Intensive Care Unit Mortality and Length of Stay Among Critically Ill Patients With Sepsis Treated With Corticosteroids: A Retrospective Cohort Study

Objectives: Sepsis is a major cause of morbidity and mortality in critically ill patients worldwide, and corticosteroids are commonly used to treat it. However, the evidence supporting the use of corticosteroids in sepsis patients admitted to the intensive care unit (ICU) is of low certainty, with conflicting results reported in previous studies. Thus, we aimed to investigate the potential association between corticosteroid treatment and various outcomes, including 30-day ICU mortality, ICU length of stay (LOS), mechanical ventilation use, new onset of infection, and hyperglycemia in patients diagnosed with sepsis and admitted to the ICU. Materials and Methods: We conducted a cohort study utilizing data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database from 2008 to 2019. The study compared users of corticosteroids following admission to the ICU with non-users. Outcomes assessed included 30-day ICU mortality, ICU length of stay (LOS), mechanical ventilation use, new onset of infection, and hyperglycemia. Doubly robust, augmented inverse propensity weighted models were employed to control for confounders and determine the average treatment effect (ATE) of corticosteroids on study outcomes. Results: A total of 10,098 patients with a first diagnosis of sepsis were identified, of which 1,235 (12.2%) received corticosteroid treatment, and 8,863 (87.8%) did not. Corticosteroid use was associated with increased 30-day ICU mortality (ATE, 0.127; 95% CI, 0.083 to 0.171), ICU LOS (ATE, 1.773; 95% CI, 1.036 to 2.510), mechanical ventilation use (ATE, 0.181; 95% CI, 0.130 to 0.233), new onset of infection (ATE, 0.063; 95% CI, 0.032 to 0.094), and hyperglycemia (ATE, 0.024; 95% CI, 0.013 to 0.035) compared to non-use. Conclusion: The safety profile of corticosteroid therapy in sepsis patients admitted to the ICU remains a concern. Clinicians should carefully consider all available evidence and patient preferences when deciding to prescribe corticosteroids. Given the low certainty of evidence supporting the current treatment guidelines, further research is warranted to provide a more conclusive understanding of the risks and benefits associated with corticosteroid use in this patient population

The Impact of Statin Use Prior to Intensive Care Unit Admission on Critically Ill Patients With Sepsis

OBJECTIVE: To evaluate the impact of pre-intensive care unit admission (pre-ICU) statin use on all-cause in-hospital mortality and ICU length of stay (LOS). DESIGN: Retrospective cohort study. SETTING: Adult ICUs at tertiary hospitals. PATIENTS: Adult critically ill patients diagnosed with sepsis admitted to the ICUs. INTERVENTION: The exposure was pre-ICU statin prescription (statin users); unexposed represented absence of pre-ICU prescription (non-users). MEASUREMENT AND MAIN RESULTS: We used the 2001-2012 Medical Information Mart for Intensive Care-III (MIMIC-III) database to determine average treatment effect (ATE) of pre-ICU statin use on 30-day ICU mortality, ICU LOS, and 30-day in-hospital mortality using the Augmented Inverse Propensity Weighted technique (AIPW), after adjusting for confounding factors (age, race, health insurance, corticosteroids use, vital signs, laboratory tests, and Sequential Organ Failure Assessment score (SOFA). We measured 30-day ICU mortality as deaths within 30 days of admission to the ICU, and ICU LOS was measured in fractional days. A 30-day in-hospital mortality was measured as death within 30 days of hospital admission. A total of 8200 patients with sepsis were identified; 19.8% (1623) were statin users, and 80.2% (6577) were non-users. Most were Caucasian, aged 80 years and above, and male. After adjusting for confounding factors, pre-ICU statin use decreased 30-day ICU mortality (ATE, -0.026; 95% confidence interval [CI], -0.048 to -0.009); ICU LOS (ATE, -0.369; 95% Cl, -0.849 to -0.096); and 30-day in-hospital mortality (ATE, -0.039; 95% CI, -0.084 to -0.026) on average compared with non-statin use, respectively. In a stratified analysis, the result for ICU LOS (ATE, -0.526; 95% CI, -0.879 to -0.241) and 30-day in-hospital mortality (ATE, -0.023; 95% CI, -0.048 to -0.002) was consistent among patients admitted to the medical ICU. CONCLUSIONS: Among patients with sepsis admitted to the medical ICU, pre-ICU statin use is causally associated with a decrease in 30-day ICU mortality, ICU LOS, and 30-day in-hospital mortality compared to non-use. This study adds to the totality of evidence on the pleiotropic effect of statin use in patients with sepsis

