 and a Behavioral Model of Health Services Utilization approach used to study hospital religious affiliation and length of stay (LOS). During 10 years there were 1,976,893 psychiatric inpatient discharges, of which 14.3% were from faith-based nonprofit hospitals (eighteen Catholic, seven Seventh-day Adventist, and one Jewish hospital). Modest differences in patient characteristics and shorter LOS (7.5 vs. 8.3 days) were observed between faith-based and other hospitals. Multivariable negative binomial regression found shorter LOS at faith-based nonprofit hospitals (coefficient = -0.1169, p < 0.001, Wald χ (2) = 55) and greater LOS at all nonprofits (coefficient = 1.5909, p < 0.001, Wald χ (2) = 2755) as compared to local government-controlled hospitals. Faith-based hospitals provide a substantial and consistent amount of psychiatric care in California and may have slightly lower LOS after adjusting for patient and other hospital characteristics.
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Affiliation(s)
- Jim E Banta
- Loma Linda University School of Public Health, 24951 North Circle Drive, Loma Linda, CA, 92350, USA.
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21
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Abstract
This article describes the trends in the incidence of and mortality from sepsis in the United States and globally. The article then discusses the known factors associated with increased risk for developing sepsis and the limitations of the current clinical definition and the clinical correlations of the current epidemiology.
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Affiliation(s)
- Jordan A Kempker
- Division of Pulmonary, Allergy, Sleep and Critical Care Medicine, Emory University School of Medicine, 615 Michael Street, Suite 205, Atlanta, GA 30322, USA.
| | - Greg S Martin
- Division of Pulmonary, Allergy, Sleep and Critical Care Medicine, Emory University School of Medicine, 615 Michael Street, Suite 205, Atlanta, GA 30322, USA
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22
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de Miguel-Yanes JM, Méndez-Bailón M, Jiménez-García R, Hernández-Barrera V, Pérez-Farinós N, López-de-Andrés A. Trends in sepsis incidence and outcomes among people with or without type 2 diabetes mellitus in Spain (2008-2012). Diabetes Res Clin Pract 2015; 110:266-75. [PMID: 26489822 DOI: 10.1016/j.diabres.2015.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 07/14/2015] [Accepted: 10/02/2015] [Indexed: 01/09/2023]
Abstract
AIMS There is conflicting evidence on how type 2 diabetes mellitus (T2DM) influences in-hospital mortality (IHM) in sepsis. We aimed to compare trends in outcomes for sepsis in people with or without T2DM in Spain between 2008 and 2012. METHODS We identified all cases with any sepsis diagnosis using national hospital discharge data. We evaluated annual incidence rates for sepsis stratified by T2DM status. We calculated IHM and analyzed trends over time. In a multivariate analysis including potential confounding factors, we tested T2DM as an independent factor for IHM. RESULTS Overall, 217,280 cases of any-stage sepsis were diagnosed, of whom 50,611 (23.3%) had T2DM. The annual incidence of sepsis increased during the 5-year period (from 76.5 to 113.3cases/10(5) population). The incidence increase was higher for the population with T2DM (from 16.8 to 27.1 cases/10(5) population; 61.3% relative increment). People with T2DM were significantly older (75.8 ± 11.2 years vs. 71.0 ± 16.4 years) and suffered from more coexisting medical conditions. In the univariate analysis, mortality was higher for the population with T2DM only when septic shock was present (53.3% vs. 51.9%; P=0.002). IHM decreased over time both in participants with (from 45.7% to 38.1%) and without T2DM (from 46.1% to 39.5%). After accounting for all other potential confounders, T2DM was significantly associated with a lower IHM (odds ratio=0.88; 95% confidence interval, 0.86-0.90). CONCLUSIONS In Spain, the annual increase in sepsis incidence was higher in people with T2DM, but the risk of dying with sepsis during admission was moderately lower in people with T2DM.
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Affiliation(s)
- J M de Miguel-Yanes
- Internal Medicine Department, Hospital General Universitario "Gregorio Marañón", 46, Doctor Esquerdo, 28007 Madrid, Spain.
| | - M Méndez-Bailón
- Internal Medicine Department, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain.
| | - R Jiménez-García
- Preventive Medicine and Public Health Department, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas s/n, 28292 Alcorcón, Madrid, Spain.
| | - V Hernández-Barrera
- Preventive Medicine and Public Health Department, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas s/n, 28292 Alcorcón, Madrid, Spain.
| | - N Pérez-Farinós
- Spanish Agency of Alimentary Safety and Nutrition, Ministry of Health, Social Policy and Equality, 56, Alcalá, 28071 Madrid, Spain.
| | - A López-de-Andrés
- Preventive Medicine and Public Health Department, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas s/n, 28292 Alcorcón, Madrid, Spain.
