Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p<0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p<0\ub70001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding: No funding

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Attributable mortality due to nosocomial sepsis in Brazilian hospitals: a case–control study

Abstract Background Nosocomial sepsis is a major healthcare issue, but there are few data on estimates of its attributable mortality. We aimed to estimate attributable mortality fraction (AF) due to nosocomial sepsis. Methods Matched 1:1 case–control study in 37 hospitals in Brazil. Hospitalized patients in participating hospitals were included. Cases were hospital non-survivors and controls were hospital survivors, which were matched by admission type and date of discharge. Exposure was defined as occurrence of nosocomial sepsis, defined as antibiotic prescription plus presence of organ dysfunction attributed to sepsis without an alternative reason for organ failure; alternative definitions were explored. Main outcome measurement was nosocomial sepsis-attributable fractions, estimated using inversed-weight probabilities methods using generalized mixed model considering time-dependency of sepsis occurrence. Results 3588 patients from 37 hospitals were included. Mean age was 63 years and 48.8% were female at birth. 470 sepsis episodes occurred in 388 patients (311 in cases and 77 in control group), with pneumonia being the most common source of infection (44.3%). Average AF for sepsis mortality was 0.076 (95% CI 0.068–0.084) for medical admissions; 0.043 (95% CI 0.032–0.055) for elective surgical admissions; and 0.036 (95% CI 0.017–0.055) for emergency surgeries. In a time-dependent analysis, AF for sepsis rose linearly for medical admissions, reaching close to 0.12 on day 28; AF plateaued earlier for other admission types (0.04 for elective surgery and 0.07 for urgent surgery). Alternative sepsis definitions yield different estimates. Conclusion The impact of nosocomial sepsis on outcome is more pronounced in medical admissions and tends to increase over time. The results, however, are sensitive to sepsis definitions

Delirium in nursing home residents: is there a role of antidepressants? A cross sectional study.

Background: Delirium is strongly associated with poor health outcomes, yet it is frequently underdiagnosed. Limited research on delirium has been conducted in Nursing Homes (NHs). Our aim is to assess delirium prevalence and its associated factors, in particular pharmacological prescription, in this care setting. Methods: Data from the Italian "Delirium Day" 2016 Edition, a national multicenter point-prevalence study on patients aged 65 and older were analyzed to examine the associations between the prevalence of delirium and its subtypes with demographics and information about medical history and pharmacological treatment. Delirium was assessed using the Assessment test for delirium and cognitive impairment (4AT). Motor subtype was evaluated using the Delirium Motor Subtype Scale (DMSS). Results: 955 residents, from 32 Italian NHs with a mean age of 84.72 ± 7.78 years were included. According to the 4AT, delirium was present in 260 (27.2%) NHs residents, mainly hyperactive (35.4%) or mixed subtypes (20.7%). Antidepressant treatment with selective serotonin reuptake inhibitors (SSRIs) was associated with lower delirium prevalence in univariate and multivariate analyses. Conclusions: The high prevalence of delirium in NHs highlights the need to systematically assess its occurrence in this care settings. The inverse association between SSRIs and delirium might imply a possible preventive role of this class of therapeutic agents against delirium in NHs, yet further studies are warranted to ascertain any causal relationship between SSRIs intake and reduced delirium incidence

