Hypermethylation of CpG island loci and hypomethylation of LINE-1 and Alu repeats in prostate adenocarcinoma and their relationship to clinicopathological features

Promoter CpG island hypermethylation is an important carcinogenic event in prostate adenocarcinoma. Regardless of tissue type, human cancers have in common both focal CpG island hypermethylation and global genomic hypomethylation. The present study evaluated CpG island loci hypermethylation and LINE-1 and Alu repeat hypomethylation in prostate adenocarcinoma, analysed the relationship between them, and correlated these findings with clinicopathological features. We examined 179 cases of prostate adenocarcinoma and 30 cases of benign prostate hypertrophy for the methylation status of 22 CpG island loci and the methylation levels of LINE-1 and Alu repeats using methylation-specific polymerase chain reaction and combined bisulphite restriction analysis, respectively. The following 16 CpG island loci were found to display cancer-related hypermethylation: RASSF1A, GSTP1, RARB, TNFRSF10C, APC, BCL2, MDR1, ASC, TIG1, RBP1, COX2, THBS1, TNFRSF10D, CD44, p16, and RUNX3. Except for the last four CpG island loci, hypermethylation of each of the remaining 12 CpG island loci displayed a close association with one or more of the prognostic parameters (ie preoperative serum prostate specific antigen level, Gleason score sum, and clinical stage). Prostate adenocarcinoma with hypermethylation of each of ASC, COX2, RARB, TNFRSF10C, MDR1, TIG1, RBP1, NEUROG1, RASSF1A, and GSTP1 showed a significantly lower methylation level of Alu or LINE-1 than prostate adenocarcinoma without hypermethylation. In addition, hypomethylation of Alu or LINE-1 was closely associated with one or more of the above prognostic parameters. These data suggest that in tumour progression a close relationship exists between CpG island hypermethylation and the hypomethylation of repetitive elements, and that CpG island hypermethylation and DNA hypomethylation contribute to cancer progression.

Fission yeast hrp1, a chromodomain ATPase, is required for proper chromosome segregation and its overexpression interferes with chromatin condensation

Hrp1 of Schizosaccharomyces pombe is a member of the CHD protein family, characterized by a chromodomain, a Myb-like telobox-related DNA-binding domain and a SNF2-related helicase/ATPase domain. CHD proteins are thought to be required for modification of the chromatin structure in transcription, but the exact roles of CHD proteins are not known. Here we examine the sub-cellular localization and biochemical activity of Hrp1 and the phenotypes of hrp1 Delta and Hrp1-overexpressing strains. Fluorescence microscopy revealed that Hrp1 protein is targeted to the nucleus. We found that Hrp1 exhibited DNA-dependent ATPase activity, stimulated by both single- and double-stranded DNA. Overexpression of Hrp1 caused slow cell growth accompanied by defective chromosome condensation in anaphase resulting in a 'cut' (celluntimelytorn) phenotype and chromosome loss. The hrp1 Delta mutation also caused abnormal anaphase and mini-chromosome loss phenotypes. Electron micrographs demonstrated that aberrantly shaped nucleoli appeared in Hrp1-overexpressing cells. Therefore, these results suggest that Hrp1 may play a role in mitotic chromosome segregation and maintenance of chromatin structure by utilizing the energy from ATP hydrolysis.

Multidisciplinary Critical Care and Intensivist Staffing: Results of a Statewide Survey and Association With Mortality

PURPOSE

The role of multidisciplinary teams in improving the care of intensive care unit (ICU) patients is not well defined, and it is unknown whether the use of such teams helps to explain prior research suggesting improved mortality with intensivist staffing. We sought to investigate the association between multidisciplinary team care and survival of medical and surgical patients in nonspecialty ICUs.

