Intensive care unit readmission in injured older adults: Modifiable risk factors and implications

BACKGROUND

Prior evaluations of intensive care unit (ICU) readmission among injured older adults have inconsistently identified risk factors, with findings limited by use of subanalyses and small sample sizes. This study aimed to identify risk factors for and implications of ICU readmission in injured older adults.

METHODS

This retrospective, single-center cohort study was conducted at a high-volume Level 1 trauma center and included injured older adult patients (65 years or older) requiring at least one ICU admission during hospitalization between 2013 and 2018. Patients who died <48 hours of admission were excluded. Exposures included patient demographics and clinical factors. The primary outcome was ICU readmission. Multivariable regression was used to identify risk factors for ICU readmission.

RESULTS

A total of 6,691 injured adult trauma patients were admitted from 2013 to 2018, 55.4% (n = 3,709) of whom were admitted to the ICU after excluding early deaths. Of this cohort, 9.1% (n = 339) were readmitted to the ICU during hospitalization. Readmitted ICU patients had a higher median Injury Severity Score (21 [interquartile range, 14-26] vs. 16 [interquartile range, 10-24]), with similar mechanisms of injury between the two groups. Readmitted ICU patients had a significantly higher mortality (19.5%) compared with single ICU admission patients (9.9%) ( p < 0.001) and higher rates of developing any complication, including delirium (61% vs. 30%, p < 0.001). On multivariable analysis, the factors associated with the highest risk of readmission were delirium (Relative Risk, 2.6; 95% confidence interval, 2.07-3.26) and aspiration (Relative Risk, 3.04; 95% confidence interval, 1.67-5.54). More patients in the single ICU admission cohort received comfort-focused care at the time of their death as compared with the ICU readmission cohort (93% vs. 85%, p = 0.035).

CONCLUSION

Readmission to the ICU is strongly associated with higher mortality for injured older adults. Efforts targeted at preventing respiratory complications and delirium in the geriatric trauma population may decrease the rates of ICU readmission and related mortality risk.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Quantitative proteomics investigation of pancreatic intraepithelial neoplasia

Patients with pancreatic cancer are usually diagnosed at late stages, when the disease is incurable. Pancreatic intraepithelial neoplasia (PanIN) 3 is believed to be the immediate precursor lesion of pancreatic adenocarcinoma, and would be an ideal stage to diagnose patients, when intervention and cure are possible and patients are curable. In this study, we used quantitative proteomics to identify dysregulated proteins in PanIN 3 lesions. Altogether, over 200 dysregulated proteins were identified in the PanIN 3 tissues, with a minimum of a 1.75-fold change compared with the proteins in normal pancreas. These dysregulated PanIN 3 proteins play roles in cell motility, the inflammatory response, the blood clotting cascade, the cell cycle and its regulation, and protein degradation. Further network analysis of the proteins identified c-MYC as an important regulatory protein in PanIN 3 lesions. Finally, three of the overexpressed proteins, laminin beta-1, galectin-1, and actinin-4 were validated by immunohistochemistry analysis. All three of these proteins were overexpressed in the stroma or ductal epithelial cells of advanced PanIN lesions as well as in pancreatic cancer tissue. Our findings suggest that these three proteins may be useful as biomarkers for advanced PanIN and pancreatic cancer if further validated. The dysregulated proteins identified in this study may assist in the selection of candidates for future development of biomarkers for detecting early and curable pancreatic neoplasia.

Proteomics on Fixed Tissue Specimens - A Review

The vast majority of clinical tissue samples are formalin-fixed and paraffin-preserved. This type of preservation has been considered an obstacle to protein extraction from these tissues. However, these are the very tissue samples that have associated patient histories, diagnoses and outcomes - ideal samples in the quest to translate bench research into clinical applications. Thus, until recently, these valuable specimens have been unavailable for proteomic analysis.Over the last decade, researchers have been exploring efficient methods to undo protein cross-linking caused by standard tissue fixatives and extract proteins from archived tissue specimens. These methods have been applied in different clinical proteomic studies. In this report, we attempt to review the development of these techniques, summarize the proteomic findings, and discuss the impact on future clinical proteomics.

Surgical management of acute necrotizing lung infections

BACKGROUND

Surgical resection for acute necrotizing lung infections is not widely accepted due to unclear indications and high risk.

OBJECTIVE

To review results of resection in the setting of acute necrotizing lung infections.

METHODS

A retrospective review of patients who underwent parenchymal resection between January 1, 2000, and January 1, 2006, for management of necrotizing pneumonia or lung gangrene.

RESULTS

Thirty-five patients underwent resection for lung necrosis. At the time of consultation, all patients presented with pulmonary sepsis, and also had the following: empyema (n = 17), hemoptysis (n = 5), air leak (n = 7), septic shock requiring pressors (n = 8) and inability to oxygenate adequately (n = 7). Twenty-four patients were ventilated preoperatively. Eleven patients had frank lobar gangrene, and the other patients had combinations of necrotizing pneumonia and abscesses. In 10 patients, preresection procedures were performed, including percutaneous drainage of an abscess (n = 4), thoracoscopic decortication (n = 4) and open decortication (n = 2). Procedures included pneumonectomy (n = 4), lobectomy (n = 18), segmentectomy (n = 2), wedge resection (n = 4) and debridement (n = 7). There were three (8.5%) postoperative deaths--two due to multiple organ failure and one due to anoxic brain injury. All patients not ventilated preoperatively were weaned from ventilatory support within three days. Of those ventilated preoperatively, three died, while four remained chronically ventilator dependent.

CONCLUSIONS

Surgical resection for necrotizing lung infections is a reasonable option in patients with persistent sepsis who are failing medical therapy. Ventilated patients have a worse prognosis but can still be candidates for resection. Patients who are hemodynamically unstable appear to have better outcomes if they can be stabilized before resection.