Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome : Insights from the LUNG SAFE study

Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). Conclusions: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073publishersversionPeer reviewe

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&lt;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&lt;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

Risco de infecção do sítio cirúrgico após colecistectomia laparoscópica comparado ao risco após colecistectomia laparotômica

Exportado OPUSMade available in DSpace on 2019-08-14T21:30:36Z (GMT). No. of bitstreams: 1 fernando_martin_biscione.pdf: 724689 bytes, checksum: b848781f4cd489f43e1b4c56fae303ef (MD5) Previous issue date: 6Introdução: existem poucos estudos comparativos com controles concorrentes avaliando o risco de infecção do sítio cirúrgico (ISC) em pacientes submetidos a colecistectomia laparoscópica (CL) ou laparotômica (CC).Objetivos: avaliar o impacto da via de abordagem e a contribuição das variáveis do componente cirúrgico NNIS (National Nosocomial Infections Surveillance) no risco global de ISC, infecção incisional e infecção de órgão/cavidade em pacientes colecistectomizados.Métodos: foi conduzido estudo de coorte histórica utilizando dados coletados entre janeiro de 1993 e maio de 2006 em cinco instituições de saúde (hospitais daqui em frente) de Belo Horizonte, Nova Lima e Contagem. Os hospitais participantes eram privados, de média ou alta complexidade e não universitários. A variável dependente foi o desenvolvimento de ISC até 30 dias após a cirurgia. As definições propostas pelos CDC (Centers for Disease Control and Prevention) em 1992 foram adotadas como critérios de definição de ISC. As ISC foram identificadas de forma prospectiva, tanto durante a permanência hospitalar do paciente quanto após a alta hospitalar. A variável de exposição foi a abordagem cirúrgica utilizada (i.e., laparoscópica vs. laparotômica). As variáveis independentes foram a idade e o sexo do paciente, o grau de contaminação do sítio cirúrgico, o estado físico do paciente segundo escore da American Society of Anesthesiologists (ASA), a duração do procedimento, a natureza da cirurgia (eletiva vs. urgente), o cirurgião principal, procedimentos adicionais através da mesma incisão, e o hospital e o ano ( 2000) da operação. A contribuição independente de cada variável na ocorrência de ISC foi avaliada utilizando-se análise de regressão logística binária.Resultados: 6.162 pacientes foram elegíveis, e dados completos estiveram disponíveis para 5.848 (94,9%) pacientes. A idade média + desvio padrão foi de 48,7 + 14,7 anos, e a razão de mulheres para homens foi 2,2:1; 59% das colecistectomias foram laparoscópicas. Em relação aos pacientes operados por laparotomia, os pacientes submetidos a CL foram mais jovens. As CL tiveram menor duração, porém neste grupo houve menor proporção de pacientes com escore da ASA > 3, de procedimentos urgentes, contaminados ou infectados, ou de procedimentos adicionais através da mesma incisão. Em pacientes submetidos a CL, a incidência global de ISC foi de 3,7% (IC 95%= 2,9-4,7%) [3,4% (IC 95%= 2,6-4,3%) para infecção incisional e 0,3% (IC 95%= 0,1-0,7%) para infecção de órgão/cavidade]. Para ambas as abordagens, a maior parte das infecções (> 80%) acometeu a parede abdominal. A contribuição independente das variáveis do componente cirúrgico NNIS no risco de ISC variou com a profundidade da infecção. Após o controle por outros fatores significativos, a chance global de ISC (OR= 0,62; IC 95%= 0,46-0,84) e de infecção incisional (OR= 0,56; IC 95%= 0,41-0,79) foi menor em pacientes submetidos a CL em relação aos submetidos a CC. Contrariamente, nenhuma diferença significativa na chance de desenvolvimento de infecção de órgão/cavidade foi demonstrada.Conclusões: comparada à CC, a CL está associada com menor risco global de ISC e de infecção incisional, mas não de infecção de órgão/cavidade. As variáveis do componente cirúrgico NNIS contribuíram de forma variável no risco de ISC.Background: few comparative studies with concurrent controls are available in the literature assessing the risk of surgical site infection (SSI) associated with the laparoscopic approach in patients undergoing cholecystectomy.Objectives: to assess the impact of the laparoscopic approach and the contribution of the NNIS (National Nosocomial Infections Surveillance) systems surgical component variables on the risk of overall SSI, incisional and organ/space infection in patients undergoing cholecystectomy.Methods: a historical cohort study was conducted using data collected from January 1993 through May 2006 in five healthcare facilities (hospitals hereafter) of Belo Horizonte, Nova Lima and Contagem. Participating hospitals are private, medium- to high-complexity, non-universitary centers. The outcome (i.e, dependent) variable was the development of an SSI within 30 days of the operation. The 1992 CDCs (Center for Disease Control and Prevention) criteria for SSI were adopted as case definition throughout the study. SSI were prospectively identified, both during hospital stay and after discharge. The exposure variable was the surgical approach used for cholecystectomy [i.e, laparoscopic (LC) vs. laparotomic (CC)]. Independent variables were age and gender of the patient, wound class, American Society of Anesthesiologists physical status (ASA-PS) classification, length of operation, type of surgery (elective vs. urgent), main surgeon, additional procedures though the same incision, and hospital and year ( 2000) of the operation. Binary logistic regression models were fit to assess the net effect of each independent variable on the odds of SSI.Results: 6.162 patients met eligibility criteria, and complete data were available for 5.848 (94,9%) patients. Mean age + SD was 48,7 + 14,7 years-old, and female-to-male ratio was 2,2:1; 59% of cholecystectomies were laparoscopic. As compared to CC, patients undergoing LC were younger and less likely to have an ASA-PS > 3, urgent procedures, contaminated or dirty procedures, or additional procedures though the same incision. LC were shorter in duration. In patients undergoing LC, overall SSI incidence was 3,7% (95% CI= 2,9-4,7%) [3,4% (95% CI= 2,6-4,3%) for incisional infections and 0,3% (95% CI= 0,1-0,7%) for organ/space infections]. For both LC and CC, most infections (> 80%) occurred at the incisions. The performance of the NNIS systems surgical component variables as predictors of SSI varied according to the depth of the infection. After controlling for other significant factors, the odds for overall SSI (OR= 0,62; 95% CI= 0,46-0,84) and incisional infection (OR= 0,56; 95% CI= 0,41-0,79) was lower in patients undergoing LC than in patients undergoing CC. Conversely, no significant reduction was demonstrated for organ/space infection.Conclusions: as compared to CC, LC is associated with a lower overall risk of SSI and incisional infection, but not organ/space infection. The NNIS systems surgical component variables performed variably as predictors of SSI