Correlates of reported modern contraceptive use among postpartum HIV-positive women in rural Nigeria: an analysis from the MoMent prospective cohort study

Abstract Background Nigeria has an annual population of ~ 200,000 women who are both pregnant and HIV-positive. High unmet need for family planning in this population could lead to unintended pregnancies, along with the increased risk of mother-to-child transmission of HIV (MTCT). To identify modifiable barriers and facilitators in effective family planning, we examined correlates of modern contraceptive use among HIV-positive women enrolled in the MoMent prevention of MTCT (PMTCT) implementation research study in rural North-Central Nigeria. Methods In this prospective cohort study, HIV-positive pregnant women were enrolled at 20 Primary Healthcare Centers and followed up to 12 months postpartum. Baseline socio-demographic, clinical and obstetric data were collected at enrollment. Participants were to receive routine family planning counselling from healthcare workers during postnatal visits. Analysis utilized baseline data linked to available family planning information collected from each woman at the first postpartum visit. Multivariate logistic regression was performed to determine factors associated with modern contraceptive use. Results Out of 497 women enrolled, family planning data was available for 399 (80.3%) women, of whom 349 (87.5%) received family planning counselling, and 321 (80.5%) were 30 years old or less. Two-thirds (268, 67.2%) of the cohort analyzed had 1–2 children at baseline; 24.8% (n = 99) had 3–4 children, and 8.0% (n = 32) had > 4 children. Approximately half (199, 49.9%) of the women reported no modern contraceptive use in the postpartum period. Male condoms (116, 29.1%) were the most reported method of contraception; other methods reported included oral hormones (71, 17.8%) and intrauterine devices (13, 3.2%). Only disclosure of HIV status to male partner or relative (aOR = 2.0, 95% CI: 1.2–3.3; p = 0.01) and receipt of family planning counselling (aOR = 2.3, 95% CI: 1.1–4.8; p = 0.03) were positively associated with reported modern contraceptive use. Age, marital or educational status, religious affiliation, employment status, gravidity and parity were non-correlates. Conclusions Family planning counselling and disclosure of HIV status are modifiable positive predictors of contraceptive use among our cohort of postpartum HIV-positive women in rural Nigeria. Rates of unintended pregnancy and concomitant risk of MTCT could be significantly reduced through strategies that facilitate these correlates. Clinical trials registration Clinicaltrials.gov registration number: NCT 01936753; registered September 3, 2013

Real-world Duration of Use and Dosing Frequency of Daratumumab in Patients With Multiple Myeloma in the United States

Daratumumab (DARA) is an anti-CD38 monoclonal antibody approved as a combination therapy for newly diagnosed multiple myeloma (MM) and as monotherapy and combination therapy for relapsed or refractory MM cases. We assessed the length of DARA use across lines of therapy and the probabilities of treatment discontinuation in patients with MM in the real-world. We used the deidentified Clinformatics Data Mart database from Optum to identify patients with MM (n=2124) who received DARA-containing treatment between November 1, 2015 and March 31, 2021 in the United States. Patients were excluded if they had received a stem cell transplant. The duration of DARA use was defined as the time interval between the first initiation and discontinuation of DARA as a time-to-event outcome using the Kaplan-Meier method. A gap of more than 60 days between 2 consequent DARA claim dates was defined as DARA discontinuation. The median duration of continuous DARA use was 16.6 months. By 24 months, 33.1% of patients remained on DARA treatment. In a subgroup analysis of patients with 12 months or more continuous insurance coverage (n=1246), the median length of DARA use was 24.7 months; by 24 months, 51.8% remained on DARA treatment. The dose adherence ratios (observed DARA doses relative to the label) were close to 1.0, particularly among patients with longer follow-up, indicating that real-world DARA dosing frequency was similar to that on the approved label. In summary, this real-world analysis reported that the median duration of continuous DARA use is 16.6 months, with high dosing adherence in patients who have MM