Drug Prescription and Delirium in Older Inpatients: Results From the Nationwide Multicenter Italian Delirium Day 2015-2016

reserved1229noObjective: This study aimed to evaluate the association between polypharmacy and delirium, the association of specific drug categories with delirium, and the differences in drug-delirium association between medical and surgical units and according to dementia diagnosis. Methods: Data were collected during 2 waves of Delirium Day, a multicenter delirium prevalence study including patients (aged 65 years or older) admitted to acute and long-term care wards in Italy (2015-2016); in this study, only patients enrolled in acute hospital wards were selected (n = 4,133). Delirium was assessed according to score on the 4 "A's" Test. Prescriptions were classified by main drug categories; polypharmacy was defined as a prescription of drugs from 5 or more classes. Results: Of 4,133 participants, 969 (23.4%) had delirium. The general prevalence of polypharmacy was higher in patients with delirium (67.6% vs 63.0%, P =.009) but varied according to clinical settings. After adjustment for confounders, polypharmacy was associated with delirium only in patients admitted to surgical units (OR = 2.9; 95% CI, 1.4-6.1). Insulin, antibiotics, antiepileptics, antipsychotics, and atypical antidepressants were associated with delirium, whereas statins and angiotensin receptor blockers exhibited an inverse association. A stronger association was seen between typical and atypical antipsychotics and delirium in subjects free from dementia compared to individuals with dementia (typical: OR = 4.31; 95% CI, 2.94-6.31 without dementia vs OR = 1.64; 95% CI, 1.19-2.26 with dementia; atypical: OR = 5.32; 95% CI, 3.44-8.22 without dementia vs OR = 1.74; 95% CI, 1.26-2.40 with dementia). The absence of antipsychotics among the prescribed drugs was inversely associated with delirium in the whole sample and in both of the hospital settings, but only in patients without dementia. Conclusions: Polypharmacy is significantly associated with delirium only in surgical units, raising the issue of the relevance of medication review in different clinical settings. Specific drug classes are associated with delirium depending on the clinical setting and dementia diagnosis, suggesting the need to further explore this relationship.mixedAloisi Gaetano, Marengoni Alessandra, Morandi Alessandro, Zucchelli, Alberto, Cherubini Antonio, Mossello Enrico, Bo Mario, Di Santo Simona, Mazzone Andrea, Trabucchi Marco, Cappa Stefano, Fimognari Filippo, Antonelli Incalzi Raffaele, Gareri Pietro, Perticone Francesco, Campanini Mauro, Montorsi Marco, Latronico Nicola, Zambon Antonella, Bellelli Giuseppe, Rispoli Vincenzo, Malara Alba, Spadea Fausto, Di Cello Serena, Ceravolo Francesco, Fabiano Francesco, Chiaradia Giuseppe, Gabriele Amedeo, Lenino Peluso, Andrea Taristano, Settembrini Vincenzo, Capomolla Domenico, Citrino Antonella, Scriva Antonietta, Bruno Irene, Secchi Roberto, De Martino Eugenio, Muccinelli Roberto, Lupi Gerardo, Paonessa Patrizio, Fabbri Andrea, Passuti Maria Teresa, Castellari Sofia, Po Andrea, Gaggioli Guido, Varesi Massimo, Moneti Paolo, Capurso Sebastiano, Latini Vincenzo, Ghidotti Stefano, Riccardelli Francesco, Macchi Maurizio, Rigo Rosaria, Claudio Pascale, Bosio Angelo, Cerrato Flavio, Bardelli Benedetta, Boffelli Stefano, Cassinadri Angela, Franzoni Simone, Spazzini Elena, Andretto Daniela, Tonini Gabriele, Andreani Laura, Coralli Mirco, Balotta Antonio, Cancelliere Roberto, Ballardini Giorgio, Simoncelli Margherita, Mancini Annarita, Strazzacapa Mara, Fabio Stefano, De Filippi Francesco, Giudice Chiara, Dentizzi Cosimo, Azzini Margherita, Cazzadori