Premorbid functional status as an outcome predictor in intensive care patients aged over 85 years

Background Poor premorbid functional status (PFS) is associated with mortality after intensive care unit (ICU) admission in patients aged 80 years or older. In the subgroup of very old ICU patients, the ability to recover from critical illness varies irrespective of age. To assess the predictive ability of PFS also among the patients aged 85 or older we set out the current study. Methods In this nationwide observational registry study based on the Finnish Intensive Care Consortium database, we analysed data of patients aged 85 years or over treated in ICUs between May 2012 and December 2015. We defined PFS as good for patients who had been independent in activities of daily living (ADL) and able to climb stairs and as poor for those who were dependent on help or unable to climb stairs. To assess patients' functional outcome one year after ICU admission, we created a functional status score (FSS) based on how many out of five physical activities (getting out of bed, moving indoors, dressing, climbing stairs, and walking 400 m) the patient could manage. We also assessed the patients' ability to return to their previous type of accommodation. Results Overall, 2037 (3.3% of all adult ICU patients) patients were 85 years old or older. The average age of the study population was 87 years. Data on PFS were available for 1446 (71.0%) patients (good for 48.8% and poor for 51.2%). The one-year mortalities of patients with good and those with poor PFS were 29.2% and 50.1%, respectively, p < 0.001. Poor PFS increased the probability of death within 12 months, adjusted odds ratio (OR), 2.15; 95% confidence interval (CI) 1.68-2.76, p < 0.001. For 69.5% of survivors, the FSS one year after ICU admission was unchanged or higher than their premorbid FSS and 84.2% of patients living at home before ICU admission still lived at home. Conclusions Poor PFS doubled the odds of death within one year. For most survivors, functional status was comparable to the premorbid status.Peer reviewe

The role of the intra-abdominal view in complicated intra-abdominal infections

BackgroundThe prognostic role of what a surgeon observes in the abdomen of patients with complicated intra-abdominal infection (cIAI) is largely unknown. The aim of this prospective study was to systemically analyze components of the intra-abdominal view (IAV) and their association to severe complicated intra-abdominal sepsis (SCIAS) or mortality.MethodsThe study cohort consisted of adult patients with cIAI. The operating surgeon filled a paper form describing the intra-abdominal view. Demographics, operative details, and preoperative physiological status were collected. Descriptive, univariate, and multivariate statistical analyses were performed, and a new score was developed based on regression coefficients. The primary outcome was a composite outcome of SCIAS or 30-day mortality, in which SCIAS was defined as organ dysfunctions requiring intensive care unit admission.ResultsA total of 283 patients were analyzed. The primary outcome was encountered in 71 (25%) patients. In the IAV, independent risk factors for the primary outcome were fecal or bile as exudate (odds ratio (OR) 1.98, 95% confidence interval 1.05-3.73), diffuse peritonitis (OR 2.15, 1.02-4.55), diffuse substantial redness of the peritoneum (OR 5.73, 2.12-15.44), and a non-appendiceal source of cIAI (OR 11.20, 4.11-30.54). Based on these factors, an IAV score was developed and its performance analyzed. The area under the receiver operating characteristic for the IAV score was 0.81. The IAV score also correlated significantly with several outcomes and organ dysfunctions.ConclusionsThe extent of peritonitis, diffuse substantial redness of the peritoneum, type of exudate, and source of infection associate independently with SCIAS or mortality. A high IAV score associates with mortality and organ dysfunctions, yet it needs further external validation. Combining components of IAV into comprehensive scoring systems for cIAI patients may provide additional value compared to the current scoring systems.Trial registrationThe study protocol was retrospectively registered on April 4, 2016, right after the first enrolled patient at Clinicaltrials.gov database (NCT02726932).Peer reviewe

Vanhuspotilaan tehohoidon mahdollisuudet ja rajoitteet

VertaisarvioituMerkittävä osa kriittisesti sairaista vanhuksista hyötyy tehohoidosta, vaikka ennuste heikkeneekin iän ¬lisääntyessä. Toisaalta huonosti kohdennettu hoito voi lisätä kuolevan kärsimyksiä ja aiheuttaa turhia ¬kustannuksia. Suomessa viime vuosina päivystysluonteisesti tehohoitoon otetuista yli 80-vuotiaista joka neljäs menehtyi saman sairaalahoitojakson aikana ja noin puolet vuoden kuluessa. Voimakkaimmin ennusteeseen vaikuttavat edeltävä toimintakyky, akuutin sairauden vaikeusaste ja ¬pitkäaikaissairaudet. Ratkaisevaa on, onko elintoimintahäiriöihin johtanut perussyy hoidettavissa.Peer reviewe

Premorbid functional status as a predictor of 1-year mortality and functional status in intensive care patients aged 80 years or older

We assessed the association between the premorbid functional status (PFS) and 1-year mortality and functional status of very old intensive care patients. Using a nationwide quality registry, we retrieved data on patients treated in Finnish intensive care units (ICUs) during the period May 2012aEuro'April 2013. Of 16,389 patients, 1827 (11.1%) were very old (aged 80 years or older). We defined a person with good functional status as someone independent in activities of daily living (ADL) and able to climb stairs without assistance; a person with poor functional status was defined as needing assistance for ADL or being unable to climb stairs. We adjusted for severity of illness and calculated the impact of PFS. Overall, hospital mortality was 21.3% and 1-year mortality was 38.2%. For emergency patients (73.5% of all), hospital mortality was 28% and 1-year mortality was 48%. The functional status at 1 year was comparable to the PFS in 78% of the survivors. PFS was poor for 43.3% of the patients. A poor PFS predicted an increased risk of in-hospital death, adjusted odds ratio (OR) 1.50 (95% confidence interval, 1.07-2.10), and of 1-year mortality, OR 2.18 (1.67-2.85). PFS data significantly improved the prediction of 1-year mortality. Of very old ICU patients, 62% were alive 1 year after ICU admission and 78% of the survivors had a functional status comparable to the premorbid situation. A poor PFS doubled the odds of death within a year. Knowledge of PFS improved the prediction of 1-year mortality.Peer reviewe