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23
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Sandoval E, Chang DW. Association Between Race and Case Fatality Rate in Hospitalizations for Sepsis. J Racial Ethn Health Disparities 2015; 3:625-634. [PMID: 27294755 DOI: 10.1007/s40615-015-0181-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/29/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Differentiating whether disparities in outcomes for sepsis among racial groups are due to differences in hospital care versus pre-hospitalization factors is an important step in developing effective strategies to reduce these disparities. As such, we examined the association between race and case fatality rates among hospitalizations for sepsis. METHODS This was a case-control study of hospitalizations for sepsis in all acute-care, non-federal California hospitals during 2011. The association between hospital mortality and race was examined using hierarchical logistic regression analysis. RESULTS Among 131,831 hospitalizations for sepsis, the unadjusted case fatality rates were 15.1 % in whites, 14.0 % in blacks, 13.8 % in Hispanics, and 16.2 % in Asians (P < 0.001). Compared to whites, the odds of hospital mortality was 0.84 (95 % CI 0.79-0.89) for blacks, 0.88 (95 % CI 0.84-0.92) for Hispanics, and 0.93 (95 % CI 0.87-0.98) for Asians after controlling for patient, healthcare systems, and hospital-level factors. There was no difference in the variability of sepsis mortality across hospitals between racial groups. The range of case fatality rates for sepsis among hospitals was 8.3-22.9 % for whites, 9.1-20.5 % for blacks, 7.0-19.1 % for Hispanics, and 10.0-23.0 % for Asians. CONCLUSION Case fatality rates for sepsis hospitalizations are lower in minority racial groups in California. Future studies and interventions that seek to reduce racial disparities in sepsis need to focus on pre-hospitalization factors that contribute to population-level racial differences in sepsis outcomes.
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Affiliation(s)
- Eric Sandoval
- Division of Respiratory and Critical Care Physiology and Medicine, Los Angeles Biomed Research Institute at Harbor-University of California Los Angeles Medical Center, Box 405, 1000 W. Carson Street, Torrance, CA, 90509, USA
| | - Dong W Chang
- Division of Respiratory and Critical Care Physiology and Medicine, Los Angeles Biomed Research Institute at Harbor-University of California Los Angeles Medical Center, Box 405, 1000 W. Carson Street, Torrance, CA, 90509, USA. .,Department of Medicine, Harbor-UCLA Medical Center, Box 405, 1000 W. Carson Street, Torrance, CA, 90509, USA.
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24
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Abstract
OBJECTIVE To compare the accuracy of surveillance of severe sepsis using electronic health record clinical data vs claims and to compare incidence and mortality trends using both methods. DESIGN We created an electronic health record-based surveillance definition for severe sepsis using clinical indicators of infection (blood culture and antibiotic orders) and concurrent organ dysfunction (vasopressors, mechanical ventilation, and/or abnormal laboratory values). We reviewed 1,000 randomly selected medical charts to characterize the definition's accuracy and stability over time compared with a claims-based definition requiring infection and organ dysfunction codes. We compared incidence and mortality trends from 2003-2012 using both methods. SETTING Two US academic hospitals. PATIENTS Adult inpatients. RESULTS The electronic health record-based clinical surveillance definition had stable and high sensitivity over time (77% in 2003-2009 vs 80% in 2012, P=.58) whereas the sensitivity of claims increased (52% in 2003-2009 vs 67% in 2012, P=.02). Positive predictive values for claims and clinical surveillance definitions were comparable (55% vs 53%, P=.65) and stable over time. From 2003 to 2012, severe sepsis incidence imputed from claims rose by 72% (95% CI, 57%-88%) and absolute mortality declined by 5.4% (95% CI, 4.6%-6.7%). In contrast, incidence using the clinical surveillance definition increased by 7.7% (95% CI, -1.1% to 17%) and mortality declined by 1.7% (95% CI, 1.1%-2.3%). CONCLUSIONS Sepsis surveillance using clinical data is more sensitive and more stable over time compared with claims and can be done electronically. This may enable more reliable estimates of sepsis burden and trends.
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25
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Nguyen YL, Wallace DJ, Yordanov Y, Trinquart L, Blomkvist J, Angus DC, Kahn JM, Ravaud P, Guidet B. The Volume-Outcome Relationship in Critical Care: A Systematic Review and Meta-analysis. Chest 2015; 148:79-92. [PMID: 25927593 DOI: 10.1378/chest.14-2195] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The purpose of this study was to systematically review the research on volume and outcome relationships in critical care. METHODS From January 1, 2001, to April 30, 2014, MEDLINE and EMBASE were searched for studies assessing the relationship between admission volume and clinical outcomes in critical illness. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. Of 127 studies reviewed, 46 met inclusion criteria, covering seven clinical conditions. Two investigators independently reviewed each article using a standardized form to abstract information on key study characteristics and results. RESULTS Overall, 29 of the studies (63%) reported a statistically significant association between higher admission volume and improved outcomes. The magnitude of the association (mortality OR between the lowest vs highest stratum of volume centers), as well as the thresholds used to characterize high volume, varied across clinical conditions. Critically ill patients with cardiovascular (n = 7, OR = 1.49 [1.11-2.00]), respiratory (n = 12, OR = 1.20 [1.04-1.38]), severe sepsis (n = 4, OR = 1.17 [1.03-1.33]), hepato-GI (n = 3, OR = 1.30 [1.08-1.78]), neurologic (n = 3, OR = 1.38 [1.22-1.57]), and postoperative admission diagnoses (n = 3, OR = 2.95 [1.05-8.30]) were more likely to benefit from admission to higher-volume centers compared with lower-volume centers. Studies that controlled for ICU or hospital organizational factors were less likely to find a significant volume-outcome relationship than studies that did not control for these factors. CONCLUSIONS Critically ill patients generally benefit from care in high-volume centers, with more substantial benefits in selected high-risk conditions. This relationship may in part be mediated by specific ICU and hospital organizational factors.
