Sex and critical illness:

Gender specific data in patients with acute appendicitis: a single center perspective

BACKGROUND

The influence of sex, socioeconomic status, and other factors on outcomes from acute illness has been found recently with an increasing interest; acute appendicitis is the most frequent urgency in pediatric age. The aim of this study was to show any gender differences.

METHODS

We retrospectively analyzed the medical records of consecutive patients who underwent surgical exploration for acute appendicitis. Inclusion and exclusion criteria were created. Patient data, demographics, characteristics, and outcomes were studied and evaluated on a gender perspective.

RESULTS

After reviewing medical charts following the inclusion and exclusion criteria, 364 patients were studied; focusing on final outcomes, it was possible to add news from a gender perspective of appendicitis: gangrenous appendicitis was associated with younger female and older female were more likely to have false positive appendicitis; female had less postoperative pain respect to age-match male for all appendicitis and males had more symptoms respect to females especially for phlegmonous and gangrenous appendicitis.

CONCLUSIONS

There is a gender difference in appendicitis; as for adult girls appear to be affected less, have fewer symptoms, and have better postoperative results.

Mean platelet volume is useful for predicting weaning failure: a retrospective, observational study

Background

To evaluate the usefulness of mean platelet volume (MPV), a marker of inflammation and stress, for predicting weaning failure in patients undergoing invasive mechanical ventilation (IMV) compared to traditional inflammation markers.

Methods

The retrospective observational study including patients who received IMV and underwent spontaneous breathing trial (SBT) was conducted in ICU at Beijing Chao-Yang hospital in China from January, 2013 to December, 2019. According to the weaning outcome, MPV, leukocyte count and C-reaction protein(CRP) were compared between weaning failure and weaning success group. Receiver-operating characteristics (ROC) curves and multivariate logistical regression analysis were constructed to analyze the value of these inflammatory markers for predicting weaning failure.

Results

A total of 261 patients were enrolled in the study and 54 patients (20.7%) experienced weaning failure (45 SBT failure and 9 extubation failure after successful SBT). MPV was a better predictor for weaning failure (AUC 0.777;95%CI, 0.722–0.826) than leukocyte count (AUC 0.6;95%CI,0.538–0.66) and CRP (0.627;95%CI,0.565–0.685). The cutoff value of MPV for predicting weaning failure was 11.3 fl with sensitivity 55.56%, specificity 87.92%, and diagnostic accuracy 81.22%. According to multivariate logistic regression analyses, MPV > 11.3 fl was an independent risk factor for predicting weaning failure.

Conclusions

MPV could be a more valuable marker for predicting weaning failure. and the patients with MPV > 11.3 fl should be attentively evaluated before weaning since they are at high risk of weaning failure, and it would be auspicable for those patients to undergo a noninvasive ventilation or high-flow nasal cannula oxygen therapy after extubation or even an early tracheostomy.

When is it considered reasonable to start a risky and uncomfortable treatment in critically ill patients? A random sample online questionnaire study

Background

Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment.

Methods

We performed an anonymous online survey in a random sample of 1,052 participants recruited via email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0–100%.

Results

Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival (0–33% survival) when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients.

Conclusion

No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the “inappropriateness” of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00705-4.

Māori health outcomes in an intensive care unit in Aotearoa New Zealand

Māori are the indigenous people of New Zealand, and suffer disparate health outcomes compared to non-Māori. Waikato District Health Board provides level III intensive care unit services to New Zealand's Midland region. In 2016, our institution formalised a corporate strategy to eliminate health inequities for Māori. Our study aimed to describe Māori health outcomes in our intensive care unit and identify inequities. We performed a retrospective audit of prospectively entered data in the Australian and New Zealand Intensive Care Society database for all general intensive care unit admissions over 15 years of age to Waikato Hospital from 2014 to 2018 (n = 3009). Primary outcomes were in-intensive care unit and in-hospital mortality. The secondary outcome was one-year mortality. In our study, Māori were over-represented relative to the general population. Compared to non-Māori, Māori patients were younger (51 versus 61 years, P < 0.001), and were more likely to reside outside of the Waikato region (37.2% versus 28.0%, P < 0.001) and in areas of higher deprivation (P < 0.001). Māori had higher admission rates for trauma and sepsis (P < 0.001 overall) and required more renal replacement therapy (P < 0.001). There was no difference in crude and adjusted mortality in-intensive care unit (16.8% versus 16.5%, P = 0.853; adjusted odds ratio 0.98 (95% confidence interval 0.68 to 1.40)) or in-hospital (23.7% versus 25.7%, P = 0.269; adjusted odds ratio 0.84 (95% confidence interval 0.60 to 1.18)). One-year mortality was similar (26.1% versus 27.1%, P=0.6823). Our study found significant ethnic inequity in the intensive care unit for Māori, who require more renal replacement therapy and are over-represented in admissions, especially for trauma and sepsis. These findings suggest upstream factors increasing Māori risk for critical illness. There was no difference in mortality outcomes.