MATERIALS AND METHODS

We conducted a community-based, retrospective cohort study of data from 60 330 patients in 181 hospitals participating in a statewide public reporting initiative, the California Hospital Assessment and Reporting Taskforce (CHART). Patient-level data were linked with ICU organizational data collected from a survey of CHART hospital ICUs between December 2010 and June 2011. Clustered logistic regression was used to evaluate the independent effect of multidisciplinary care on the in-hospital mortality of medical and surgical ICU patients. Interactions between multidisciplinary care and intensity of physician staffing were examined to explore whether team care accounted for differences in patient outcomes.

RESULTS

After adjustment for patient characteristics and interactions, there was no association between team care and mortality for medical patients. Among surgical patients, multidisciplinary care was associated with a survival benefit (odds ratio 0.79; 95% confidence interval (CI), 0.62-1.00; P = .05). When stratifying by intensity of physician staffing, although the lowest odds of death were observed for surgical patients cared for in ICUs with multidisciplinary teams and high-intensity staffing (odds ratio, 0.77; 95% CI, 0.55-1.09; P = .15), followed by ICUs with multidisciplinary teams and low-intensity staffing (odds ratio 0.84, 95% CI 0.65-1.09, p = 0.19), these differences were not statistically significant.

CONCLUSIONS

Our results suggest that multidisciplinary team care may improve outcomes for critically ill surgical patients. However, no relationship was observed between intensity of physician staffing and mortality.

Isolation and characterization of hrp1+, a new member of the SNF2/SWI2 gene family from the fission yeast Schizosaccharomyces pombe

The SNF2/SWI2 ATPase/helicase family comprises proteins from a variety of species, which serve a number of functions, such as transcriptional regulation, maintenance of chromosome stability during mitosis, and various types of DNA repair. Several proteins with unknown functions are also included in this family. The number of genes that belong to this family is rapidly expanding, which makes it easier to analyze the common biological functions of the family members. This study was designed to clone the SNF2/SWI2 helicase-related genes from the fission yeast Schizosaccharomyces pombe in the hope that this would help to elucidate the common functions of the proteins in this family. The hrp1+ (helicase-related gene from S. pombe) gene was initially cloned by PCR amplification using degenerate primers based on conserved SNF2 motifs within the ERCC6 gene, which encodes a protein involved in DNA excision repair. The hrp1+ ORF codes for an 1373-amino acid polypeptide with a molecular mass of 159 kDa. Like other SNF2/SWI2 family proteins, the deduced amino acid sequence of Hrp1 contains DNA-dependent ATPase/7 helicase domains, as well as a chromodomain and a DNA-binding domain. This configuration is similar to that of mCHD1 (mouse chromo-ATPase/helicase-DNA-binding protein 1), suggesting that Hrp1 is a S. pombe homolog of mCHD1, which is thought to function in altering the chromatin structure to facilitate gene expression. Northern blot analysis showed that the hrp1+ gene produces a 4.6-kb transcript, which reaches its maximal level just before the cells enter the exponential growth phase, and then decreases gradually. DNA-damaging agents, such as MMS, MNNG and UV, decrease the rate of transcription of hrp1+. Deletion of the hrp1+ gene resulted in accelerated cell growth. On the other hand, overexpression of Hrp1 caused a reduction in growth rate. These results indicate that hrp1+ may act as a negative regulator of cellular growth.

The effect of physician staffing model on patient outcomes in a medical progressive care unit

PURPOSE

Although evidence supports the impact of intensivist physician staffing in improving intensive care unit (ICU) outcomes, the optimal coverage for progressive care units (PCU) is unknown. We sought to determine how physician staffing models influence outcomes for intermediate care patients.

MATERIALS AND METHODS

We conducted a retrospective observational comparison of patients admitted to the medical PCU of an academic hospital during 12-month periods of high-intensity and low-intensity staffing.

RESULTS

A total of 318 PCU patients were eligible for inclusion (143 high-intensity and 175 low-intensity). We found that low-intensity patients were more often stepped up from the emergency department and floor, whereas high-intensity patients were ICU transfers (61% vs 42%, P = .001). However, Mortality Probability Model scoring was similar between the 2 groups. In adjusted analysis, there was no association between intensity of staffing and hospital mortality (odds ratio, 0.84; 95% confidence interval, 0.36-1.99; P = .69) or PCU mortality (odds ratio, 0.96; 95% confidence interval, 0.38-2.45; P = .69). There was also no difference in subsequent ICU admission rates or in PCU length of stay.