Marco, Mastroeni Valeria, Bertassello Paolo, Santana Helena, Benati Claudia, Nesta Elisa, Tobaldini Chiara, Guerini Fabio, Tambara Elena, Mombelloni Paolo, Fontanini Fulvio, Lassa Gabriella, Lassa, Pizzorni Crosio, Oliverio Martina, del Grosso, Luciano Luca, Giavedoni Cristina, Bidoli Giuliano, Mazzei Bruno, Corsonello Andrea, Fusco Sergio, Vena Silvio, De Vuono Tommaso, Maiuri Giorgio, Fimognari Filippo Luca, Arone Andrea, Sgro Giovanni, Nicolazzo Rossella, Castegnaro Eugenio, De Rosa Salvatore, Sechi Bazzano Rossella, Benvenuti Enrico, Del Lungo Ilaria, Giardini Sante, Giulietti Chiara, Di Bari Mauro, Barghini Eleonora, Paoli Martina, Fiordelli Irene, Barucci Riccardo, Sgrilli Federica, Del Lungo Ilaria, Bertoletti Erik, D'Amico Ferdinando, Caronzolo Francesco, Grippa Alessandro, Lombardo Giuseppina, Pipicella Tiziana, Saitta Antonino, Corica Francesco, Cucinotta Valeria, Giaritta Prestipino, Larosa Daniela, Cucinotta Domenico, Basile Giorgio, March Albert, Nitti Maria Teresa, Felici Alessandro, Pavan Silvia, Piazzani Fabrizio, Lunelli Alessandra, Dimori Sergio, Margotta Alessandro, Soglia Tiziano, Postacchini Demetrio, Brunelli Roberto, Santini Silvia, Francavilla Monia, Macchiati Ilenia, Sorvillo Francesca, Giuli Cinzia, Mecocci Patrizia, Longo Annalisa, Perticone Francesco, Addesi Desiree, Rosa Paola Cerra, Bencardino Giuseppe, Falbo Tania, Grillo Nadia, Filice Marco, Mirella Filippo, Fanto Fausto, Isaia Gianluca, Pezzilli Stella, Bergamo Daniele, Furno Elisabetta, Rrodhe Sokol, Lucarini Simonetta, Dijk Babette, Dall'Acqua Francesca, Cappelletto Francesco, Calvani Donatella, Becheri Dimitri, Mottino Giuseppe, Mitidieri Costanza, Antonio Vito, Bartalucci Francesca, Magherini Lorenza, Malin Novella, Boni Franca, Gambardella Paoli Martina Lucia, Valente Carlo, Bracali Ilaria, Bracali, Foschini Alice, Bo Mario, Porrino Paola, Ceci Giacomo, Bottignole Giuliana, Tibaldi Michela, Coppo Eleonora, Ettore Evaristo, Camellini Cinzia, Servello Adriana, Grassi Alessandro, Rozzini Renzo, Tironi Sara, Grassi Maria Grazia, Troisi Elio, Caltagirone Carlo, Di Santo Simona, Franchini Flaminia, Ratto Federica, Pavoni Beatrice, Toniolo Sofia, Gabutto Anna, Quazzo Loredana, Rosatello Annalisa, Suraci Domenico, Tagliabue Benedetta, Perrone Chiara, Ferrara Lucia, Castagna Alberto, Tremolada Maria Luisa, Castoldi Giuseppe, Barbero Stefano, Oltramonti Davide, Piano Simonetta, Serviddio Gaetano, Lo Buglio Aurelio, Gurrera Tiziana, Merlo Valeria, Rovai Carla, Cotroneo Antonino Maria, Carlucci Rosaria, Abbaldo Anna, Monzani Fabio, Qasem Ahmad Amedeo, Bini Giacomo, Tafuto Silvia, Galli Giovanni, Bruni Amalia Cecilia, Mancuso Giovanna, Mancuso Gerardo, Calipari Daniela. De Luca Giuseppe Massimiliano, Bernardini Bruno, Corsini Carla, Ciccarelli Michele, Dal Farra Sara, Dal Farra, Cagnin Annachiara, Fragiacomo Federica, Pompanin Sara, Amodio Piero, Cagnin Marco, Zurlo Amedeo, Guerra Gianluca, Pala Marco, Menozzi Luca, Delli Gatti Chiara, Magon Stefania, Manfredini Roberto, De Giorgi Alfredo, Fabbian Fabio, Tiseo Ruana, Misurati Elisa, Boari Benedetta, Molino, Christian, Gallerani Massimo, Di Francesco Vincenzo, Faccioli Silvia, Pellizzari Luca, Fontana Giorgia, Barbagallo Giuseppe, Lunardelli Maria Lia, Martini Emilio, Ferrari Eleonora, Macchiarulo Maria, Corneli Maria, Bacci Monica, Battaglia Giuseppe, Anastasio Luigi, Lo Storto Mario Sostene, Seresin Chiara, Simonato Matteo, Loreggian Michele, Cestonaro Fausta, Durando Mario, Latella Raffaele, Mazzoleni Marta, Russo Giuseppe, Ponte Martino, Valchera Alessandro, Salustri Giuseppe, Petritola Donatella, Costa Alfredo, Sinforiani Elena, Cotta Matteo Ramusino, Piano Simonetta, Pizio Renato Nicola, Cester Alberto, Formilan Marino, Bonometto Pietro, Carbone Pasqualina, Cazzaniga Ilaria, Appollonio Ildebrando, Cereda