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Affiliation(s)
- Yên-Lan Nguyen
- Anesthesiology and Surgical Critical Care Department, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris Descartes University, Paris, France; Clinical Epidemiology Center, Institut National de la Santé et de la Recherche Médicale (INSERM) U1153, Hôtel-Dieu Hospital, APHP, Paris, France; Institut Pierre Louis d'Epidémiologie et de Santé Publique INSERM U1136, UPMC Université Paris 06, Sorbonne Universités, Paris, France.
| | - David J Wallace
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Youri Yordanov
- Clinical Epidemiology Center, Institut National de la Santé et de la Recherche Médicale (INSERM) U1153, Hôtel-Dieu Hospital, APHP, Paris, France; Emergency Department, Saint Antoine Hospital, APHP, Paris, France
| | - Ludovic Trinquart
- Clinical Epidemiology Center, Institut National de la Santé et de la Recherche Médicale (INSERM) U1153, Hôtel-Dieu Hospital, APHP, Paris, France; French Cochrane Centre, The Cochrane Collaboration, Paris, France
| | - Josefin Blomkvist
- Clinical Epidemiology Center, Institut National de la Santé et de la Recherche Médicale (INSERM) U1153, Hôtel-Dieu Hospital, APHP, Paris, France; French Cochrane Centre, The Cochrane Collaboration, Paris, France
| | - Derek C Angus
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeremy M Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Philippe Ravaud
- Clinical Epidemiology Center, Institut National de la Santé et de la Recherche Médicale (INSERM) U1153, Hôtel-Dieu Hospital, APHP, Paris, France; French Cochrane Centre, The Cochrane Collaboration, Paris, France
| | - Bertrand Guidet
- Institut Pierre Louis d'Epidémiologie et de Santé Publique INSERM U1136, UPMC Université Paris 06, Sorbonne Universités, Paris, France; Medical Intensive Care Unit, Saint Antoine Hospital, APHP, Paris, France
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Becerra MB, Becerra BJ, Banta JE, Safdar N. Impact of Clostridium difficile infection among pneumonia and urinary tract infection hospitalizations: an analysis of the Nationwide Inpatient Sample. BMC Infect Dis 2015; 15:254. [PMID: 26126606 PMCID: PMC4487835 DOI: 10.1186/s12879-015-0925-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 01/14/2015] [Accepted: 04/01/2015] [Indexed: 12/15/2022] Open
Abstract
Background Clostridium difficile infection (CDI) remains one of the major hospital acquired infections in the nation, often attributable to increased antibiotic use. Little research, however, exists on the prevalence and impact of CDI on patient and hospital outcomes among populations requiring such treatment. As such, the goal of this study was to examine the prevalence, risk factors, and impact of CDI among pneumonia and urinary tract infection (UTI) hospitalizations. Methods The Nationwide Inpatient Sample (2009–2011), reflecting a 20% stratified sample of community hospitals in the United States, was used. A total of 593,038 pneumonia and 255,770 UTI discharges were included. Survey-weighted multivariable regression analyses were conducted to assess the predictors and impact of CDI among pneumonia and UTI discharges. Results A significantly higher prevalence of CDI was present among men with UTI (13.3 per 1,000) as compared to women (11.3 per 1,000). CDI was associated with higher in-hospital mortality among discharges for pneumonia (adjusted odds ratio [aOR] for men = 3.2, women aOR = 2.8) and UTI (aOR for men = 4.1, women aOR = 3.4). Length of stay among pneumonia and UTI discharges were also double upon presence of CDI. In addition, CDI increased the total charges by at least 75% and 55% among pneumonia and UTI discharges, respectively. Patient and hospital characteristics associated with CDI included being 65 years or older, Charlson Deyo index for comorbidity of 2 or more, Medicare as the primary payer, and discharge from urban hospitals, among both pneumonia and UTI discharges. Conclusion CDI occurs frequently in hospitalizations among those discharged from hospital for pneumonia and UTI, and is associated with increased in-hospital mortality and health resource utilization. Interventions to mitigate the burden of CDI in these high-risk populations are urgently needed.