Quarantine and Appendicitis: A Macro-Area Experience

PURPOSE

Appendicitis is the most frequent urgency in pediatric age; the aim of this study was to investigate the association of quarantine for severe acute respiratory syndrome coronavirus 2 pandemic and the incidence of pediatric appendicitis in a specific macro area.

METHODS

We retrospectively analyzed the medical records of consecutive patients who underwent surgical exploration for acute appendicitis in the period March-April since 2014. This specific quarantine period was divided into two phases as indicated by National government. Patient data, demographics, characteristics and outcomes were studied and evaluated comparing patients treated during quarantine especially phase 1 vs. phase 2 (March-April 2020).

RESULTS

After reviewing medical charts following the inclusion and exclusion criteria, 155 patients were studied; focusing on the final outcome, it is possible to show a decreased amount of appendicitis during phase 1 and a progressive increase during phase 2; respect to previous years, there was a statistical increase in severity of appendicitis during quarantine (gangrenous vs. phlegmonous appendicitis).

CONCLUSION

During this specific quarantine there was a reduction in appendicitis and a progressive increase during phase 2. These results offer new perspective among disease incidences during lockdown.

Nursing workload in intensive care units and the influence of patient and nurse characteristics

BACKGROUND

Understanding factors that can potentially influence patient care and nursing workload in intensive care units is important. Previous studies have shown contradictory outcomes about the relationships between nursing workload and patient and nurse characteristics.

AIMS AND OBJECTIVES

This study aimed to investigate nursing workload in intensive care units and examine the association between this in relation to patient and nurse characteristics.

DESIGN

A cross-sectional design was conducted.

METHODS

All nurses who were working in the intensive care units of five hospitals and met the study criteria were enrolled in the study. Two demographic questionnaires collected nurse and patient demographic information. The Nursing Activities Score was applied to determine nursing workload in three shifts (morning, evening, night) for each nurse. Data were analysed using the independent sample t-test, one-way analysis of variance, and multivariable linear regression analysis.

RESULTS

The Nursing Activities Score was calculated for 509 patients who were under the care of 105 intensive care unit nurses. The mean (SD) Nursing Activities Score was 72.84% (22.07%). Morning shifts, male patients, medical treatments, and referred patients from the emergency ward and other intensive care units imposed a higher workload for nurses. Specifically, female nurses, increased number of patients receiving care, and increased patient length of intensive care unit stay were directly associated with increased Nursing Activities Scores. Work in surgical and burn intensive care units were inversely associated with the Nursing Activities Score.

CONCLUSION

This study suggests that the workload of nurses in intensive care units can be affected by both nurse and patient characteristics.

RELEVANCE TO CLINICAL PRACTICE

The findings can be used to ensure appropriate staffing of intensive care units by nurses. However, nurse and patient characteristics should not be considered the only factors that influence nursing workload in intensive care units.

Age, SAPS 3 and female sex are associated with decisions to withdraw or withhold intensive care

BACKGROUND

Intensive care treat critically ill patients. When intensive care is not considered beneficial for the patient, decisions to withdraw or withhold treatments are made. We aimed to identify independent patient variables that increase the odds for receiving a decision to withdraw or withhold intensive care.

METHODS

Registry study using data from the Swedish Intensive Care Registry (SIR) 2014-2016. Age, condition at admission, including co-morbidities (Simplified Acute Physiology Score version 3, SAPS 3), diagnosis, sex, and decisions on treatment limitations were extracted. Patient data were divided into a full care (FC) group, and a withhold or withdraw (WW) treatment group.

RESULTS

Of all 97 095 cases, 47.1% were 61-80 years old, 41.9% were women and 58.1% men. 14 996 (15.4%) were allocated to the WW group and 82 149 (84.6%) to the FC group. The WW group, compared with the FC group, was older (P < 0.001), had higher SAPS 3 (P < 0.001) and were predominantly female (P < 0.001). Compared to patients 16-20 years old, patients >81 years old had 11 times higher odds of being allocated to the WW group. Higher SAPS 3 (continuous) increased the odds of being allocated to the WW group by odds ratio [OR] 1.085, (CI 1.084-1.087). Female sex increased the odds of being allocated to the WW group by 18% (1.18; CI 1.13- 1.23).