CONCLUSIONS

We found no evidence that high-intensity intensivist physician staffing improves outcomes for intermediate care patients. In a strained critical care system, our study raises questions about the role of the intensivist in the graded care options between intensive and conventional ward care.

Identification of the DNA damage-responsive elements of the rhp51+ gene, a recA and RAD51 homolog from the fission yeast Schizosaccharomyces pombe

The Schizosaccharomyces pombe rhp51+ gene encodes a recombinational repair protein that shares significant sequence identities with the bacterial RecA and the Saccharomyces cerevisiae RAD51 protein. Levels of rhp51+ mRNA increase following several types of DNA damage or inhibition of DNA synthesis. An rhp51::ura4 fusion gene was used to identify the cis-acting promoter elements involved in regulating rhp51+ expression in response to DNA damage. Two elements, designated DRE1 and DRE2 (for damage-responsive element), match a decamer consensus URS (upstream repressing sequence) found in the promoters of many other DNA repair and metabolism genes from S. cerevisiae. However, our results show that DRE1 and DRE2 each function as a UAS (upstream activating sequence) rather than a URS and are also required for DNA-damage inducibility of the gene. A 20-bp fragment located downstream of both DRE1 and DRE2 is responsible for URS function. The DRE1 and DRE2 elements cross-competed for binding to two proteins of 45 and 59 kDa. DNase I footprint analysis suggests that DRE1 and DRE2 bind to the same DNA-binding proteins. These results suggest that the DRE-binding proteins may play an important role in the DNA-damage inducibility of rhp51+ expression.

Adults with childhood-onset chronic conditions admitted to US pediatric and adult intensive care units

PURPOSE

The purpose of the study is to compare demographics, intensive care unit (ICU) admission characteristics, and ICU outcomes among adults with childhood-onset chronic conditions (COCCs) admitted to US pediatric and adult ICUs.

MATERIALS AND METHODS

Retrospective cross-sectional analyses of 6088 adults aged 19 to 40 years admitted in 2008 to 70 pediatric ICUs that participated in the Virtual Pediatric Intensive Care Unit Performance Systems and 50 adult ICUs that participated in Project IMPACT.

RESULTS

Childhood-onset chronic conditions were present in 53% of young adults admitted to pediatric units, compared with 9% of those in adult units. The most common COCC in both groups were congenital cardiac abnormalities, cerebral palsy, and chromosomal abnormalities. Adults with COCC admitted to pediatric units were significantly more likely to be younger, have lower functional status, and be nontrauma patients than those in adult units. The median ICU length of stay was 2 days, and the intensive care unit mortality rate was 5% for all COCC patients with no statistical difference between pediatric or adult units.

CONCLUSIONS

There are marked differences in characteristics between young adults with COCC admitted to pediatric ICUs and adult ICUs. Barriers to accommodating these young adults may be reasons why many such adults have not transitioned from pediatric to adult critical care.

Tocilizumab in the Management of COVID-19: A Preliminary Report

IMPORTANCE

Pneumonia due to COVID-19 can lead to respiratory failure and death due to the development of the acute respiratory distress syndrome. Tocilizumab, a monoclonal antibody targeting the interleukin-6 receptor, is being administered off-label to some patients with COVID-19, and although early small studies suggested a benefit, there are no conclusive data proving its usefulness.

OBJECTIVE

To evaluate outcomes in hospitalized patients with COVID-19 with or without treatment with Tocilizumab.

DESIGN, SETTING, PARTICIPANTS

Retrospective study of 1938 patients with confirmed COVID-19 pneumonia admitted to hospitals within the Jefferson Health system in Philadelphia, Pennsylvania, between March 25, 2020 and June 17, 2020, of which 307 received Tocilizumab.

