Variation in risk-adjusted cardiac intensive care unit (CICU) length of stay and the association with in-hospital mortality: An analysis from the Critical Care Cardiology Trials Network (CCCTN) registry

BACKGROUND

Previous studies have suggested that there is wide variability in cardiac intensive care unit (CICU) length of stay (LOS); however, these studies are limited by the absence of detailed risk assessment at the time of admission. Thus, we evaluated inter-hospital differences in CICU LOS, and the association between LOS and in-hospital mortality.

METHODS

Using data from the Critical Care Cardiology Trials Network (CCCTN) registry, we included 22,862 admissions between 2017 and 2022 from 35 primarily tertiary and quaternary CICUs that captured consecutive admissions in annual 2-month snapshots. The primary analysis compared inter-hospital differences in CICU LOS, as well as the association between CICU LOS and all-cause in-hospital mortality using a Fine and Gray competing risk model.

RESULTS

The overall median CICU LOS was 2.2 (1.1-4.8) days, and the median hospital LOS was 5.9 (2.8-12.3) days. Admissions in the longest tertile of LOS tended to be younger with higher rates of pre-existing comorbidities, and had higher Sequential Organ Failure Assessment (SOFA) scores, as well as higher rates of mechanical ventilation, intravenous vasopressor use, mechanical circulatory support, and renal replacement therapy. Unadjusted all-cause in-hospital mortality was 9.3%, 6.7%, and 13.4% in the lowest, intermediate, and highest CICU LOS tertiles. In a competing risk analysis, individual patient CICU LOS was correlated (r2 = 0.31) with a higher risk of 30-day in-hospital mortality. The relationship remained significant in admissions with heart failure, ST-elevation myocardial infarction and non-ST segment elevation myocardial infarction.

CONCLUSIONS

In a large registry of academic CICUs, we observed significant variation in CICU LOS and report that LOS is independently associated with all-cause in-hospital mortality. These findings could potentially be used to improve CICU resource utilization planning and refine risk prognostication in critically ill cardiovascular patients.

Right Ventricular Dysfunction Patterns among Patients with COVID-19 in the Intensive Care Unit: A Retrospective Cohort Analysis

Rationale: Right ventricular (RV) dysfunction is common among patients hospitalized with coronavirus disease (COVID-19); however, its epidemiology may depend on the echocardiographic parameters used to define it. Objectives: To evaluate the prevalence of abnormalities in three common echocardiographic parameters of RV function among patients with COVID-19 admitted to the intensive care unit (ICU), as well as the effect of RV dilatation on differential parameter abnormality and the association of RV dysfunction with 60-day mortality. Methods: We conducted a retrospective cohort study of ICU patients with COVID-19 between March 4, 2020, and March 4, 2021, who received a transthoracic echocardiogram within 48 hours before to at most 7 days after ICU admission. RV dysfunction and dilatation, respectively, were defined by guideline thresholds for tricuspid annular plane systolic excursion (TAPSE), RV fractional area change, RV free wall longitudinal strain (RVFWS), and RV basal dimension or RV end-diastolic area. Association of RV dysfunction with 60-day mortality was assessed through logistic regression adjusting for age, prior history of congestive heart failure, invasive ventilation at the time of transthoracic echocardiogram, and Acute Physiology and Chronic Health Evaluation II score. Results: A total of 116 patients were included, of whom 69% had RV dysfunction by one or more parameters, and 36.3% of these had RV dilatation. The three most common patterns of RV dysfunction were the presence of three abnormalities, the combination of abnormal RVFWS and TAPSE, and isolated TAPSE abnormality. Patients with RV dilatation had worse RV fractional area change (24% vs. 36%; P = 0.001), worse RVFWS (16.3% vs. 19.1%; P = 0.005), higher RV systolic pressure (45 mm Hg vs. 31 mm Hg; P = 0.001) but similar TAPSE (13 mm vs. 13 mm; P = 0.30) compared with those with normal RV size. After multivariable adjustment, 60-day mortality was significantly associated with RV dysfunction (odds ratio, 2.91; 95% confidence interval, 1.01-9.44), as was the presence of at least two parameter abnormalities. Conclusions: ICU patients with COVID-19 had significant heterogeneity in RV function abnormalities present with different patterns associated with RV dilatation. RV dysfunction by any parameter was associated with increased mortality. Therefore, a multiparameter evaluation may be critical in recognizing RV dysfunction in COVID-19.