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Affiliation(s)
- Monideepa B Becerra
- Department of Health Science and Human Ecology, California State University, San Bernardino, USA. .,William S Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA. .,Primary Address: 5500 University Parkway, San Bernardino, CA, 92407, USA.
| | - Benjamin J Becerra
- William S Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA. .,School of Public Health, Loma Linda University, Primary Address: 24951 North Circle Drive, Loma Linda, CA, 92350, USA.
| | - Jim E Banta
- School of Public Health, Loma Linda University, Primary Address: 24951 North Circle Drive, Loma Linda, CA, 92350, USA.
| | - Nasia Safdar
- William S Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA. .,University of Wisconsin, Primary Address: 1685 Highland Ave., Madison, Wisconsin, 53705, USA.
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Tulloch LG, Chan JD, Carlbom DJ, Kelly MJ, Dellit TH, Lynch JB. Epidemiology and Microbiology of Sepsis Syndromes in a University-Affiliated Urban Teaching Hospital and Level-1 Trauma and Burn Center. J Intensive Care Med 2015; 32:264-272. [PMID: 26130580 DOI: 10.1177/0885066615592851] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE To use the 2010 to 2011 data collected by structured chart review to provide a detailed up-to-date description of the epidemiology and microbiology of the sepsis syndromes. METHODS Prospective observational study conducted at a university-affiliated urban teaching hospital and level-1 trauma and burn center. All adult patients who triggered a Code Sepsis in the emergency department (ED) between January 2010 and December 2011 were included. RESULTS One hundred eighty four patients presented with a verified sepsis syndrome and triggered a Code Sepsis in the ED during the studied time period. The mean hospital and intensive care unit length of stays (LOSs) were 15.4 (interquartile range [IQR] = 14) and 6.7 (IQR = 5) days, respectively. The total inpatient mortality was 19% (n = 35). Patients with an unspecified source of infection and those without an isolated pathogen had the highest inpatient mortality, 42.1% (n = 8) and 23.3% (n = 10), respectively. CONCLUSION Hospital mortality and hospital LOS of sepsis are similar to those reported in other observational studies. Our study confirms a decline in the mortality of sepsis predicted by earlier longitudinal studies and should prompt a resurgence of epidemiological research of the sepsis syndromes in the United States.
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Affiliation(s)
- Luis G Tulloch
- 1 Department of Medicine, University of Washington and Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Jeannie D Chan
- 2 Department of Pharmacy, Harborview Medical Center, and School of Pharmacy, University of Washington, Seattle, WA, USA
| | - David J Carlbom
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| | - Mary Jo Kelly
- 4 Department of Nursing, Harborview Medical Center, Seattle, WA, USA
| | - Timothy H Dellit
- 5 Division of Allergy & Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| | - John B Lynch
- 5 Division of Allergy & Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
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Assessing the ability of comorbidity indexes to capture comorbid disease in the inpatient rehabilitation burn injury population. Am J Phys Med Rehabil 2015; 94:373-84. [PMID: 25171665 DOI: 10.1097/phm.0000000000000180] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Burn patients exhibit comorbidities that influence outcomes. This study examines whether existing comorbidity measures capture comorbidities in the burn inpatient rehabilitation population. DESIGN Data were obtained from the Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury. International Classification of Diseases, 9th Revision, codes were used to assess three comorbidity measures (Charlson Comorbidity Index, Elixhauser Comorbidity Index, Centers for Medicare and Medicaid Services Comorbidity Tiers). The number of subjects and unique comorbidity codes (>1% of frequency) captured by each comorbidity measure was calculated. RESULTS The study included 5347 patients with a median total body surface area burn decile of 20%-29%, mean age of 51.6 yrs, and mean number of comorbidities of 7.6. There were 2809 unique International Classification of Diseases, 9th Revision, comorbidity codes. The Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Centers for Medicare and Medicaid Services Comorbidity Tiers did not capture 67%, 27%, and 58% of the subjects, respectively. There were 107 unique comorbidities that occurred with a frequency of greater than 1%. Of these, 67% were not captured in all three comorbidity measures. CONCLUSIONS Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the burn rehabilitation population. Future work is needed to assess the need for comorbidity indexes specific to the inpatient rehabilitation setting.
