Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

First report of the Suicide Support and Information System.

The SSIS pilot study was conducted in County Cork over the period September 2008 – March 2011. The SSIS operates according to a stepped approach whereby step 1 involves pro-active facilitation of support for family members bereaved by suicide, followed by step 2: obtaining information from different sources including information from coroners’ records, family informants and health care professionals who had been in contact with the deceased in the year prior to death. In total 178 cases of suicide and 12 open verdicts (total 190) were ascertained in the Cork region during the pilot phase of the SSIS, with very satisfactory response rates for the three information sources. Key outcomes include: • In 39.5% of cases the SSIS pro-actively facilitated bereavement and other support. In 47.5% of cases bereavement support had been obtained prior to contact with the SSIS team. In 8.2% of cases the bereaved did not wish to avail of formal bereavement support from a specific service, but they welcomed further contact with a member of the SSIS team. A small proportion (4.8%) did not wish to receive further contact following the initial letter from the SSIS team. • Mental health risk factors associated with suicide included mood disorder of the deceased, mental disorder of family members, history of deliberate self harm and lifetime alcohol abuse in the year prior to death. • Major precipitating factors in the month prior to suicide included significant losses, significant or perceived significant disruption of a primary relationship and significant life changes. Evidence was found for the impact of the economic recession in terms of job loss, increased suicide risk associated with specific occupations, financial problems and loss of possessions, such as house etc. • Evidence was found for long term adversity in the lives of people who died by suicide, often starting in childhood or early adolescence and continuing in later life, such as mental and physical maltreatment, problems in making contact with others and loneliness over a long period of time. • The majority of the deceased had been in contact with their GP or a mental health service in the year prior to death, and those who had contacted their GP had done so 4 times or more. • Challenges exist in the contact with health services including difficulties in accessing health care services, difficulties in adhering to treatment appointments and lack of compliance with instructions related to prescribed medication. • The SSIS has been able to use official data sooner than the CSO, which has facilitated the identification of emerging suicide clusters. • Through the multiple sources of information accessed by the SSIS, contagion effects could be identified and direct and indirect relationships among the suicide cluster cases could be established. • Even though the number of open verdicts was relatively small, comparison with confirmed suicide cases revealed more similarities than differences, such as alcohol consumption at time of death, history of deliberate self harm, a high prevalence of mood disorders and use of psychotropic medication. • During the SSIS pilot phase, first analyses were performed to link the SSIS data with the data from the National Registry of Deliberate Self Harm (NRDSH). Examination of suicides and deaths classified as open verdicts ascertained by the SSIS between 2008 and 2010 showed that at least 10% of the cases had been medically treated for deliberate self harm in the Cork region over the time period 2007-2009. Key recommendations: 1. The outcomes of the SSIS pilot study and the independent evaluation by the University of Manchester recommend the maintenance of the SSIS in Cork and expansion to other regions in the country, in particular regions with high rates of suicide and a history of suicide clusters. Recommended options for expansion of the SSIS include: a) Phased implementation in collaboration with the Department of Health and the Department of Justice and Equality;1 b) Phased implementation in collaboration with suicide bereavement support services.1 2. Pro-active facilitation of bereavement support would be the recommended approach for services working with families bereaved by suicide, ensuring that all families bereaved by suicide are offered bereavement support through the services currently in place. 3. It is recommended to increase the awareness of coroners of local bereavement services and materials and to offer these as a matter of course. 4. The association between the impact of the recession (unemployment, financial problems, loss of possessions) and suicide, as identified by the SSIS, underlines the fact that suicide prevention programmes should be prioritised during times of economic recession. 5. Based on the association between alcohol/drug abuse and suicide as identified by the SSIS, it is recommended that: a) National strategies to increase awareness of the risks involved in the use and misuse of alcohol should be intensified, starting at pre-adolescent age b) National strategies to reduce access to alcohol and drugs should be intensified c) Active consultation and collaboration between the mental health services and addiction treatment services be arranged in the best interest of patients who present with dual diagnosis (psychiatric disorder and alcohol/drug abuse) 6. The fact that the majority of people who died by suicide had been in contact with their GP 4 times or more in the year prior to death provides evidence for increased suicide awareness and skills training for GPs. 7. In areas with emerging suicide clusters, it is recommended to encourage involvement of GPs and other primary care professionals in a response plan and in early identification of people at risk of suicidal behaviour. 8. It is recommended to improve access to health care services for people who have engaged in deliberate self harm, people at high risk of suicide and people with multiple mental health and social problems. 9. In areas with emerging suicide clusters, the HSE-NOSP guidelines for responding to suicide clusters should be implemented and supported by additional capacity and specialist expertise as a matter of priority. 10. Comparing the characteristics of confirmed cases of suicide to open verdicts, the SSIS identified more similarities than differences, which underlines the need for further in-depth investigation into cases classified as open verdicts

Heterogeneity in high-risk prostate cancer treated with high-dose radiation therapy and androgen deprivation therapy