Editor’s Choice-Prospective registry of cardiac critical illness in a modern tertiary care Cardiac Intensive Care Unit

Background:

The changing landscape of care in the Cardiac Intensive Care Unit (CICU) has prompted efforts to redesign the structure and organization of advanced CICUs. Few studies have quantitatively characterized current demographics, diagnoses, and outcomes in the contemporary CICU.

Methods:

We evaluated patients in a prospective observational database, created to support quality improvement and clinical care redesign in an AHA Level 1 (advanced) CICU at Brigham and Women’s Hospital, Boston, MA, USA. All consecutive patients ( N=2193) admitted from 1 January 2015 to 31 December 2017 were included at the time of admission to the CICU.

Results:

The median age was 65 years (43% >70 years) and 44% of patients were women. Non-cardiovascular comorbidities were common, including chronic kidney disease (27%), pulmonary disease (22%), and active cancer (13%). Only 7% of CICU admissions were primarily for an acute coronary syndrome, which was the seventh most common individual diagnosis. The top three reasons for admission to the CICU were shock/hypotension (26%), cardiopulmonary arrest (11%), or primary arrhythmia without arrest (9%). Respiratory failure was a primary or major secondary reason for triage to the CICU in 17%. In-hospital mortality was 17.6%.

Conclusions:

In a tertiary, academic, advanced CICU, patients are elderly with a high burden of non-cardiovascular comorbid conditions. Care has shifted from ACS toward predominantly shock and cardiac arrest, as well as non-ischemic conditions, and the mortality of these conditions is high. These data may be useful to guide cardiac critical care redesign.

Effect of lysyl oxidase inhibition on angiotensin II-induced arterial hypertension, remodeling, and stiffness

It is well accepted that angiotensin II (Ang II) induces altered vascular stiffness through responses including both structural and material remodeling. Concurrent with remodeling is the induction of the enzyme lysyl oxidase (LOX) through which ECM proteins are cross-linked. The study objective was to determine the effect of LOX mediated cross-linking on vascular mechanical properties. Three-month old mice were chronically treated with Ang II with or without the LOX blocker, β -aminopropionitrile (BAPN), for 14 days. Pulse wave velocity (PWV) from Doppler measurements of the aortic flow wave was used to quantify in vivo vascular stiffness in terms of an effective Young’s modulus. The increase in effective Young’s modulus with Ang II administration was abolished with the addition of BAPN, suggesting that the material properties are a major controlling element in vascular stiffness. BAPN inhibited the Ang II induced collagen cross-link formation by 2-fold and PWV by 44% (P<0.05). Consistent with this observation, morphometric analysis showed that BAPN did not affect the Ang II mediated increase in medial thickness but significantly reduced the adventitial thickness. Since the hypertensive state contributes to the measured in vivo PWV stiffness, we removed the Ang II infusion pumps on Day 14 and achieved normal arterial blood pressures. With pump removal we observed a decrease of the PWV in the Ang II group to 25% above that of the control values (P=0.002), with a complete return to control values in the Ang II plus BAPN group. In conclusion, we have shown that the increase in vascular stiffness with 14 day Ang II administration results from a combination of hypertension-induced wall strain, adventitial wall thickening and Ang II mediated LOX ECM cross-linking, which is a major material source of vascular stiffening, and that the increased PWV was significantly inhibited with co-administration of BAPN.

Radically rethinking agriculture for the 21st century

Population growth, arable land and fresh water limits, and climate change have profound implications for the ability of agriculture to meet this century's demands for food, feed, fiber, and fuel while reducing the environmental impact of their production. Success depends on the acceptance and use of contemporary molecular techniques, as well as the increasing development of farming systems that use saline water and integrate nutrient flows.