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Banta JE, Addison A, Beeson WL. Spatial patterns of epilepsy-related emergency department visits in california. J Public Health Res 2015; 4:441. [PMID: 25918697 PMCID: PMC4407042 DOI: 10.4081/jphr.2015.441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/10/2015] [Indexed: 11/22/2022] Open
Abstract
Background Socio-demographic factors are associated with increased emergency department (ED) use among patients with epilepsy. However, there has been limited spatial analysis of such visits. Design and methods California ED visit at the patient ZIP Code level were examined using Kulldorf’s spatial scan statistic to identify clusters of increased risk for epilepsy-related visits. Logistic regression was used to examine the relative importance of patient socio-demographics, Census-based and hospital measures. Results During 2009-2011 there were 29,715,009 ED visits at 330 hospitals, of which 139,235 (0.5%) had epilepsy (International Classification of Disease-9 345.xx) as the primary diagnosis. Three large urban clusters of high epilepsy-related ED visits were centred in the cities of Los Angeles, Oakland and Stockton and a large rural cluster centred in Kern County. No consistent pattern by age, race/ethnicity, household structure, and income was observed among all clusters. Regression found only the Los Angeles cluster significant after adjusting for other measures. Conclusions Geospatial analysis within a large and geographically diverse region identified a cluster within its most populous city having an increased risk of ED visits for epilepsy independent of selected socio-demographic and hospital measures. Additional research is necessary to determine whether elevated rates of ED visits represent increased prevalence of epilepsy or an inequitable system of epilepsy care. Significance for public health There have been few spatial analyses regarding treatment for epilepsy. This paper significantly expands upon previous work by simultaneously considering multiple urban centres and sparsely populated agricultural and desert/mountain areas in a large state. Furthermore, most epilepsy studies involve one system of care or funding source (such as Department of Veterans Affairs, Medicare, Medicaid, or private insurance plans). This paper considers all funding sources at community-based hospitals. Patient socio-demographics, area-based summaries of socio-demographics, and basic hospital characteristics explain most of the observed spatial variation in rates of emergency department (ED) visits related to epilepsy. However, preliminary spatial analysis demonstrated that an area within downtown Los Angeles did have a higher rate of epilepsy-related visits compared to the rest of the state. A more comprehensive surveillance approach with ED visit data could be readily applied to other large geographic areas and be useful both for on-going monitoring and public health intervention
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Affiliation(s)
- Jim E Banta
- School of Public Health, Loma Linda University , CA
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Oud L, Watkins P. Evolving trends in the epidemiology, resource utilization, and outcomes of pregnancy-associated severe sepsis: a population-based cohort study. J Clin Med Res 2015; 7:400-16. [PMID: 25883702 PMCID: PMC4394912 DOI: 10.14740/jocmr2118w] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2015] [Indexed: 12/29/2022] Open
Abstract
Background Infections are a well-known complication of pregnancy. However, pregnancy-associated severe sepsis (PASS) has not been as well-characterized, with limited population-level data reported to date. We performed a population-based study of the evolving patterns of the epidemiology, clinical characteristics, resource utilization, and outcomes of PASS in Texas over the past decade. Methods The Texas Inpatient Public Use Data File was used to identify pregnancy-associated hospitalizations and PASS hospitalizations for the years 2001 - 2010. The Texas Center for Health Statistics reports of live births, abortions and fetal deaths, and a previously reported population-based, age-specific linkage study on miscarriage were used to derive the annual total estimated pregnancies (TEPs). The incidence, demographics, clinical characteristics, resource utilization and outcomes of PASS were examined. Logistic regression modeling was used to explore the predictors of PASS and its associated mortality. Results There were 4,060,201 pregnancy-associated hospitalizations and 1,007 PASS hospitalizations during study period. The incidence of PASS was increased by 236% over the past decade, rising from 11 to 26 hospitalizations per 100,000 TEPs. The key changes between 2001 - 2002 and 2009 - 2010 within PASS hospitalizations included: admission to ICU 78% vs. 90% (P = 0.002); development of ≥ 3 organ failures 9% vs. 35% (P < 0.0001); and inflation-adjusted median hospital charges (2,010 dollars) $64,034 vs. $89,895 (P = 0.0141). Hospital mortality (11%) remained unchanged during study period. Chronic liver disease (adjusted odds ratio (aOR) 41.4) and congestive heart failure (CHF) (aOR 20.5) were associated with the highest risk of PASS, in addition to black race, poverty, drug abuse, and lack of health insurance. The highest risk of death was among women with HIV infection (aOR 45.5), need for mechanical ventilation (aOR 4.5), drug abuse (aOR 3.0), and lacking health insurance (aOR 2.9). Conclusions The incidence, severity, and fiscal burden of PASS rose substantially over the past decade. Case fatality was lower than that for severe sepsis in the general population. Chronic liver disease and CHF pose especially high risk of PASS. Pregnant women with history of drug abuse and lacking health insurance are at high risk of both developing and dying with PASS, requiring extra vigilance for early diagnosis and targeted intervention.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th St., Odessa, TX 79763, USA
