The Utility of ICU Readmission as a Quality Indicator and the Effect of Selection

Objectives: Intensive care readmission rates are used to signal quality, yet it is unclear whether they represent poor quality in the transition of care from the ICU to the ward, patient factors, or differences in survival of the initial admission. This study aims to measure the selection effect of surviving the initial ICU admission on readmission rates. Design: Retrospective cohort study of adult patients admitted to ICUs participating in the Case Mix Program database from the Intensive Care National Audit Research Centre. Settings: The study includes 262 ICUs in the United Kingdom. Patients: The study includes 682,975 patients admitted to ICUs between 2010 and 2014. Interventions: None. Measurements and Main Results: The study includes 682,975 patients admitted to ICUs in the United Kingdom. There were 591,710 patients discharged alive, of which 9,093 (1.53%) were readmitted within the first 2 days of ICU discharge. Post-ICU admission hospital mortality and ICU readmission were poorly correlated (r = 0.130). The addition of a selection model resulted in a weaker correlation (r = 0.082). Conclusions: ICU readmission performed poorly as a performance metric. The selection process by which only patients who survive their index admission are eligible for readmission has a significant effect on ICU readmission rankings, particularly the higher ranked ICUs. Failure to consider this selection bias gives misleading signals about ICU performance and leads to faulty design of incentive schemes. These data derive from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database. The Case Mix Programme is the national comparative audit of patient outcomes from adult critical care coordinated by ICNARC. For more information on the representativeness and quality of these data, please contact ICNARC. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of Intensive Care National Audit and Research Centre. Dr. Maharaj contributed to conception and design. All authors contributed to analysis and interpretation and drafting the article for important intellectual content. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/29S62lw). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Ritesh.maharaj@kcl.ac.uk Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Outcomes of Ethics Consultations in Adult ICUs: A Systematic Review and Meta-Analysis

Objectives: Clinical ethics consultation as a mechanism for supporting patients, family, and staff during ethically challenging situations has become standard of care. Despite this, there is a lack of consensus about the effectiveness of clinical ethics consultation consultation in the ICU. We performed a systematic review of outcomes associated with clinical ethics consultation within adult ICUs. Data Sources: We searched MEDLINE, PubMed, Cochrane CENTRAL, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature from 1984 to May 2017. Study Selection: Two reviewers independently screened articles, assessed eligibility, extracted data, and assessed risk of bias using the Cochrane Collaboration Risk of Bias tool and the Newcastle-Ottawa Scale. Pooled estimates of effect were calculated where possible. We screened 3,970 abstracts and reviewed 325 full-text articles of which 16 met all eligibility criteria. Data Extraction: We examined changes in processes and outcomes as a result of clinical ethics consultation in the ICU. Categories of outcomes included user perception, clinical decision, or conflict resolution and resource utilization. Data Synthesis: The use of clinical ethics consultation in the ICU was associated with positive user experience (383/435 found clinical ethics consultation helpful), although stress and disagreement with clinical ethics consultation recommendations was greater in a subset (113/431 surrogates and providers). Consensus for a clinical decision was more frequently achieved with clinical ethics consultation (odds ratio, 4.09; 95% CI, 1.01–16.55; p = 0.05). Clinical ethics consultation was associated with lower resource utilization including significantly decreased ICU length of stay (mean difference, –4.65 d; 95% CI, –8.86 to –0.44; p = 0.03). Conclusions: Our review identified outcome-based assessment as the predominant measure used to report effectiveness of clinical ethics consultation consultations. In particular, clinical ethics consultation decreased ICU length of stay and increased family and healthcare provider satisfaction. However, using outcome measures as the primary endpoint may not reflect the original intent of the clinical ethics consultation service. Based on our review, we propose a list of process measures that may better capture the key domains of a quality clinical ethics consultation. Protocol registration: PROSPERO CRD42014015480. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/29S62lw). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Selena.Au@AlbertaHealthServices.ca Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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The Association Between Acute Respiratory Distress Syndrome Hospital Case Volume and Mortality in a U.S. Cohort, 2002–2011

Objectives: This study examines the relationships between hospitals' annual acute respiratory distress syndrome case volume with hospitals' acute respiratory distress syndrome case fatality rates and individuals' odds of acute respiratory distress syndrome hospital mortality. Design: Retrospective cohort study. Setting: The U.S. Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, 2002–2011. Patients: Acute respiratory distress syndrome discharges defined by the presence of an acute respiratory distress syndrome International Classification of Diseases, 9th revision, Clinical Modification diagnosis code (518.82 or 518.5) and a mechanical ventilation procedure code (96.70, 96.71 or 96.72) on the discharge diagnosis and procedure lists. If the procedure code 96.71 was on the discharge record (mechanical ventilation

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Cerebral Autoregulation in the Prediction of Delayed Cerebral Ischemia and Clinical Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage Patients