Diletta, Stabile Andrea, Xhani Rubjona, Acampora Roberto, Tremolizzo Lucio, Pieruzzi Federico, Ciaccio Antonio, Pontecorvi Valerio, Burti Cesare, Mokini Zhirajr, Vitale Giovanni, Amigoni Maria, Sparacino Mariaelena, Bottacchi Edo, Bucciantini Elisabetta, Di Giovanni Marco, Franchi Fabrizio, Lucchetti Lucio, Mariani Claudio, Grande Giulia, Rapazzini Piero, Mauri Marco, Romanelli Giuseppe, Marengoni Alessandra, Nicosia Franco, Margola Alessio, Bonardelli Stefano, Latronico Nicola, Porcella Laura, Portolani Nazario, Concoreggi Carlo, Grassini Chiara, Salvi Andrea, Bianchetti Luca, Spagnoli Francesca, Apuzzo Roberto, Fontanella, Ceraso Anna, Castelli Francesco, Fugazza Luciano, Guerrini Chiara, De Paduanis Giovanna, Iallonardo Lucia, Palumbo Pasquale, Zuliani Giovanni, Ortolani Beatrice, Capatti Eleonora, Soavi Cecilia, Bianchi Lara, Francesconi Daniela, Miselli, Agata, Brombo Gloria, Romagnoli Tommaso, Pazzaglini Chiara, Miselli Maria Agata, Dall'Agata Marco, Suardi Teresa, Mazzone Andrea, Zaccarini Cinzia, Riva Manuela, Mirra Gianluca, Muti Ettore, Bottura Renato, Moretti Gianpaolo, Secreto Piero, Bisio Erika, Cecchettani Marco, Naldi Tamara, Pallavicino Alessandra, Pugliese Michela, Iozzo Rosaria Cosima, Grassi Guido, Bombelli Michele, DellOro Raffaella, Quarti Trevano Fosca, Giussani Carlo Giorgio, Paterno Giovanni, Contro Ernesto, Mannironi Antonio, Giorli Elisa, Oberti Sara, Fierro Brigida, Piccoli Tommaso, Giacalone Fabio, Mandas Antonella, Serchisu Luca, Costaggiu Diego, Pinna Elisa, Orru Francesca, Mannai Martina, Cordioli Zeno, Pelizzari Luca, Turcato Emanuela, Arduini Pietro, Cacace Carlo, Chiloiro Roberta, Cimino Rosella, Ruberto Carmen, Ruotolo Giovanni, Gareri Pietro, Greco Laura, Castagna Alberto, Dal Santo Pierluigi, Andriolli Antonino, Burattin Giuseppe, Rossi Laura, Andreolli Antonino, Cervati Giovanna, Catalano Giuseppe, Tezza Fabiana, Pizzardini Maddalena, Stievano Laura, Crippa Patrizia, Aloisio Paola, Di Monda Tiziana, Malighetti Alessandro, Galbassini Gloria, Ivaldi Claudio, Russo Anna Maria, Bennati Ettore, Pino Elisabetta, Zavarise Gianmaria, Pesci Alberto, Suigo Giulia, Faverio Paola, Gori Andrea, Perego Sabrina Perego, Zanasi Massimo, Moniello Giovanni, Rostagno Carlo, Cartei Alessandro, Polidori Gianluca, Ungar Andrea, Melis Maria Ramona, Martellini Eleonora, Mossello Enrico, Torrini Monica, Giordano Antonella, Leone Giovanna, Migliorini Marta, Caramelli Francesca, Battiston Bruno, Berardino Maurizio, Cavallo Simona, Masse Alessandro, Santoro Anna, Lombardi Bruna, D'Ippolito Pierpaolo, Furini Angela, Villani Daniele, Raimondi Clara, Guarneri Massimo, Paolucci Stefano, Bassi Andrea, Coiro Paola, De Angelis Domenico, Morone Giovanni, Venturiero Vincenzo, Palleschi Lorenzo, Raganato Paolo, Di Niro Giuseppina, Casini Anna Rosa, Bove Loredana, Imoscopi Alessandra, Isaia Giancarlo, Tibaldi Vittoria, Bottignole Giuliana, Calvi Elisa, Clementi Carlotta, Zanocchi Mauro, Agosta Luca, Criasia Antonio, Spertino Elena, Nortarelli Antonella, Provenzano Giuseppe, Principato Pietro, Rizzo Anita, Cellura Eleonora, Mari Daniela, Romano Federica Ylenia, Rosini Francesca, Mansi Marta, Rossi Silvia, Riccardelli Alex, Inzaghi Lorenzo, Bonini Giulia, Rossi Paolo, Potena Alfredo, Lichii Mihaela, Candiani Tiziana, Grimaldi William, Bertani Emiliano, Porta Alessandra, Calogero Pietro, Pinto Daniela, Bernardi Roberto, Nicolino Francesco, Galetti Caterina, Gianstefani Alice, Corvalli Giulia, Mulazzani Lorenzo, Odetti Patrizio, Monacelli Fiammetta, Prefumo Matteo, Monacelli Fiammetta, Canepa Marta, Minaglia Cecilia, Paolisso Giuseppe, Rizzo Maria Rosaria, Prestano Raffaele, Dalise Anna Maria, Barra Davide, Dal Bosco Livio, Asprinio Vincenzo, Dallape Luciana, Maina Paola, Perina Elisa, Bartoli Rossi Isaura, Pluderi Alice, Maina