Representation of the hierarchical and functional structure of an ambulatory network of medical consultations through Social Network Analysis, with an emphasis on the role of medical specialties.

BackgroundAmbulatory Health Care Networks (Amb-HCN) are circuits of patient referral and counter-referral that emerge, explicitly or spontaneously, between doctors who provide care in their offices. Finding a meaningful analytical representation for the organic and hierarchical functioning of an Amb-HCN may have managerial and health policymaking implications. We aimed to characterize the structural and functional topology of an Amb-HCN of a private health insurance provider (PHIP) using objective metrics from graph theory.MethodsThis is a cross-sectional quantitative study with a secondary data analysis study design. A Social Network Analysis (SNA) was conducted using office visits performed between April 1, 2021 and May 15, 2022, retrieved from secondary administrative claim databases from a PHIP in Belo Horizonte, Southeastern Brazil. Included were beneficiaries of a healthcare plan not restricting the location or physician caring for the patient. A directional and weighted network was constructed, where doctors were the vertices and patient referrals between doctors, within 7-45 days, were the network edges. Vertex-level SNA measures were calculated and grouped into three theoretical constructs: patient follow-up (aimed at assessing the doctor's pattern of patient follow-up); relationship with authorities (which assessed whether the doctor is an authority or contributes to his or her colleague's authority status); and centrality (aimed at positioning the doctor relative to the network graph). To characterize physician profiles within each dimension based on SNA metrics results, a K-means cluster analysis was conducted. The resulting physician clusters were assigned labels that sought to be representative of the observed values of the vertex metrics within the clusters.FindingsOverall, 666,263 individuals performed 3,863,222 office visits with 4,554 physicians. A total of 577 physicians (12.7%) had very low consultation productivity and contributed very little to the network (i.e., about 1.1% of all referrals made or received), being excluded from subsequent doctor profiles analysis. Cluster analysis found 951 (23.9%) doctors to be central in the graph and 1,258 (31.6%) to be peripheral; 883 (22.2%) to be authorities and 266 (6.7%) as seeking authorities; 3,684 (92.6%) mostly shared patients with colleagues, with patient follow-up intensities ranging from weak to strong. Wide profile dispersion was observed among specialties and, more interestingly, within specialties. Non-primary-care medical specialties (e.g., cardiology, endocrinology etc.) were associated with central profile in the graph, while surgical specialties predominated in the periphery, along with pediatrics. Only pediatrics was associated with strong and prevalent (i.e., low patient sharing pattern) follow-up. Many doctors from internal medicine and family medicine had unexpectedly weak and shared patient follow-up profiles. Doctor profiles exhibited pairwise relationships with each other and with the number of chronic comorbidities of the patients they treated. For example, physicians identified as authorities were frequently central and treated patients with more comorbidities. Ten medical communities were identified with clear territorial and specialty segregation.ConclusionsViewing the Amb-HCN as a social network provided a topological and functional representation with potentially meaningful and actionable emerging insights into the most influential actors and specialties, functional hierarchies, factors that lead to self-constituted medical communities, and dispersion from expected patterns within medical specialties