| | - Phillip Watkins
- Clinical Research Institute, Texas Tech University HSC, 3601 4th Street, MS6238, Lubbock, TX 79430, USA
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Wilson CN, Vance CO, Lechner MG, Matuschak GM, Lechner AJ. Adenosine A1 receptor antagonist, L-97-1, improves survival and protects the kidney in a rat model of cecal ligation and puncture induced sepsis. Eur J Pharmacol 2014; 740:346-52. [PMID: 25041842 PMCID: PMC4147868 DOI: 10.1016/j.ejphar.2014.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 07/07/2014] [Accepted: 07/09/2014] [Indexed: 11/17/2022]
Abstract
Previously it was reported that combining antibiotics with L-97-1, an adenosine A1 receptor antagonist, significantly improves survival and blocks acute lung injury induced by Yersinia pestis CO 99 in a rat model of pneumonic plague. In the current studies using a conscious rat model of cecal ligation and puncture (CLP) sepsis, L-97-1 was administered in daily intravenous infusions in combination with antibiotics to simulate the use of L-97-1 as an anti-sepsis therapeutic in the clinical setting. In these studies, when administered at 12 h following CLP, in combination with broad spectrum antibiotics, ceftriaxone and clindamycin, L-97-1 improves 7 day (d) survival [25%, 35%, and 75% for L-97-1 (10 mg/kg/h, 12.5 mg/kg/h, and 15 mg/kg/h, respectively) versus (vs.) 25% for antibiotics alone] in a dose-dependent manner. The addition of L-97-1, 15 mg/kg/h to antibiotics significantly increased 7 d survival following CLP compared to therapy with either antibiotics alone (P=0.002) or L-97-1 at 15 mg/kg/h alone (P<0.001) and was not significantly different than survival in sham CLP animals (Log-rank (Mantel-Cox) test with Bonferroni׳s correction for multiple comparisons). Moreover, in these studies, in combination with antibiotics L-97-1 dose-dependently protects the kidney, significantly improving renal function at 24 h post CLP at 10 mg/kg/h (P<0.001), 12.5 mg/kg/h (P<0.0001), and 15 mg/kg/h (P<0.0001) vs. antibiotics alone (ANOVA followed by Tukey׳s post-hoc test for pair-wise comparisons). The results of these studies support efficacy for L-97-1 as an anti-sepsis therapeutic.
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Affiliation(s)
- Constance N Wilson
- Endacea Inc., 2 Davis Drive, P.O. Box 12076, Research Triangle Park, NC 27709-2076, United States.
| | - Constance O Vance
- Endacea Inc., 2 Davis Drive, P.O. Box 12076, Research Triangle Park, NC 27709-2076, United States
| | - Melissa G Lechner
- Department of Medicine Brigham and Women׳s Hospital 75 Francis Street, Boston MA 02115, United States
| | | | - Andrew J Lechner
- Saint Louis University School of Medicine, St. Louis MO, United States
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Chang DW, Brass EP. Patient and hospital-level characteristics associated with the use of do-not-resuscitate orders in patients hospitalized for sepsis. J Gen Intern Med 2014; 29:1256-62. [PMID: 24928264 PMCID: PMC4139525 DOI: 10.1007/s11606-014-2906-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 04/20/2014] [Accepted: 05/16/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Identifying factors associated with do-not-resuscitate (DNR) orders is an informative step in developing strategies to improve their use. As such, a descriptive analysis of the factors associated with the use of DNR orders in the early and late phases of hospitalizations for sepsis was performed. METHODS A retrospective cohort of adult patients hospitalized for sepsis was identified using a statewide administrative database. DNR orders placed within 24 h of hospitalization (early DNR) and after 24 h of hospitalization (late DNR) were the primary outcome variables. Multivariable logistic regression analysis was used to identify patient, hospital, and healthcare system-related factors associated with the use of early and late DNR orders. RESULTS Among 77,329 patients hospitalized for sepsis, 27.5 % had a DNR order during their hospitalization. Among the cases with a DNR order, 75.5 % had the order within 24 h of hospitalization. Smaller hospital size and the absence of a teaching program increased the likelihood of an early DNR order being written. Additionally, greater patient age, female gender, White race, more medical comorbidities, Medicare payer status and admission from a skilled nursing facility were all significantly associated with the likelihood of having an early DNR. The strength of association between these factors and the use of late DNR orders was weaker. In contrast, the greater the burden of medical comorbidities, the more likely a patient was to receive a late DNR order. CONCLUSION Multiple patient, hospital, and healthcare system-related factors are associated with the use of DNR orders in sepsis, many of which appear to be independent of a patient's clinical status. Over the course of the hospitalization, the burden of medical illness shows a stronger association relative to other variables. The influence of these multi-level factors needs to be recognized in strategies to improve the use of DNR orders. .