EXPOSURES

Confirmed COVID-19 pneumonia.

MAIN OUTCOMES AND MEASURES

Outcomes data related to length of stay, admission to intensive care unit (ICU), requirement of mechanical ventilation, and mortality were collected and analyzed.

RESULTS

The average age was 65.2, with 47% women; 36.4% were African-American. The average length of stay was 22 days with 26.3% of patients requiring admission to the ICU and 14.9% requiring mechanical ventilation. The overall mortality was 15.3%. Older age, admission to an ICU, and requirement for mechanical ventilation were associated with higher mortality. Treatment with Tocilizumab was also associated with higher mortality, which was mainly observed in subjects not requiring care in an ICU with estimated odds ratio (OR) of 2.9 (p = 0.0004). Tocilizumab treatment was also associated with higher likelihood of admission to an ICU (OR = 4.8, p < 0.0001), progression to requiring mechanical ventilation (OR = 6.6, p < 0.0001), and increased length of stay (OR = 16.2, p < 0.0001).

CONCLUSION AND RELEVANCE

Our retrospective analysis revealed an association between Tocilizumab administration and increased mortality, ICU admission, mechanical ventilation, and length of stay in subjects with COVID-19. Prospective trials are needed to evaluate the true effect of Tocilizumab in this condition.

Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage

PURPOSE

To compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage.

MATERIALS AND METHODS

Retrospective, observational study of patients refused MICU admission at an urban university hospital.

RESULTS

Of 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22-0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99).

CONCLUSIONS

Patients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety.

Critical Care Utilization and Outcomes of Interhospital Medical Transfers at Lower Risk of Death

PURPOSE

To evaluate utilization and mortality outcomes of interhospital transferred critically-ill medical patients with lower predicted risk of hospital mortality.

MATERIALS & METHODS

Multisite retrospective cohort analysis of patients with Acute Physiology and Chronic Health Evaluation (APACHE) IV-a predicted mortality of ≤20% from 335 ICUs in 208 hospitals in the Philips eICU database between 2014-2015. Differences in length-of-stay (LOS) and mortality between transferred and local patients were evaluated using negative binomial logistic regression and logistic regression, respectively. Stratified analyses were conducted for subgroups of predicted mortality: 0%-5%, 6%-10%, 11%-15%, and 16%-20%.

RESULTS

Transfers had a higher risk of longer ICU and hospital LOS across all risk strata (IRR 1.12; 95% CI 1.09-1.16, P < 0.001 and IRR 1.11; 95% CI 1.07-1.14, P < 0.001 respectively). Mortality was higher among transfers, largely driven by the 6%-10% mortality risk strata (OR 1.30; 95% CI 1.09-1.54, P = 0.003).

CONCLUSIONS

Interhospital transfer of critically-ill medical patients with lower illness severity is associated with higher ICU and hospital utilization and increased mortality. Better understanding of factors driving patient selection for and characteristics of interhospital transfer for this population will have an impact on ICU resource utilization, care efficiency, and hospital quality.

The Impact of Chronic Medical Conditions on Mortality in Acute Respiratory Distress Syndrome

PURPOSE

To examine the impact of chronic comorbidities on mortality in Acute Respiratory Distress Syndrome (ARDS).

MATERIALS AND METHODS

Retrospective cohort study of adults with ARDS (ICD-10-CM code J80) from the National Inpatient Sample between January, 2016 and December, 2018. For the primary outcome of mortality, we conducted weighted logistic regression adjusting for factors identified on univariate analysis as potentially significant or differing between the two groups at baseline. We used negative binomial regression adjusting for the same comorbidities to identify risk factors for longer length of stay (LOS) among ARDS survivors.