Calcium and vitamin D status of pregnant teenagers in Maiduguri, Nigeria

This study investigates parameters related to calcium and bone metabolism by determining the concentrations of total calcium, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, parathyroid hormone, and phosphorous in young pregnant women. The patient population was 30 pregnant Nigerian teenage women grouped by trimester (10 per group), 10 women immediately following delivery, and 21 healthy age-matched controls. On the basis of serum prealbumin levels, the general nutrition of the pregnant women was found to be significantly below that of the more privileged and better-educated nonpregnant controls. The mean total calcium concentration in sera of the third-trimester women was 8.83 mg/dL, which was significantly below that of the controls (9.77 mg/dL) and the first-trimester group (9.30 mg/dL). Despite the 10% to 15% decline in the serum level of total calcium during pregnancy, the parathyroid hormone level decreased markedly from 0.60 to 0.61 ng/mL in the first and second trimesters to 0.41 ng/mL in the third trimester. Serum vitamin D and 1,25-dihydroxyvitamin D levels in the second and third trimesters were within the normal range. These data indicate that toward the end of gestation, pregnant teenagers in northern Nigeria appear to become calcium deficient and do not exhibit the expected increase in serum parathyroid hormone levels normally seen in pregnant women.

Characterization of muscarinic receptors of bovine adrenal chromaffin cells: binding, secretion and anti-microtubule drug effects

1. Binding of [3H]QNB to adrenal membranes is saturable, specific and to a single class of receptors. 2. Tubulozole, and not other microtubule drugs, inhibits [3H]QNB binding. 3. Pretreating cultured chromaffin cells with oxotremorine, a muscarinic receptor agonist, has no effect on either basal, nicotine (10 microM) or K(+)-stimulated catecholamine release and failed to enhance secretion of submaximal concentrations of nicotine (3-5 microM). 4. These results confirm that binding of [3H]QNB is associated with muscarinic receptors on bovine adrenal medullary tissue. 5. These studies also demonstrate that although bovine adrenal chromaffin cells possess muscarinic receptors, these receptors do not appear to be coupled to secretory processes.

Low-Input Cropping for Acid Soils of the Humid Tropics

A low-input cropping system has been developed at Yurimaguas, Peru, to serve as a transition technology between shifting and continuous cultivation for acid soils of the humid tropics. Principal features are slash-and-burn clearing, rotation of acid-tolerant upland rice and cowpea cultivars, maximum residue return, no tillage, and no lime or fertilizer applications. When yields decline as a result of increasing weed pressure and nutrient deficiencies, a kudzu fallow is grown for 1 year. Subsequent options include fertilizer-based continuous cultivation, pastures, or agroforestry. The system preserves some agroecosystem diversity and contributes toward a sustainable level of production and income for farmers in humid tropical regions.

Aortopulmonary window with anomalous origin of the right coronary artery from the pulmonary trunk

A case of aortopulmonary window associated with an anomalous origin of the right coronary artery from the pulmonary artery in a 3-month-old boy is reported. Angiographic diagnosis could be difficult because of the simultaneous filling of both great arteries that obscure the origin of the anomalous vessel; however, a careful evaluation of the angiogram may contribute to an accurate diagnosis. The surgical correction of this association of defects requires the connection of the aorta with the anomalous coronary ostium. An intrapulmonary tunneling procedure by means of a baffle is described.

Amazon Basin Soils: Management for Continuous Crop Production

Technology has been developed which permits continuous production of annual crops in some of the acid, infertile soils of the Amazon Basin. Studies in Yurimaguas, Peru, show that three grain crops can be produced annually with appropriate fertilizer inputs. Twenty-one crops have been harvested during the past 8(1/2) years in the same field, with an average annual production of 7.8 tons of grain per hectare. Soil properties are improving with continuous cultivation. The technology has been validated by local farmers, who normally practice shifting cultivation. Economic interpretations indicate large increases in annual family farm income and a high return on the investment of chemical inputs. Other promising land use alternatives include low-input crop production systems, paddy rice production in fertile alluvial soils, and pastures or agroforestry in rolling areas. Stable, continuous food crop production is an attractive alternative to shifting cultivation in humid tropical regions experiencing severe demographic pressures. For each hectare of land managed in a highly productive manner, there may be less need for clearing additional tropical forests to meet food demands.