Intensive care of traumatic brain injury and aneurysmal subarachnoid hemorrhage in Helsinki during the Covid-19 pandemic

Background To ensure adequate intensive care unit (ICU) capacity for SARS-CoV-2 patients, elective neurosurgery and neurosurgical ICU capacity were reduced. Further, the Finnish government enforced strict restrictions to reduce the spread. Our objective was to assess changes in ICU admissions and prognosis of traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH) during the Covid-19 pandemic. Methods Retrospective review of all consecutive patients with TBI and aneurysmal SAH admitted to the neurosurgical ICU in Helsinki from January to May of 2019 and the same months of 2020. The pre-pandemic time was defined as weeks 1-11, and the pandemic time was defined as weeks 12-22. The number of admissions and standardized mortality rates (SMRs) were compared to assess the effect of the Covid-19 pandemic on these. Standardized mortality rates were adjusted for case mix. Results Two hundred twenty-four patients were included (TBIn= 123, SAHn= 101). There were no notable differences in case mix between TBI and SAH patients admitted during the Covid-19 pandemic compared with before the pandemic. No notable difference in TBI or SAH ICU admissions during the pandemic was noted in comparison with early 2020 or 2019. SMRs were no higher during the pandemic than before. Conclusion In the area of Helsinki, Finland, there were no changes in the number of ICU admissions or in prognosis of patients with TBI or SAH during the Covid-19 pandemic.Peer reviewe

A novel score for predicting 1‐year mortality of intensive care patients

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Non-interventional follow-up versus fluid bolus in RESPONSE to oliguria in hemodynamically stable critically ill patients : a randomized controlled pilot trial

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Evidences on the Ability of Mycorrhizal Genus Piloderma to Use Organic Nitrogen and Deliver It to Scots Pine

Ectomycorrhizal (ECM) symbiosis has been proposed to link plant photosynthesis and soil organic matter (SOM) decomposition through the production of fungal enzymes which promote SOM degradation and nitrogen (N) uptake. However, laboratory and field evidence for the existence of these processes are rare. Piloderma sp., a common ECM genus in boreal forest soil, was chosen as model mycorrhiza for this study. The abundance of Piloderma sp. was studied in root tips and soil over one growing season and in winter. Protease production was measured from ectomycorrhiza and soil solution in the field and pure fungal cultures. We also tested the effect of Piloderma olivaceum on host plant organic N nutrition in the laboratory. The results showed that Piloderma sp. was highly abundant in the field and produced extracellular proteases, which correlated positively with the gross primary production, temperature and soil respiration. In the laboratory, Piloderma olivaceum could improve the ability of Pinus sylvestris L. to utilize N from extragenous proteins. We suggest that ECM fungi, although potentially retaining N in their hyphae, are important in forest C and N cycling due to their ability to access proteinaeous N. As Piloderma sp. abundance appeared to be seasonally highly variable, recycling of fungal-bound N after hyphal death may therefore be of primary importance for the N cycling in boreal ecosystems.Peer reviewe

Association of extracerebral organ failure with 1-year survival and healthcare-associated costs after cardiac arrest : an observational database study

BackgroundOrgan dysfunction is common after cardiac arrest and associated with worse short-term outcome, but its impact on long-term outcome and treatment costs is unknown.MethodsWe used nationwide registry data from the intensive care units (ICU) of the five Finnish university hospitals to evaluate the association of 24-h extracerebral Sequential Organ Failure Assessment (24h-EC-SOFA) score with 1-year survival and healthcare-associated costs after cardiac arrest. We included adult cardiac arrest patients treated in the participating ICUs between January 1, 2003, and December 31, 2013. We acquired the confirmed date of death from the Finnish Population Register Centre database and gross 1-year healthcare-associated costs from the hospital billing records and the database of the Finnish Social Insurance Institution.ResultsA total of 5814 patients were included in the study, and 2401 were alive 1year after cardiac arrest. Median (interquartile range (IQR)) 24h-EC-SOFA score was 6 (5-8) in 1-year survivors and 7 (5-10) in non-survivors. In multivariate regression analysis, adjusting for age and prior independency in self-care, the 24h-EC-SOFA score had an odds ratio (OR) of 1.16 (95% confidence interval (CI) 1.14-1.18) per point for 1-year mortality.Median (IQR) healthcare-associated costs in the year after cardiac arrest were Euro47,000 (Euro28,000-75,000) in 1-year survivors and Euro12,000 (Euro6600-25,000) in non-survivors. In a multivariate linear regression model adjusting for age and prior independency in self-care, an increase of one point in the 24h-EC-SOFA score was associated with an increase of Euro170 (95% CI Euro150-190) in the cost per day alive in the year after cardiac arrest. In the same model, an increase of one point in the 24h-EC-SOFA score was associated with an increase of Euro4400 (95% CI Euro3300-5500) in the total healthcare-associated costs in 1-year survivors.ConclusionsExtracerebral organ dysfunction is associated with long-term outcome and gross healthcare-associated costs of ICU-treated cardiac arrest patients. It should be considered when assessing interventions to improve outcomes and optimize the use of resources in these patients.Peer reviewe