Abstract Background Our aim was to assess the heterogeneity of high-risk (HR) prostate cancer managed with high-dose external beam radiotherapy (EBRT) with androgen deprivation therapy (ADT). Methods We identified 547 patients who were treated with modern EBRT from 1997 to 2013, of whom 98% received ADT. We analyzed biochemical relapse-free survival (bRFS) and distant metastases-free survival (DMFS). Results Median EBRT dose was 74 Gy, and median ADT duration was 8 months. At 5 years, the DMFS was 85%. On multivariate analysis, significant predictors of shorter bRFS were biopsy Gleason score (bGS) of 8 to 10, higher prostate-specific antigen (PSA) level, shorter duration of ADT and lower radiation dose while predictors of shorter DMFS were bGS of 8 to 10, higher PSA level, and lower radiation dose. We identified an unfavorable high-risk (UHR) group of with 2–3 HR factors based on 2015 National Comprehensive Cancer Network (NCCN) criteria and a favorable high-risk (FHR) group, with 1 HR feature. Comparing very-HR prostate cancer, UHR & FHR, 5 year bRFS rates were 58.2%, 66.2%, and 69.2%, and 5 year DMFS rates were 78.4%, 81.2%, and 88.0%. Conclusion Patients with multiple HR factors have worse outcome than patients with 1 HR factor. Future studies should account for this heterogeneity in HR prostate cancer

Discovery and Longitudinal Evaluation of Candidate Protein Biomarkers for Disease Recurrence in Prostate Cancer

When compared with hormonal therapy alone, treatment with combined hormone and radiation therapy (CHRT) gives improved disease-specific survival outcomes for patients with prostate cancer; however, a significant number of CHRT patients still succumb to recurrent disease. The purpose of this study was to use longitudinal patient samples obtained as part of an ongoing noninterventional clinical trial (ICORG06-15) to identify and evaluate a potential serum protein signature of disease recurrence. Label-free LC–MS/MS based protein discovery was undertaken on depleted serum samples from CHRT patients who showed evidence of disease recurrence (<i>n</i> = 3) and time-matched patient controls (<i>n</i> = 3). A total of 104 proteins showed a significant change between these two groups. Multiple reaction monitoring (MRM) assays were designed for a subset of these proteins as part of a panel of putative prostate cancer biomarkers (41 proteins) for evaluation in longitudinal serum samples. These data revealed significant interpatient variability in individual protein expression between time of diagnosis, disease recurrence, and beyond and serve to highlight the importance of longitudinal patient samples for evaluating the use of candidate protein biomarkers in disease monitoring

Temporal patterns of late bowel and bladder radiotherapy toxicity in a randomised controlled trial assessing duration of neo-adjuvant hormones in prostate cancer

<div><p></p><p><b>Background.</b> To assess the temporal patterns of late gastrointestinal (GI) and genitourinary (GU) radiotherapy toxicity and resolution rates in a randomised controlled trial (All-Ireland Cooperative Oncology Research Group 97-01) assessing duration of neo-adjuvant (NA) hormone therapy for localised prostate cancer.</p><p><b>Material and methods.</b> Node negative patients with > 1 of: PSA > 20 ng/mL, Gleason score ≥ 7, and stage T3 or more, were included. Follow-up, including toxicity assessment, was three-monthly in the early stages and yearly thereafter.</p><p><b>Results.</b> Median follow-up from the end of RT was 6.8 years. In the interval between 90 days following the end of RT and the last toxicity assessment, GI and GU toxicity (any grade) was found in 50% and 51% of 240 and 241 patients, respectively. For those who did develop toxicity, the median time from end of RT until the first development of any grade GI or GU toxicity was 1.2 years and 1.6 years, respectively, whilst median time to final resolution was 1.6 years and 2.2 years, respectively. Grade 2 (G2) or greater GI and GU toxicity occurred in 29 (12.1%) and 40 (16.6%) patients, respectively. The proportion with unresolved G2 + GI and GU toxicity was 89% and 79%, respectively, in year 1, 69% and 65% in year 2, 59% and 52% in year 3 and 27% and 32% in year 5.</p><p><b>Conclusion.</b> Long-term toxicities continue to occur many years after NA hormone therapy and RT. The rate of occurrence does not appear to reduce within the time frame during which our patients were followed. The percentage of patients suffering from G2 + toxicity at any time is however low. Resolution of these toxicities continues for the duration of the follow-up.</p></div

Recent peritonitis associates with mortality among patients treated with peritoneal dialysis

Peritonitis is a major complication of peritoneal dialysis, but the relationship between peritonitis and mortality among these patients is not well understood. In this case-crossover study, we included the 1316 patients who received peritoneal dialysis in Australia and New Zealand from May 2004 through December 2009 and either died on peritoneal dialysis or within 30 days of transfer to hemodialysis. Each patient served as his or her own control. The mean age was 70 years, and the mean time receiving peritoneal dialysis was 3 years. In total, there were 1446 reported episodes of peritonitis with 27% of patients having ≥ 2 episodes. Compared with the rest of the year, there were significantly increased odds of peritonitis during the 120 days before death, although the magnitude of this association was much greater during the 30 days before death. Compared with a 30-day window 6 months before death, the odds for peritonitis was six-fold higher during the 30 days immediately before death (odds ratio, 6.2; 95% confidence interval, 4.4-8.7). In conclusion, peritonitis significantly associates with mortality in peritoneal dialysis patients. The increased odds extend up to 120 days after an episode of peritonitis but the magnitude is greater during the initial 30 days.Neil Boudville, Anna Kemp, Philip Clayton, Wai Lim, Sunil V. Badve, Carmel M. Hawley, Stephen P. McDonald, Kathryn J. Wiggins, Kym M. Bannister, Fiona G. Brown and David W. Johnso