CONCLUSION

Older age, higher SAPS 3 at admission and female sex were found to be independent variables that increased the odds to receive a decision to withdraw or withhold intensive care.

Age-Specific Distribution of Diagnosis and Outcomes of Children Admitted to ICUs: A Population-Based Cohort Study

OBJECTIVES

Although several studies have reported outcome data on critically ill children, detailed reports by age are not available. We aimed to evaluate the age-specific estimates of trends in causes of diagnosis, procedures, and outcomes of pediatric admissions to ICUs in a national representative sample.

DESIGN

A population-based retrospective cohort study.

SETTING

Three hundred forty-four hospitals in South Korea.

PATIENTS

All pediatric admissions to ICUs in Korea from August 1, 2009, to September 30, 2014, were covered by the Korean National Health Insurance Corporation, with virtually complete coverage of the pediatric population in Korea. Patients less than 18 years with at least one ICUs admission between August 1, 2009, and September 30, 2014. We excluded neonatal admissions (< 28 days), neonatal ICUs, and admissions for health status other than a disease or injury. The final sample size was 38,684 admissions from 32,443 pediatric patients.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The overall age-standardized admission rate for pediatric patients was 75.9 admissions per 100,000 person-years. The most common primary diagnosis of admissions was congenital malformation (10,897 admissions, 28.2%), with marked differences by age at admission (5,712 admissions [54.8%] in infants, 3,994 admissions [24.6%] in children, and 1,191 admissions [9.9%] in adolescents). Injury was the most common primary diagnosis in adolescents (3,248 admissions, 27.1%). The overall in-hospital mortality was 2,234 (5.8%) with relatively minor variations across age. Neoplasms and circulatory and neurologic diseases had both high frequency of admissions and high in-hospital mortality.

CONCLUSIONS

Admission patterns, diagnosis, management, and outcomes of pediatric patients admitted to ICUs varied by age groups. Strategies to improve critical care qualities of pediatric patients need to be based on the differences of age and may need to be targeted at specific age groups.

Gender differences in outcome and use of resources do exist in Swedish intensive care, but to no advantage for women of premenopausal age

INTRODUCTION

Preclinical data indicate that oestrogen appears to play a beneficial role in the pathophysiology of and recovery from critical illness. In few previous epidemiologic studies, however, have researchers analysed premenopausal women as a separate group when addressing potential gender differences in critical care outcome. Our aim was to see if women of premenopausal age have a better outcome following critical care and to investigate the association between gender and use of intensive care unit (ICU) resources.

METHODS

On the basis of our analysis of 127,254 consecutive Simplified Acute Physiology Score III-scored Swedish Intensive Care Registry ICU admissions from 2008 through 2012, we determined the risk-adjusted 30-day mortality, accumulated nurse workload score and ICU length of stay. To investigate associations with sex, we used logistic regression and multivariate analyses on the entire cohort as well as on two subgroups stratified by median age for menopause (up to and including 45 years and older than 45 years) and six selected diagnostic subgroups (sepsis, multiple trauma, chronic obstructive pulmonary disease, acute respiratory distress syndrome, pneumonia and cardiac arrest).

RESULTS

There was no sex difference in risk-adjusted mortality for the cohort as a whole, and there was no sex difference in risk-adjusted mortality in the group 45 years of age and younger. For the group of patients older than 45 years of age, we found a reduced risk-adjusted mortality in men admitted for cardiac arrest. For the cohort as a whole, and for those admitted with multiple trauma, male sex was associated with a higher nurse workload score and a longer ICU stay.

CONCLUSIONS

Using information derived from a large multiple ICU register database, we found that premenopausal female sex was not associated with a survival advantage following intensive care in Sweden. When the data were adjusted for age and severity of illness, we found that men used more ICU resources per admission than women did.

Gender-specific issues in traumatic injury and resuscitation: consensus-based recommendations for future research

Traumatic injury remains an unacceptably high contributor to morbidity and mortality rates across the United States. Gender-specific research in trauma and emergency resuscitation has become a rising priority. In concert with the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," a consensus-building group consisting of experts in emergency medicine, critical care, traumatology, anesthesiology, and public health convened to generate research recommendations and priority questions to be answered and thus move the field forward. Nominal group technique was used for the consensus-building process and a combination of face-to-face meetings, monthly conference calls, e-mail discussions, and preconference surveys were used to refine the research questions. The resulting research agenda focuses on opportunities to improve patient outcomes by expanding research in sex- and gender-specific emergency care in the field of traumatic injury and resuscitation.