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Affiliation(s)
- Dong W Chang
- Division of Respiratory and Critical Care Physiology and Medicine, Los Angeles Biomed Research Institute, Harbor-University of California Los Angeles Medical Center, Torrance, CA, USA,
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Brown T, Ghelani-Allen A, Yeung D, Nguyen HB. Comparative effectiveness of physician diagnosis and guideline definitions in identifying sepsis patients in the emergency department. J Crit Care 2014; 30:71-7. [PMID: 25241088 DOI: 10.1016/j.jcrc.2014.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/23/2014] [Accepted: 08/17/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of our study was to compare the agreement of emergency physician diagnoses relative to the 1991 American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) and 2001 ACCP/SCCM/European Society of Intensive Care Medicine/American Thoracic Society/Surgical Infection Society internationally accepted definitions of sepsis, severe sepsis, and septic shock. MATERIALS AND METHODS This study was an observational cohort study of adult patients presenting to the emergency department (ED) with a chief complaint suggestive of infection over a 6-week period, during a daily enrollment schedule from 7:00 am to 10:00 pm. Patients were categorized as having "no sepsis," "sepsis," "severe sepsis," or "septic shock" based on ED physician diagnosis, the 1991 definitions, or 2001 definitions. Agreement statistics were performed. RESULTS A total of 1275 patients were enrolled with age 50.1 ± 21.7 years and 59.1% were female. Among the enrolled patients, 228 were identified as having a source of infection. Temperature, heart rate, and white blood cell count were significantly higher in patients with infection, compared with those without (P < .001). The odds ratio for disagreement between a physician-designated no sepsis diagnosis and the 1991 definitions was 4.47 (95% confidence interval, 3.01-7.53) and 5.96 (3.78-9.46) between the same physician-designated diagnosis and the 2001 definitions. The odds ratios for disagreement of a severe sepsis physician diagnosis in relation to the 1991 and 2001 definitions were 0.06 (0.01-0.19) and 0.06 (0.01-0.20), respectively. The 1991 and 2001 consensus definitions had strong agreement, with κ = 0.86 and 91.2% agreement. No agreement was found between the physician diagnosis and 1991 consensus sepsis definitions (κ = 0.11 and 52.2% agreement) or between the physician diagnosis and the 2001 consensus sepsis definitions (κ = 0.13 and 50.0% agreement). CONCLUSIONS Our study showed that ED physician diagnosis of sepsis may disagree with the international definitions such that severe sepsis is underrecognized by clinical judgment alone. Although these results are limited to a single center, we raise concern that early treatments for these high-risk patients may be delayed due to inaccurate clinical diagnosis. Efforts are needed to increase the application of sepsis guideline definitions to better identify ED patients with this potentially deadly condition.
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Affiliation(s)
- Tyler Brown
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Azmina Ghelani-Allen
- Department of Medicine, Loma Linda University, Loma Linda, CA, USA; Center for Comparative Effectiveness and Outcomes Research, Loma Linda University, Loma Linda, CA, USA
| | - Denise Yeung
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - H Bryant Nguyen
- Department of Medicine, Loma Linda University, Loma Linda, CA, USA; Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA; Center for Comparative Effectiveness and Outcomes Research, Loma Linda University, Loma Linda, CA, USA.
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Abstract
OBJECTIVE To determine the evolution of the outcome of patients with cirrhosis and septic shock. DESIGN A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data. SETTING The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area. PATIENTS Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Compared with noncirrhotic patients, patients with cirrhosis had higher Simplified Acute Physiology Score II (63.1 ± 22.7 vs 58.5 ± 22.8, p < 0.0001) and higher prevalence of renal (71.5% vs 54.8%, p < 0.0001) and neurological (26.1% vs 19.5%, p < 0.0001) dysfunctions. Over the study period, in-ICU and in-hospital mortality was higher in patients with cirrhosis (70.1% and 74.5%) compared with noncirrhotic patients (48.3% and 51.7%, p < 0.0001 for both comparisons). Cirrhosis was independently associated with an increased risk of death in ICU (adjusted odds ratio = 2.524 [2.279-2.795]). In patients with cirrhosis, factors independently associated with in-ICU mortality were as follows: admission for a medical reason, Simplified Acute Physiology Score II, mechanical ventilation, renal replacement therapy, spontaneous bacterial peritonitis, positive blood culture, and infection by fungus, whereas direct admission and admission during the most recent midterm period (2004-2010) were associated with a decreased risk of death. From 1998 to 2010, prevalence of septic shock in patients with cirrhosis increased from 8.64 to 15.67 per 1,000 admissions to ICU (p < 0.0001) and their in-ICU mortality decreased from 73.8% to 65.5% (p = 0.01) despite increasing Simplified Acute Physiology Score II. In-ICU mortality decreased from 84.7% to 68.5% for those patients placed under mechanical ventilation (p = 0.004) and from 91.2% to 78.4% for those who received renal replacement therapy (p = 0.04). CONCLUSIONS The outcome of patients with cirrhosis and septic shock has markedly improved over time, akin to the noncirrhotic population. In 2010, the in-ICU survival rate was 35%, which now fully justifies to admit these patients to ICU.