Antonella, Pecoraro Elisabetta, Sciarra Michela, Prudente Angela, Mete Francesca, Ventura Manuel, Cesari Luisella, Pernigotti Luigi Maria, Santangelo Tina, Benini Lucia, Levato Francesco, Mhiuta Victor, Alius Florin, Davidoaia Diana, Giardini Vittorio, Garancini Mattia, Bellamoli Claudio, Terranova Luciano, Bozzini Claudia, Tosoni Paolo, Provoli Emma, Cascone Luisa, Dioli Andrea, Ferrarin Gianfranco, Gabutto Anna, Bucci Adelmo, Bua Guido, Fenu Sara, Bianchi Giovanna, Casella Silvia, Romano Valentina, Poli Maurizio, Mascherona Ilenia, Belotti Gloria, Cavaliere Sabina, Cuni Estella, Merciuc Nina, Oberti Rosella, Veneziani Silvia, Capoferri Emanuela, De Bernardi Elisabetta, Colombo Katia, Bravi Marco, Negrinotti Nicoletta, D'Arcangelo Paolo, Montenegro Nicola, Galli Giovanni, Montanari Roberto, Lamanna Pierpaolo, Gasperini Beatrice, Montesi Isabella, Diotallevi Stefania, Altobelli Gaia, Cacinaro Filippo, Palama Chiara, Di Emidio Chiara, Scarpini Elio, Arighi Andrea, Scrimieri Antonia, Fumagalli Giorgio, Basilico Paola, Migone De Amicis Margherita, Mancarella Marta, Maira Diletta, D'Amico Ferdinando, Granata Antonino, Ranalli Claudia, Cammilli Alessandra, Cavallini Maria Chiara, Tricca Manola, Natella Daniela, Gabbani Luciano, Tesi Francesca, Martella Letizia, Gurrera Tiziana, Imbrici Rosalba, Pacchioni Maurizio, Gianbattista Guerrini, Scotuzzi Anna Maria, Sozzi Ferdinando, Valenti Luigi, Chiarello Antonino, Monella Monia, Pilotto Alberto, Prete Camilla, Senesi Barbara, Meta Anna Cristina, Pendenza Enrico, Monzani Fabio, Pasqualetti Giuseppe, Polini Antonio, Tognini Sara, Ballino Elena, Cherubini Antonio, Dell'Aquila Giuseppina, Gasparrini Pina Maria, Marotti Elisabetta, Migale Monica, Falsetti Lorenzo, Salvi Aldo, Toigo Gabriele, Ceschia Giuliano, Rosso Alessia, Tongiorgi Chiara, Scarpa Cristina, De Dominicis Luigino, Pucci Eugenio, Renzi Sara, Cartechini Elisabetta, Tomassini Pia Francesca, Del Gobbo Maurizio, Ugenti Francesca, Romeo Pasquale, Nardelli Anna, Lauretani Fulvio, Visioli Sandra, Montanari Ilaria, Ermini Francesca, Giordano Antonio, Pigato Giorgio, Simeone Emilio, Colameco Franco, Cecamore Antonella, Scurti Rosa, Lupinetti Maria Cristina, Barbujani Mario, Perazzi Beatrice, Giampieri Marina, Amoruso Raffaele, Piccinini Maristella, Ferrari Camilla, Gambetti Claudio, Sfrappini Mario, Semeraro Letizia, Striuli Rinaldo, Mariani Claudia, Pelliccioni Giuseppe, Marinelli Donatella, Fabi Katia, Rossi Tommaso, Pesallaccia Martina, Sabbatini Debora, Gobbi Beatrice, Cerqua Raffaella, Tagliani Giancarla, Schlauser Elena, Caser Luciano, Caramello Elisa, Sandigliano Franca, Rosso Giorgio, Bendini Chiara, Davoli Maria, Casella Monica, Prampolini Raffaella, Scevola Moreno, Vitale Enrico, Brugiolo Roberto, Brugiolo, Fagherazzi Carlo, Fusco Sergio, Scarpa Alberto, Zara Daniela, Bertozzo Giulia, Granziera Serena, Barazzuol Michele, Maugeri Domenico, Sorace Rosaria, Anzaldi Massimiliano, De Gesu Roberto, Morrone Giuseppe, Davolio Federica, Fabbo Andrea, Palmieri Marina, Forti Paola, Pirazzoli Luca, Fabbri Elisa, Terenzi Laura, Bergolari Federica, Wenter Christian, Ruffini Ingrid, Insam Miriam, Abraham Elisabeth, Kirchlechner Christine, Lasco Antonino, Basile Giorgio, Arena Maria Grazia, Parise Pasquale, Boccali Andrea, Amici Serena, Gambacorta Maurizia, Ferrari Alberto, Lasagni Anna, Lovati Roberto, Giovinazzo Francesca, Kimak Elzbieta, Zappa Paolo, Medici Francesco, Lo Castro Marika, Mauro Flavia, De Luca Alessandro, Sancesario Giuseppe, Martorana Alessandro, Scaricamazza Beatrice, Toniolo Sofia, Di Lorenzo Francesco, Liguori Claudio, Lasco Antonino, Basile Giorgio, Vita Natale, Giomi Mirna, Dimori Sergio, Forte Floriana, Padovani Alessandro, Rozzini Luca, Ceraso Anna, Caratozzolo Salvatore, Padovani Alessandro, Cottino Maria, Vitali