Objectives: Pressure reactivity index and oxygen reactivity index are used to assess cerebral autoregulation after acute brain injury. The value of autoregulation indices in the prediction of delayed cerebral ischemia and outcome in patients with subarachnoid hemorrhage is still inconclusive. In this study, we aimed to focus on the predictive value of the first 72 hours commonly referred to as "early brain injury" in comparison to the overall monitoring period. Design: Retrospective observational cohort study. Setting: Neurocritical care unit at a tertiary academic medical center. Patients: Forty-three consecutive poor-grade patients with nontraumatic subarachnoid hemorrhage admitted between 2012 and 2016 undergoing continuous high-frequency monitoring. Interventions: High-frequency monitoring includes arterial blood pressure, intracranial pressure, and brain tissue oxygen tension. Pressure reactivity index and oxygen reactivity index were evaluated as moving correlation coefficient between mean arterial pressure/intracranial pressure and cerebral perfusion pressure/brain tissue oxygen tension, respectively. Measurements and Main Results: Median autoregulation monitoring time was 188 ± 91 hours per patient. Initial pressure reactivity index was 0.31 ± 0.02 and decreased significantly to 0.01 ± 0.01 (p

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Insulo-opercular cortex generates oroalimentary automatisms in temporal seizures

Summary

Objective

Oroalimentary automatisms (OAAs) resembling normal alimentary behavior are stereotyped complex movements that may occur during epileptic seizures. They are considered common clinical signs in temporal lobe seizures, but their anatomofunctional mechanisms are not established. We took the opportunity of presurgical intracerebral recordings to study the relations between the occurrence of OAAs and temporal/spatial features of ictal activities.

Methods

We retrospectively reviewed patients with medically intractable medial temporal lobe epilepsy who underwent stereoelectroencephalography (SEEG) at Cleveland Clinic between 2009 and 2016. Patients presenting oroalimentary automatisms during seizures, with intracerebral electrodes spanning temporal and extratemporal areas, were selected. SEEG-clinical correlations with latency measurements were done. Coherence analyses were performed on regions of interest as defined by the areas involved at the onset of oroalimentary automatisms.

Results

Fifteen patients (115 seizures) were analyzed. Sixty-nine seizures exhibited overt oroalimentary automatisms. Only insulo-opercular cortex ictal involvement was consistently related to the occurrence of OAAs, with a linear correlation between OAA onset and ictal oscillatory activity onset in the insulo-opercular cortex. SEEG signal processing showed an increase in theta coherence preceding oroalimentary automatism onset between mediobasal-temporal structures and insulo-opercular cortex, as well as between the 2 insulo-opercular regions.

Significance

The underlying mechanism for the production of oroalimentary automatisms in medial temporal seizures is based on temporal-insulo-opercular theta coherence leading to a synchronous state generating rhythmic patterned outputs from the cortical masticatory area.

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Immunologic Milieu of Mature T-Cell and NK-Cell Lymphomas—Implications for Therapy

Abstract

Purpose of the Review

T-cells and natural killer (NK) cells share the same ontogeny, and lymphomas derived from them are clinically diverse, occurring in nodal and extranodal sites. In addition to inherent properties of these lymphomas, their microenvironment also impacts on pathogenesis and response to therapy. An understanding of the milieu of T-cell and NK cell lymphomas has important implications on treatment.

Recent Findings

Components of the microenvironment include tumour-associated macrophages (TAM), non-neoplastic T-cells and B-cells, eosinophils, dendritic cells, endothelial cells and blood vessels. TAM typically undergoes M2 polarization, promoting angiogenesis and inhibiting anti-tumour cellular immunity. In lymphomas of follicular helper T-cell derivation, increased B-cell proliferation occurs, which may in turn enhance neoplastic T-cell growth. The expression of immune checkpoint ligands on TAM, dendritic cells or lymphoma cells induces an immunosuppressive environment conducive to neoplastic proliferation. Strategies against this complex cellular and immunologic microenvironment have shown promises. These include the use of signal transduction inhibitors, monoclonal antibodies against chemokines or non-neoplastic microenvironmental cells, immunomodulatory drugs and immune checkpoint blockade. As T-cell and NK cell lymphomas are highly heterogeneous, clinical trials to demonstrate efficacy of a given therapeutic approach requires careful design aiming at enriching patient populations who will best respond.

Summary

Targeting of the immunologic milieu in T-cell and NK-cell lymphomas offers exciting challenges and opportunities.

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Increased expression of senescence-associated cell cycle regulators in the progression of biliary atresia: an immunohistochemical study

Abstract

Aims

Cellular senescence plays a role in tumor suppression and in the pathogenesis of various non-neoplastic diseases, including primary biliary cholangitis and other adult cholangiopathies. Less is known about the role of cellular senescence in cholangiopathies in children. With that in mind, we examined the expression of senescence-associated cell cycle regulators in biliary atresia, the most common form of pediatric obliterative cholangiopathy.

Methods and Results

The expression of s senescence-associated cell cycle regulators (p16^Ink4a and p21^WAF1/Cip1) and a ductular reaction related marker (neural cell adhesion molecule - NCAM), was examined in bile ducts and bile ductules in liver samples taken from the patients with biliary atresia (n=80; including 23 samples at the time of Kasai-procedure (KP) and 63 obtained from the explanted liver (LT) [6 cases with samples at both surgical stages of disease]) and from appropriate controls (n=17). The degree of ductular reaction and cholestasis was significantly more extensive in LT than KP (p<0.01). The expression of p16^INK4a and NCAM was significantly more extensive in bile ducts and bile ductules in ductular reaction in both KP and LT compared to controls and in LT compared to KP (p<0.05). The expression of p21^WAF1/Cip1 was significantly more extensive in bile ducts and bile ductules in KP compared to both LT and controls (p<0.01).

Conclusions

Cellular senescence may play a role in the progression of bile duct loss in biliary atresia in a manner similar to that of adult cholangiopathies.

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