RESULTS

After exclusions, 1046 records were analyzed (3355 ARDS survivors and 1875 non-survivors.) The comorbidities examined included hypertension, diabetes mellitus, obesity, hypothyroidism, alcohol and drug use, chronic kidney disease (CKD), cardiovascular disease, chronic liver disease, chronic pulmonary disease and malignancy. In multivariate analysis, we found that malignancy (OR 2.26, 95% CI 1.84-2.78, p < 0.001), cardiovascular disease (OR 1.54, 95% CI 1.23-1.92, p < 0.001), and CKD (OR 1.75, 95% CI 1.22-2.50, p  =  0.002) increased the risk of death. In interaction analyses, cardiovascular disease combined with either malignancy or CKD conferred higher odds of death compared to either risk factor alone.

CONCLUSIONS

The comorbidity of malignancy confers the most reliable risk of poor outcomes in ARDS with higher odds of hospital death and a simultaneous association with longer hospital LOS among survivors.

Resistive switching characteristics of the Cr/ZnO/Cr structure

Resistive random access memory (ReRAM) with conductor-dielectric-conductor structures has attracted extensive attention for next generation nonvolatile memory devices. The resistive switching effect has been observed in various materials, such as metal oxides and chalcogenide oxides. From our findings, we advocate the resistive switching characteristics of zinc oxide thin film, due to its simple composition and ease of manipulation. In this study, we investigated the current-voltage (I-V) characteristics of the Cr/ZnO/Cr capacitor structure. The Cr electrode and ZnO thin film were deposited by radio frequency magnetron sputtering at room temperature. The top electrode layers were patterned by 100 microm x 100 microm. The fabricated devices of the Cr/ZnO/Cr structures exhibited bipolar switching behavior. In addition, using the Cr-coated AFM tip replaced with the top electrode enabled us to map the local current image and measure the current flow at each point. This gave us more information to verify the resistive switching mechanism of ZnO thin film.

Mechanically ventilated COVID-19 patients admitted to the intensive care unit in the United States with or without respiratory failure secondary to COVID-19 pneumonia: a retrospective comparison of characteristics and outcomes

BACKGROUND

There is increasing heterogeneity in the clinical phenotype of patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19,) and reasons for mechanical ventilation are not limited to COVID pneumonia. We aimed to compare the characteristics and outcomes of intubated patients admitted to the ICU with the primary diagnosis of acute hypoxemic respiratory failure (AHRF) from COVID-19 pneumonia to those patients admitted for an alternative diagnosis.

METHODS

Retrospective cohort study of adults with confirmed SARS-CoV-2 infection admitted to nine ICUs between March 18, 2020, and April 30, 2021, at an urban university institution. We compared characteristics between the two groups using appropriate statistics. We performed logistic regression to identify risk factors for death in the mechanically ventilated COVID-19 population.

RESULTS

After exclusions, the final sample consisted of 319 patients with respiratory failure secondary to COVID pneumonia and 150 patients intubated for alternative diagnoses. The former group had higher ICU and hospital mortality rates (57.7% vs. 36.7%, P<0.001 and 58.9% vs. 39.3%, P<0.001, respectively). Patients with AHRF secondary to COVID-19 pneumonia also had longer ICU and hospital lengths-of-stay (12 vs. 6 days, P<0.001 and 20 vs. 13.5 days, P=0.001). After risk-adjustment, these patients had 2.25 times higher odds of death (95% confidence interval, 1.42-3.56; P=0.001).

CONCLUSIONS

Mechanically ventilated COVID-19 patients admitted to the ICU with COVID-19-associated respiratory failure are at higher risk of hospital death and have worse ICU utilization outcomes than those whose reason for admission is unrelated to COVID pneumonia.

Influence of Incorporated Pt-Fe2O3 Core-Shell Nanoparticles on the Resistive Switching Characteristics of ZnO Thin Film