Management of patent ductus arteriosus in preterm babies

There is a higher incidence of delayed closure of the patent ductus arteriosus in premature babies with respiratory distress syndrome. From July, 1975, to December, 1977, 57 small, preterm infants with patent ductus arteriosus were diagnosed at our neonatal intensive care unit. From July, 1975, until September, 1976 (first period), 23 patients were diagnosed, and 11 underwent surgical ligation of a patent ductus arteriosus. There were 3 early deaths. From October, 1976, until December, 1977, out of a total of 34 patients with diagnosed patent ductus, 18 were treated with indomethacin, and only 3 required ligation. Our present policy for patent ductus arteriosus with respiratory distress syndrome in the premature baby is to initiate early treatment with indomethacin. If this treatment fails and the infant's status deteriorates, we perform early surgical ligation of the ductus in order to minimize the time on mechanical ventilation and lessen the chances of the development of bronchopulmonary dysplasia.

Soils of the Tropics and the World Food Crisis

The properties and potential of soils of the tropics are poorly understood. The old idea that laterite is formed when tropical soils are cleared is true of only a small proportion of the area. In most features, soils in the tropics are similar or equivalent to soils in the temperate regions. Specifically, soil organic matter contents, commonly believed to be low in the tropics, are essentially similar to those of the temperate regions. While the basic concepts about physical and chemical behavior developed in the nonglaciated temperate regions are directly applicable to the tropics, the development of soil management practices for sustained food production involves different strategies because of environmental and economic constraints. A major distinction is made between the development of high base status and low base status soils. With the former, soil management practices should be aimed at maximizing the potential of high-yielding varieties and improving intercropping systems with relatively intensive fertilizer inputs. With the low base status soils of the vast savanna and jungle areas energyrelated inputs should be optimized by (i) selecting of crop varieties and species more tolerant to nutritional deficiencies or toxicities, (ii) applying fertilizers at lower rates than those recommended by classic marginal analysis, and (iii) increasing the efficiency of applied fertilizers in such soils.

Ascending aorta-right pulmonary artery anastomosis: Waterston's operation

The results of 180 cases of congenital heart disease with diminished pulmonary flow operated upon with Waterston's technique are presented.

It is considered that Waterston's operation is to be preferred in children under 2 years of age and in older children who have had a previous thrombotic or insufficient Blalock operation and in whom total correction is not indicated.

The problem of pseudotruncus with hypoplastic pulmonary arteries is discussed. The convenience of the Waterston operation in these cases, and the importance of creating an anastomosis at the pulmonary bifurcation and as far back as possible in the aorta, is emphasized.

The need to perform this technique in the correct way is stressed. This will avoid the kinking and pulling of the right pulmonary artery, which are causes of preferential blood flow to the right lung, as we have demonstrated experimentally.

The possible complications caused by such a technical failure are discussed. The necessity for previous angiocardiographic study, in order properly to repair the defect during total correction, is also considered.

Laboratory and clinical studies during prolonged partial extracorporeal circulation using the Bramson membrane lung

The survival rate, electrolyte changes, hematological changes, arterial gas analysis, and pulmonary compliances in 14 prolonged venovenous perfusions with the Bramson membrane oxygenator are presented. The Bramson membrane oxygenator functioned efficiently.

There were two deaths in the series, neither attributable to the perfusion. Arterial gas studies and pulmonary compliance studies indicated no measurable detrimental effect on the lungs. Platelet counts decreased and white blood cell counts increased during perfusion.

A clinical prolonged veno-venous perfusion is reported.

Endocardial cushion defects

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