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Jensen-Otsu E, Ward EK, Mitchell B, Schoen JA, Rothchild K, Mitchell NS, Austin GL. The Effect of Medicaid Status on Weight Loss, Hospital Length of Stay, and 30-Day Readmission After Laparoscopic Roux-en-Y Gastric Bypass Surgery. Obes Surg 2014; 25:295-301. [DOI: 10.1007/s11695-014-1367-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Theodoro D, Owens PL, Olsen MA, Fraser V. Rates and timing of central venous cannulation among patients with sepsis and respiratory arrest admitted by the emergency department*. Crit Care Med 2014; 42:554-64. [PMID: 24145846 PMCID: PMC3944374 DOI: 10.1097/ccm.0b013e3182a66a2a] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Clinical guidelines for the acute management of emergency department patients with severe sepsis encourage the placement of central venous catheters. Data examining the timing of central venous catheter insertion among critically ill patients admitted from the emergency department are limited. We examined the hypothesis that prompt central venous catheter insertion during hospitalization among patients admitted from the emergency department acts as a surrogate marker for early aggressive care in the management of critically ill patients. DESIGN Retrospective cross-sectional analysis of emergency department visits using 2003-2006 discharge data from California, State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. SETTING General medical or general surgical hospitals (n = 310). PATIENTS Patient hospitalizations beginning in the emergency department with the two most common diagnoses associated with central venous catheter (sepsis and respiratory arrest). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified the occurrence and timing of central venous catheter using International Classification of Diseases, 9th Revision, Clinical Modifications procedure codes. The primary outcomes measured were annual central venous catheters per 1,000 hospitalizations that began in the emergency department occurring emergently (procedure day 0), urgently (procedure day 1-2), or late (procedure day 3 or later). A total of 129,288 hospital discharges had evidence of central venous catheter. In 2003, 5,759 central venous catheters were placed emergently compared with 10,469 in 2006. The rate of emergent central venous catheter/1,000 increased annually from 228 in 2003, 239 in 2004, 257 in 2005, up to 269 in 2006. Urgent and late central venous catheter rates trended down (p < 0.001). In a multilevel model, the odds of undergoing emergent central venous catheter relative to 2003 increased annually: 1.08 (95% CI, 1.03-1.12) in 2004, 1.19 (95% CI, 1.14-1.23) in 2005, and 1.28 (95% CI, 1.23-1.33) in 2006. CONCLUSIONS Central venous catheters are inserted earlier and more frequently among critically ill patients admitted from the emergency department. Earlier central venous catheter insertion may require systematic changes to meet increasing utilization and enhanced mechanisms to measure central venous catheter outcomes.
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Affiliation(s)
- Daniel Theodoro
- 1Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO. 2Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO. 3Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
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Chen M, Wang B, Xu Y, Deng Z, Xue H, Wang L, He L. Diagnostic value of serum leptin and a promising novel diagnostic model for sepsis. Exp Ther Med 2014; 7:881-886. [PMID: 24669245 PMCID: PMC3961119 DOI: 10.3892/etm.2014.1506] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 01/03/2014] [Indexed: 12/20/2022] Open
Abstract
Diagnosis of sepsis in critically ill patients is important to reduce morbidity and mortality. The present study was conducted to determine the role of serum leptin in the early diagnosis of sepsis and to establish a diagnostic model for sepsis. A retrospective study was conducted of 331 patients from an intensive care unit. All patients underwent consistent blood collection at 6:00 a.m. every morning after fasting. Serum leptin concentrations and additional markers of sepsis were compared between the sepsis group (n=128) and the non-sepsis group (n=203). Septic patients displayed significantly higher leptin serum concentrations compared with those of the non-sepsis group (mean concentration, 11.67 versus 4.824 mg/dl; P<0.001). The leptin levels in male patients were higher than those in female patients, particularly in the sepsis group. The accuracy of serum leptin levels in distinguishing septic patients from non-septic patients was 76%, and the area under the receiver operating characteristic (ROC) curve of serum leptin was ≤0.8. Additional markers of inflammation in the sepsis group were also significantly higher than those in the non-sepsis group. Positive correlations were identified between leptin and body temperature, heart rate and creatinine levels. Therefore, a prognostic model comprising a combination of leptin with temperature, platelet count, white blood cell count and heart rate was evaluated as an effective logistic regression model for the diagnosis of sepsis. The logistic regression output cut-off value was 0.46 and the area under the ROC curve was 0.953 (P<0.0001). It may be concluded that leptin is a valuable marker in the diagnosis of sepsis and the proposed prognostic model is an effective logistic regression model for the diagnosis of sepsis. The prognostic model is able to aid the differentiation of septic patients from non-septic patients.
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Affiliation(s)
- Mingyi Chen
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Bin Wang
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Yaping Xu
- Center of Inspection of Clinical Division, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Zihui Deng
- Research Laboratory of Biochemistry, Basic Medical Institute, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Hui Xue
- Research Laboratory of Biochemistry, Basic Medical Institute, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Luhuan Wang
- Research Laboratory of Biochemistry, Basic Medical Institute, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Lei He
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
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Trends in hospitalizations of patients with sepsis and factors associated with inpatient mortality in the Region of Madrid, 2003–2011. Eur J Clin Microbiol Infect Dis 2013; 33:411-21. [DOI: 10.1007/s10096-013-1971-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/28/2013] [Indexed: 11/25/2022]
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