The resistance-switching characteristics of metal oxides have attracted great interest for the non-volatile memory applications such as resistive random access memory. A basic resistive random access memory device has a metal/insulator/metal structure, and its memory effect is achieved by applying voltage to change the resistance of the insulating layer. One of the promising candidates for explaining the resistance-switching mechanism is the formation and rupture of nanoscale conductive filaments. However, this model has an issue that needs to be addressed: the wide distribution of switching voltage due to randomly formed filaments. Therefore, some researchers have reported a decrease in switching voltage distribution and an increase in switching stability by incorporating nanoparticles into the insulating layer. In this study, we investigated influence of incorporated Pt-Fe2O3 core-shell nanoparticles on the resistive switching characteristics of ZnO thin films. Devices were fabricated on SiO2 wafers. A 100-nm-thick Cr layer was used as the bottom electrode. A 50-nm-thick ZnO layer was deposited using the sputtering method, and Pt-Fe2O3 nanoparticles were deposited on it by the dip coating method. A 50-nm-thick ZnO layer was then deposited again. A top Cr electrode (size: 100 μm x 100 μm) was deposited using a shadow mask and sputtering system. All the devices showed bipolar resistance-switching behavior that is observed in Cr/ZnO/Cr structures. However, the on/off voltage was dramatically lowered by incorporating nanoparticles into the insulating layer when compared with that of the devices without nanoparticles. In addition, the switching stability of the devices was improved upon the incorporation of nanoparticles. On the basis of these results, we can conclude that Pt-Fe2O3 nanoparticles may be used to enhance the resistance switching properties of ZnO thin films by incorporating them into the films.

Improving the Quality of Visualization Dashboards in Critical Care: A Mixed-Methods Study

Intensive care units (ICUs) lack both standardized performance indicators to better understand the effectiveness of interventions and uniform platforms to present these indicators. The goal of this study was to identify ICU metrics meaningful to stakeholders to help guide the development of a local visualization dashboard. Individual ICU directors were interviewed to collate their input on metrics important to their units. These qualitative data were used to develop a dashboard draft, after which the authors surveyed 20 stakeholders from different hospital departments for feedback on its content and structure. The varied survey results reinforced the inherent difficulties of adapting previously developed measurement tools while also selecting ICU performance measures that are simultaneously widely accepted yet relevant to local practice. These results also call attention to the importance of interdisciplinary input in quality dashboard development, thereby enabling more successful implementation and utilization for ICU quality improvement.

The Impact of Chronic Comorbidities on Outcomes in Acute Exacerbations of Idiopathic Pulmonary Fibrosis

INTRODUCTION

Idiopathic pulmonary fibrosis is a chronic progressive lung disease of unknown cause with a high associated mortality. We aimed to compare the impact of chronic medical conditions on hospital outcomes of patients with acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF).

METHODS

This was a retrospective cohort study using the NIS database from 2016 to 2018. We included patients aged 60 and older hospitalized in academic medical centers with the diagnoses of IPF and acute respiratory failure. We examined factors associated with hospital mortality and length of stay (LOS) using survey-weighted multivariate logistic and negative binomial regression.

RESULTS

Out of 4975 patients with AE-IPF, 665 (13.4%) did not survive hospitalization. There was no difference in the mean age between survivors and non-survivors. Patients were more likely to be male, predominantly white, and have Medicare coverage. Most non-survivors were from households with higher median income. Hospital LOS was longer among non-survivors than survivors (9.4 days vs. 9.8 days; p < 0.001). After multivariate-logistic regression, diabetes was found to be protective (aOR 0.62, 95% CI 0.50-0.77; p < 0.0001) while chronic kidney disease (CKD) conferred a significantly higher risk of death after AE-IPF (aOR 6.85, 95% CI 1.90-24.7; p = 0.00). Our multivariate adjusted negative binomial regression model for LOS identified obesity (IRR 0.85, 95% CI 0.76-0.94; p ≤ 0.00) and hypothyroidism (IRR 0.90, 95% CI 0.83-0.98; p = 0.02) to be associated with shorter hospital LOS.

CONCLUSIONS

Our results suggest that CKD is a significant contributor to hospital mortality in AE-IPF, and diabetes mellitus may be protective. Obesity and hypothyroidism are linked with shorter hospital LOS among patients hospitalized with AE-IPF in US academic medical centers.