Low serum creatine kinase activity is associated with worse outcome in critically ill patients

PURPOSE

To investigate the prognostic significance of low serum creatine kinase (CK) activity in intensive care unit patients.

MATERIALS AND METHODS

The study population consisted of 1899 patients, divided in a "normal" (CK > 20 U/L) and "low" CK group (CK ≤ 20 U/L). The latter group was divided into 2 subgroups by duration of CK activity decrease. Measurement of routine clinical chemistry parameters, calculation of critical care severity scores, and registration of length of stay and mortality rates were performed.

RESULTS

The proportion of patients showing a low serum CK activity for at least 1 day was 15.5%. In this group, 24.5% had a prolonged CK activity decrease for at least 5 days. Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were lower in the normal than in the low CK group (P < .0001) and higher in the prolonged CK activity decrease group in comparison with the short-term CK activity decrease group (P < .0001, P = .001). A low serum CK activity was an independent predictor of mortality. Kaplan-Meier analysis showed an overall survival in the low CK group of 243 ± 152 vs 291 ± 139 days in the normal CK group (P < .0001).

CONCLUSIONS

Low serum CK activities are associated with a higher severity of illness and higher mortality rates.

Sex and inflammation in respiratory diseases: a clinical viewpoint

This review discusses sex differences in the prognosis of acute or chronic inflammatory diseases. The consequences of severe inflammation vary in relation to sex, depending on illness duration. In the majority of acute diseases, males present higher mortality rates, whereas continuous chronic inflammation associated with tissue damage is more deleterious in females. The recruitment of cells, along with its clinical expression, is more significant in females, as reflected by higher inflammatory markers. Given that estrogens or androgens are known to modulate inflammation, their different levels in males and females cannot account for the sexual dimorphism observed in humans and animals from birth to death with regard to inflammation. Numerous studies evaluated receptors, cytokine production, and clinical outcomes in both animals and humans, revealing that estrogens clearly modulate the immune response, but the results are contradictory and difficult to link to hormone concentrations. Even in prepubescent children, the presentation of acute pneumonia or chronic diseases mimics the adult pattern. Several genes located on the X chromosome have been shown to encode molecules involved in inflammation. Moreover, 10% to 15% of the genes from silenced X chromosome may escape inhibition. Females are also a mosaic of cells with genes from either paternal or maternal X chromosome. Therefore, polymorphism of X-linked genes would result in the presence of two cell populations with distinct regulatory arsenals, providing females with greater diversity to fight against infectious challenges, in comparison with the uniform cell populations in hemizygous males. The similarities observed between males and Turner syndrome patients using an endotoxin stimulation model support the difference in gene expression between monosomy and disomy for the X chromosome. Considering the enhanced inflammation in females, cytokine production may be assumed to be higher in females than males. Even if all results are not clear-cut, nonetheless, many studies have reported higher cytokine levels in both male humans and animals than in females. High IL-6 levels in males correlated with poorer prognosis and shorter longevity. A sound understanding of the basic regulatory mechanisms responsible for these gender differences may lead to new therapeutic targets.

The value of the lipopolysaccharide-induced acute lung injury model in respiratory medicine

Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a syndrome characterized by pulmonary edema and acute inflammation. Lipopolysaccharide (LPS), a major component in Gram-negative bacteria, has been used to induce ALI/ARDS. LPS-induced animal models highlight ways to explore mechanisms of multiple diseases and provide useful information on the discovery of novel biomarkers and drug targets. However, each model has its own merits and drawbacks. The goal of this article is to summarize and evaluate the results of experimental findings in LPS-induced ALI/ARDS, and the possible mechanisms and treatments elucidated. Advantages and disadvantages of such models in pulmonary research and new directions for future investigations are also discussed.

Profile and severity of the patients of intensive care units: prospective application of the APACHE II index

This study aimed to understand the profile and severity of patients in physiotherapy treatment after their admission to the intensive care unit (ICU) by applying the APACHE II index. One hundred and forty six subjects, with a mean age of 60.5 +/- 19.2 years, were evaluated. The APACHE II index was applied in the first 24 hours to evaluate the severity and mortality risk score. Patients were monitored until hospital discharge or death. The mean APACHE II score was 20+/-7.3 with an estimated risk of death of 32.4% and observed mortality of 58.2%. The mean hospital stay was 27.8+/-25.2 days. The patients in physiotherapy at the institution studied were predominantly male, elderly, from the emergency service for treatment (non-surgical), and had clear severity, suggested by the APACHE II score and the observed mortality.