Silvia, Marelli Eleonora, Tripi Gabriele, Miceli Salvatore, Urso Giovanni, Grioni Giuseppe, Vezzadini Giuliana, Misaggi Giulia, Forlani Chiara, Avanzi Stefano, Saulle Serena, Casarini Claudia, Viggiano Marilena, Alberto Luisa, Ghianda Diego, Giordano Alessandro, Iemolo Francesco, Giordano, Antonello, Sanzaro Enzo, D'Asta Gabriele, Proietto Maria, Carnemolla Anna, Razza Grazia, Spadaro Daniela, Bertolotti Marco, Mussi Chiara, Neviani Francesca, Chiesa Roberto, Guerzoni Valentina, Morselli Linda, Venturelli Francesca, Tarozzi Adriano, Balestri Francesca, Torrini Monica, Mannarino Giulio, Tesi Francesca, Bigolari Michela, Natale Alessia, Grassi Simona, Bottaro Cinzia, Stefanelli Sara, Bovone Ugo, Tortorolo Umberto, Quadri Roberto, Leone Giuseppe, Ponzetto Maria, Frasson Paola, Annoni Giorgio, Bellelli Giuseppe, Bruni Adriana, Confalonieri Roberto, Corsi Maurizio, Moretti Daniela, Teruzzi Fabiola, Umidi Simona, Mazzola Paolo, Perego Sabrina, Persico Ilaria, Olivieri Giulia, Bonfanti Alessandra, Hajnalka Szabo, Galeazzi Marianna, Massariello Francesca, Anzuini Alessandra, Caffarra Paolo, Barocco Federica, Spallazzi Marco, Ceda Gian Paolo, Morganti Simonetta, Artoni Andrea, Chioatto Paolo, Bortolamei Sandra, Soattin Lucia, Ruotolo Giovanni, Beneamino Borelli, Gareri Pietro, Barilaro Giuseppe, Ruberto Carmen, Castagna Alberto, Bertazzoli Marco, Rota Elisabetta, Adobati Annamaria, Scarpa Alberto, Granziera Serena, Zuccher Paola, Dal Fabbro Angela, Zara Daniela, Lo Nigro Ambra, Franchetti Lorena, Toniolo Marika, Marcuzzo Cinzia, Piano Simonetta, Rollone Marco, Guerriero Fabio, Sgarlata Carmelo, Masse Alessandro, Berardino Maurizio, Cavallo Simona, Anna Santoro, Zatti Giovanni, Piatti Massimiliano, Graci Jole, Benati Giuseppe, Boschi Federica, Biondi Mario, Fiumi Nicoletta, Erika Tamburini, Locatelli Sergio Mario, Mauri Sabrina, Beretta Mauro, Margheritis Laura, Desideri Giovanbattista, Liberatore Ester, Carucci Anna Cecilia, Bonino Paolo, Caput Margherita, Antonietti Maria Paola, Polistena Giuseppe, De la Pierre Franz, Mari Marcello, Massignani Paola, Tombesi Fabio, Selvaggio Fabio, Verbo Brunella, Bodoni Paolo, Marchionni Niccolo, Mossello Enrico, Cavallini Maria Chiara, Sabatini Tony, Mussio Eleonora, Magni Eugenio, Bianchetti Angelo, Crucitti Andrea, Titoldini Giulia, Cossu Beatrice, Fascendini Sara, Licini Cristina, Tomasoni Angela, Calderazzo Massimo, Tropiano Daniela, Lagana Valentina, Ferrari Alberto, Prampolini Raffaella, Melotti Rita Maria, Lilli Albina, Buda Simona, Adversi Marco, Noro Gabriele, Turco Renato, Ubezio M. Chiara, Mantovani Anna Roberta, Viola Maria Cristina, Serrati Carlo, Pretta Stefano, Infante Maria, Gentile Simona, Morandi Alessandro, D'Ambrosio Viviana, Mazzanti Paolo, Brambilla Cristina, Sportelli Silvia, Platto Caterina, Faraci Bianca, Quattrocchi Daniela, Pisu Cristina, Sicuro Francesca, Oliverio Martina, Del Grosso Luciano Luca, Zagnoni Piergiuseppe, Ghiglia Stefania, Mosca Massimiliano, Corazzin Ileana, Deola Mariangela, Biagini Carlo Adriano, Bencini Francesca, Cantini Claudia, Tonon Elisabetta, Pierinelli Silvia, Onofrj Marco, Thomas, Astrid, Borbone Filomena, Bonanni Laura, Cacchio Gabriella, Comi Giancarlo, Magnani Giuseppe, Santangelo Roberto, Mazzeo Salvatore, Magnani Giuseppe, Caso Francesca, Cecchetti Giordano, Sant’Angelo Roberto, Barbieri Cristina, Giroldi Liviana, Davolio Federica, Bandini Fabio, Masina Marco, Malservisi Simona, Cicognani Annalena, Ricca Laura, Piccininni Maristella, Ferrari Camilla, Gambetti Claudio, Tassinari Tiziana, Brogi Davide, Sugo Annalisa, Filippi Alessandra, Manfredi Sonia, Vanni Valerio, Usai carlo Andrea, Colombo Enrico, Renna Vera Francesca, Sauchella Assunta, Zavarise Gianmaria, Prete Mauro, Bisagni Pietro, Masini Roberto, Carrabetta Salvatore, Barone Antonella, Razzano