Evidences for possible involvement of Rhp51 protein in mitotic events including chromosome segregation

To understand the role of the Rhp51 protein in Schizosaccharomyces pombe, we examined the phenotypes of the null mutant for the rhp51+ gene. Unlike Saccharomyces cerevisiae rad51 mutants, S. pombe rhp51 mutants (rhp51delta cells) displayed slow growth and heterogeneity in cell size, indicating perturbation of the cell cycle. Furthermore, many aberrant nuclear structures found in 4',6'-diamidino-2-phenylindole (DAPI)-stained rhp51delta cells and the caffeine hypersensitivity of the mutant cells suggested an involvement of the Rhp51 protein in normal chromosome segregation. These data suggested that the Rhp51 proteins were required for normal cell growth as well as a DNA repair pathway. Moreover, rhp51delta mutants showed a considerable sensitivity to ultraviolet (UV) light-irradiation as well as methyl methanesulfonate (MMS) treatment, indicating that the Rhp51 proteins are involved in both the active excision mechanism of UV-induced DNA damage and recombinational repair in S. pombe. Taken together, we suggest that the role(s) of the Rhp51 protein in S. pombe may be different from those of Rad51 in S. cerevisiae.

Characteristics and Outcomes of Patients Discharged Directly Home From a Medical Intensive Care Unit: A Retrospective Cohort Study

OBJECTIVE

To evaluate the safety of directly discharging patients home from the medical intensive care unit (MICU).

MATERIALS AND METHODS

Single-center retrospective observational study of consecutive MICU direct discharges to home from an urban university hospital between June, 1, 2017, and June 30, 2019.

RESULTS

Of 1061 MICU discharges, 331 (31.2%) patients were eligible for analysis. Patients were divided into 2 groups based on duration of wait-time (< or ≥24 hours) between ward transfer order and ultimate hospital discharge. Most patients (68.2%) were discharged in <24 hours. Patients who waited for a floor bed for ≥24 hours prior to discharge had longer hospital length-of-stay (LOS, median 3.83 versus 2.00 days) and ICU LOS (median 3.51 versus 1.74 days). Overall, 44 (13.3%) direct MICU discharges were readmitted to the hospital within 30-days, but there was no difference in this outcome or in 30-day mortality when comparing the 2 wait-time groups.

CONCLUSIONS

The practice of directly discharging MICU patients home does not negatively influence patient outcomes. Patients who overstay in the ICU after being deemed transfer-ready are unlikely to be benefiting from critical care, but impact hospital throughput and resource utilization. Prospective investigation into this practice may provide further confirmation of its feasibility and safety.

Weekend Admission Does Not Confer an Increased Risk of Mortality in Septic Shock

Purpose: To investigate the impact of weekend admission on mortality for patients with septic shock. Material and Methods: Retrospective cohort study of adults in the 2017 to 2018 National Inpatient Sample coded as R65.21 (severe sepsis with septic shock) within the first 3 diagnosis codes according to the 10th revision of the International Classification of Diseases. Measurements and Main Results: After exclusions, 100,584 records were analyzed (73,966 weekday and 26,618 weekend admissions). Severity-of-illness was estimated using the Charlson-Deyo comorbidity index. Using weighted logistic regression adjusted for factors identified on univariate analysis as potentially significant, we found no higher odds of death for weekday compared to weekend admissions (OR 1.00, 95% CI 0.99-1.02, P = .84). There was a temporal improvement in septic shock outcomes with 2018 admissions having lower odds of death (OR 0.97, 95% CI 0.96-0.98, P < .001). There was no evidence for interaction between weekend admission and individual years of admission (P = .17 and P = .05 for 2017 and 2018, respectively). However, weekend mortality did seem to vary by region in our interaction analysis with higher odds of death seen in the West (OR 1.08, 95% CI 1.05-1.11, P < .001). Conclusion: We found no evidence for higher mortality among patients admitted on weekends with septic shock.