Results of the vertex-level measures.

BackgroundAmbulatory Health Care Networks (Amb-HCN) are circuits of patient referral and counter-referral that emerge, explicitly or spontaneously, between doctors who provide care in their offices. Finding a meaningful analytical representation for the organic and hierarchical functioning of an Amb-HCN may have managerial and health policymaking implications. We aimed to characterize the structural and functional topology of an Amb-HCN of a private health insurance provider (PHIP) using objective metrics from graph theory.MethodsThis is a cross-sectional quantitative study with a secondary data analysis study design. A Social Network Analysis (SNA) was conducted using office visits performed between April 1, 2021 and May 15, 2022, retrieved from secondary administrative claim databases from a PHIP in Belo Horizonte, Southeastern Brazil. Included were beneficiaries of a healthcare plan not restricting the location or physician caring for the patient. A directional and weighted network was constructed, where doctors were the vertices and patient referrals between doctors, within 7–45 days, were the network edges. Vertex-level SNA measures were calculated and grouped into three theoretical constructs: patient follow-up (aimed at assessing the doctor’s pattern of patient follow-up); relationship with authorities (which assessed whether the doctor is an authority or contributes to his or her colleague’s authority status); and centrality (aimed at positioning the doctor relative to the network graph). To characterize physician profiles within each dimension based on SNA metrics results, a K-means cluster analysis was conducted. The resulting physician clusters were assigned labels that sought to be representative of the observed values of the vertex metrics within the clusters.FindingsOverall, 666,263 individuals performed 3,863,222 office visits with 4,554 physicians. A total of 577 physicians (12.7%) had very low consultation productivity and contributed very little to the network (i.e., about 1.1% of all referrals made or received), being excluded from subsequent doctor profiles analysis. Cluster analysis found 951 (23.9%) doctors to be central in the graph and 1,258 (31.6%) to be peripheral; 883 (22.2%) to be authorities and 266 (6.7%) as seeking authorities; 3,684 (92.6%) mostly shared patients with colleagues, with patient follow-up intensities ranging from weak to strong. Wide profile dispersion was observed among specialties and, more interestingly, within specialties. Non-primary-care medical specialties (e.g., cardiology, endocrinology etc.) were associated with central profile in the graph, while surgical specialties predominated in the periphery, along with pediatrics. Only pediatrics was associated with strong and prevalent (i.e., low patient sharing pattern) follow-up. Many doctors from internal medicine and family medicine had unexpectedly weak and shared patient follow-up profiles. Doctor profiles exhibited pairwise relationships with each other and with the number of chronic comorbidities of the patients they treated. For example, physicians identified as authorities were frequently central and treated patients with more comorbidities. Ten medical communities were identified with clear territorial and specialty segregation.ConclusionsViewing the Amb-HCN as a social network provided a topological and functional representation with potentially meaningful and actionable emerging insights into the most influential actors and specialties, functional hierarchies, factors that lead to self-constituted medical communities, and dispersion from expected patterns within medical specialties.</div

Pearson correlation coefficients between vertex-level measures.

Pearson correlation coefficients between vertex-level measures.</p

Distribution of physicians according to their profiles of centrality, relationship with authorities and patient follow-up by medical specialty.

Distribution of physicians according to their profiles of centrality, relationship with authorities and patient follow-up by medical specialty.</p