Monica, Imperoli Giuseppe, Bini Angela, Serra Francesco, D’Agostino Valeria, Gianolla Federico, Pietrangeli Lucia, Velardi Antonella, Di Cello Elisabetta, Rosati Cristina, Casali Nadia, Casali, Sessa Maria, Abruzzi Luciano, Costanzi Chiara, Bini Paolo, Pignata Michele, Buonaugurio Enrico, Vollery Maria, Carrieri Giovanni, Cioni Giorgio, Toschi Andrea, Metra Marco, Ceraso Anna, Ranieri Piera, Zucchelli Alberto, Ceccon Anna, Magrin Laura, Marin Sara, Barbara Sofia, Masina Marco, Ghedini Laura, Moroni Matteo, Paragona Marco, Pallotti Maria Caterina, Rota Carla, Gottardi Federica, Tomasoni Clara, Cappuccio Melania, Bonini Giampaolo, Guerini Stefano, Guerini Valeria, Merlaj Lucia, Liberatore Ester, Carucci Anna Cecilia, Tovaglieri Maurizio, Filippi Alessandra, Antonio Grillo, Francesca Arenare, Mineo Tonino, Kanah David, Vianello Giorgio, Vianello Piero, Balducci Ubaldo, Sidoti Vincenzo, Montanari Stefano, Formilan Marino, Murelli Flavio Teodolindo Busonera, Albanese Paolo, Maselli Monica, Bolzetta Francesco, Fabris Roberto, Bonino Paolo, Durante-Mangoni Emanuele, Testoni Michela, Di Stefano Fabio, Seccia Loredana, Sonzini Valeria, Fabiano Maria, Di Giorgio Annabella, De Cosmo Salvatore, Greco Antonio, D’Onofrio Grazia, Sancarlo Daniele, Resta Gianluca, Girardello Renzo, Girardello, Minervini Sergio, Boni Morena, Vitali Mariagrazia, Pizzoni Marina, De Colle Paolo, Scarpa Cristina, Frattola Alessandra, Orlandini Francesco, La Regina Micaela, Addesi Desiree, Mirella Filippo, Filice Marco, Bo Mario, Porrino Paola, Bottignole Giuliana, Tibaldi Michela, Coppo Eleonora, Padulo Filomena, Margheriti Cristina, Rolano Dario, Moscatelli Giancarla, Radaelli Guido, Montini Elena, Prete Cosimo, Novello Marileda, Bramuzzo Igor, Bertin Nicole, Rinaldo Elena, Paolillo Ciro, Riccardi Angela, Benedetti Claudia, Rizzi Barbara, Montagna Francesca, Vitali Silvia, Cutaia Chiara, Baca Oliver, Colombo Mauro, Marelli Eleonora, Procino Giuseppe, Tarara Rosaria, Cottino Maria, Dell’Acqua Davide, Cislaghi Stefania, Cairati Marco, Porta Massimo, Scaglione Luca, De Feo Martina, Vertolli Paola, Salvati Lia, Cinotti Sandro, De Santis Valentina, Biferi Erminia, Cheli Paola, Rebizzo Romina, Salvatore Minisola, Luciano Colangelo, Abete Pasquale, Liguori Ilaria, Curcio Francesca, Spassini Guglielmo, Engheben Marco, Rotunno Sara, Rotunno, Arosio Paola, Angelini Claudio, Reggiani Francesco, Cappelli Alessandro, Marcheselli Simona, Fratticci Lara, Ranzani Paola, Cesarini Simonetta, Cerini Antonella, Gallucci Fernando, Ceschia Giuliano, Serra Emanuela, Sola Mariolina, Delitala Alessandro, Pes Chiara, Lobianco Giulia, Giani Alessandro, Famularo Simone, Sandini Marta, Pinotti Enrico, Gianotti Luca, Battuello Antonella, Pintore Giulia, Giardini Sante, Rossi Andrea, Rubele Sofia, Sant Selena, Vignati Marco, Clerici Danila, Rosa Fabio, Bandirali Maria Pia, Cattaneo Nicoletta, Boffi Laura, Tosoni Paolo, Terranova Luciano, Avalli Leonello, Scanziani Margherita, De Notaris Stefania, Del Santo Pierluigi, Del Santo, Rossi Laura, Tezza Fabiana, Andreolli An

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.13Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Understanding Factors Associated With Psychomotor Subtypes of Delirium in Older Inpatients With Dementia