Patient outcomes after interhospital transfer: the impact of early intensive care unit upgrade

BACKGROUND

There is little known about the prevalence and outcomes of medical patients requiring early intensive care unit upgrade (EIU) following interhospital transfer, and previous studies of EIU focus on patients admitted through the emergency room. We aimed to examine the characteristics and risk factors for poor outcome among medical patients undergoing EIU after interhospital transfer.

MATERIALS AND METHODS

The publicly available Medical Information Mart for Intensive Care (MIMIC) IV database (2008-2019) was queried to identify non-surgical patients undergoing interhospital transfer. Patients who subsequently underwent EIU, defined as ICU admission within 24 hours of arrival after interhospital transfer, were compared to those who did not experience EIU for differences in mortality and length-of-stay (LOS.) We used multivariate logistic regression to identify risk factors for hospital death in this population and negative binomial regression to estimate the impact of EIU on hospital LOS.

RESULTS

We identified 5,619 patients who underwent interhospital transfer, of which 339 (6.0%) experienced EIU and 5280 (94.0%) did not. Patients undergoing EIU after interhospital transfer were significantly older (median age 69 vs. 64 years; p = 0.001,) but there was no difference in sex. After risk-adjustment, we found an association between EIU and a higher risk of mortality (aOR 6.9, 95%CI 5.24-9.08). Increased comorbidity burden as measured by Charlson Comorbidity Index (CCI) was linked to higher odds of death (aOR 1.26, 95% CI 1.22-1.31,) as was nonwhite race (aOR 1.69, 95% CI 1.34-2.14). EIU was associated with a longer hospital LOS (IRR 1.40, 95%CI 1.28-1.54).

CONCLUSION

EIU after interhospital transfer is associated with higher mortality and longer LOS. Further study will help identify process features of transfer and patient characteristics contributing to poor outcome after arrival from an outlying facility and guide efforts to mitigate risk and provide equitable care across the transfer continuum.

What every intensivist should know about: Trust in the ICU

Trust is an essential element in the relationship between patients and intensive care unit (ICU) clinicians. Without a foundation of trust, communication is difficult, conflict is more likely, and even clinical outcomes can be affected. The ICU is a particularly challenging environment for trust to flourish. Illness occurs suddenly, emotions can be charged, the environment is impersonal, and there is rarely a prior relationship between patients and their caregivers. Therefore, intensivists must have some understanding of the factors that impact patient and family trust, as well as the actions they can take to improve it.

A retrospective cohort study of short-stay admissions to the medical intensive care unit: Defining patient characteristics and critical care resource utilization

Background

Little is known about the mortality and utilization outcomes of short-stay intensive care unit (ICU) patients who require <24 h of critical care. We aimed to define characteristics and outcomes of short-stay ICU patients whose need for ICU level-of-care is ≤24 h compared to nonshort-stay patients.

Methods

Single-center retrospective cohort study of patients admitted to the medical ICU at an academic tertiary care center in 2019. Fisher's exact test or Chi-square for descriptive categorical variables, t-test for continuous variables, and Mann-Whitney two-sample test for length of stay (LOS) outcomes.

Results

Of 819 patients, 206 (25.2%) were short-stay compared to 613 (74.8%) nonshort-stay. The severity of illness as measured by the Mortality Probability Model-III was significantly lower among short-stay compared to nonshort-stay patients (P = 0.0001). Most short-stay patients were admitted for hemodynamic monitoring not requiring vasoactive medications (77, 37.4%). Thirty-six (17.5%) of the short-stay cohort met Society of Critical Care Medicine's guidelines for ICU admission. Nonfull-ICU LOS, or time spent waiting for transfer out to a non-ICU bed, was similar between the two groups. Hospital mortality was lower among short-stay patients compared to nonshort-stay patients (P = 0.01).

Conclusions

Despite their lower illness severity and fewer ICU-level care needs, short-stay patients spend an equally substantial amount of time occupying an ICU bed while waiting for a floor bed as nonshort-stay patients. Further investigation into the factors influencing ICU triage of these subacute patients and contributors to system inefficiencies prohibiting their timely transfer may improve ICU resource allocation, hospital throughput, and patient outcomes.