Objectives: Few studies have analyzed factors associated with delirium subtypes. In this study, we investigate factors associated with subtypes of delirium only in patients with dementia to provide insights on the possible prevention and treatments. Design: This is a cross-sectional study nested in the \u201cDelirium Day\u201d study, a nationwide Italian point-prevalence study. Setting and Participants: Older patients admitted to 205 acute and 92 rehabilitation hospital wards. Measures: Delirium was evaluated with the 4-AT and the motor subtypes with the Delirium Motor Subtype Scale. Dementia was defined by the presence of a documented diagnosis in the medical records and/or prescription of acetylcholinesterase inhibitors or memantine prior to admission. Results: Of the 1057 patients with dementia, 35% had delirium, with 25.6% hyperactive, 33.1% hypoactive, 34.5% mixed, and 6.7% nonmotor subtype. There were higher odds of having venous catheters in the hypoactive (OR 1.82, 95% CI 1.18-2.81) and mixed type of delirium (OR 2.23, CI 1.43-3.46), whereas higher odds of urinary catheters in the hypoactive (OR 2.91, CI 1.92-4.39), hyperactive (OR 1.99, CI 1.23-3.21), and mixed types of delirium (OR 2.05, CI 1.36-3.07). We found higher odds of antipsychotics both in the hyperactive (OR 2.87, CI 1.81-4.54) and mixed subtype (OR 1.84, CI 1.24-2.75), whereas higher odds of antibiotics was present only in the mixed subtype (OR 1.91, CI 1.26-2.87). Conclusions and Implications: In patients with dementia, the mixed delirium subtype is the most prevalent followed by the hypoactive, hyperactive, and nonmotor subtype. Motor subtypes of delirium may be triggered by clinical factors, including the use of venous and urinary catheters, and the use of antipsychotics. Future studies are necessary to provide further insights on the possible pathophysiology of delirium in patients with dementia and to address the optimization of the management of potential risk factors

Drug Prescription and Delirium in Older Inpatients: Results From the Nationwide Multicenter Italian Delirium Day 2015-2016

Objective: This study aimed to evaluate the association between polypharmacy and delirium, the association of specific drug categories with delirium, and the differences in drug-delirium association between medical and surgical units and according to dementia diagnosis. Methods: Data were collected during 2 waves of Delirium Day, a multicenter delirium prevalence study including patients (aged 65 years or older) admitted to acute and long-term care wards in Italy (2015-2016); in this study, only patients enrolled in acute hospital wards were selected (n = 4,133). Delirium was assessed according to score on the 4 "A's" Test. Prescriptions were classified by main drug categories; polypharmacy was defined as a prescription of drugs from 5 or more classes. Results: Of 4,133 participants, 969 (23.4%) had delirium. The general prevalence of polypharmacy was higher in patients with delirium (67.6% vs 63.0%, P =.009) but varied according to clinical settings. After adjustment for confounders, polypharmacy was associated with delirium only in patients admitted to surgical units (OR = 2.9; 95% CI, 1.4-6.1). Insulin, antibiotics, antiepileptics, antipsychotics, and atypical antidepressants were associated with delirium, whereas statins and angiotensin receptor blockers exhibited an inverse association. A stronger association was seen between typical and atypical antipsychotics and delirium in subjects free from dementia compared to individuals with dementia (typical: OR = 4.31; 95% CI, 2.94-6.31 without dementia vs OR = 1.64; 95% CI, 1.19-2.26 with dementia; atypical: OR = 5.32; 95% CI, 3.44-8.22 without dementia vs OR = 1.74; 95% CI, 1.26-2.40 with dementia). The absence of antipsychotics among the prescribed drugs was inversely associated with delirium in the whole sample and in both of the hospital settings, but only in patients without dementia. Conclusions: Polypharmacy is significantly associated with delirium only in surgical units, raising the issue of the relevance of medication review in different clinical settings. Specific drug classes are associated with delirium depending on the clinical setting and dementia diagnosis, suggesting the need to further explore this relationship