Notes

Racial variations treatment choices amid older people in Eastern Birmingham.
Resuscitation with IV fluids is a critical component in the management of sepsis. Although the optimal volume of IV fluid is unknown, there is evidence that excessive administration can be deleterious. Static measures of volume status have not proven to be meaningful resuscitative endpoints. Determination of volume responsiveness has putative benefits over static measures, but its effect on outcomes is unknown. The goal of this systematic review and meta-analysis was to determine if resuscitation with a volume responsiveness-guided approach leads to improved outcomes in septic patients. Data Sources We searched PubMed, EMBASE, CINAHL, Web of Science, Cochrane Library, and Google Scholar from inception until April 2018. Study Selection Prospective studies of patients with sepsis, severe sepsis, or septic shock that compared volume responsiveness-guided fluid resuscitation to standard techniques and reported mortality data. Data Extraction We extracted study details, patient characteristics, volume responsiveness assessment method, and mortality data. Data Synthesis Of the 1,224 abstracts and 31 full-texts evaluated, four studies (total 365 patients) met inclusion criteria. Using random effects modeling, the pooled odds ratio for mortality at time of longest follow-up with a volume responsiveness-guided strategy was 0.87 (95% CI, 0.49-1.54). Pooling of clinical data was not possibly owing to heterogeneity of reporting in individual studies. Conclusions We found no significant difference in mortality between septic patients resuscitated with a volume responsiveness-guided approach compared with standard resuscitative strategies. It remains unclear whether the findings are due to the small sample size or a true lack of efficacy of a volume responsiveness-guided approach. Copyright (c) 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.Since endothelial function is closely related to organ dysfunction in sepsis and the relationship among endothelial injury, organ dysfunction, and other biomarkers remains unclear, we aimed to evaluate the correlation among endothelial injury, organ dysfunction, and several biomarkers in patients with sepsis. Design This was a retrospective observational study. Setting The study was conducted in a university hospital with 14 mixed ICU beds. Patients ICU patients with sepsis from June 2011 to December 2017 were enrolled in this study. Interventions Endothelial biomarkers (soluble thrombomodulin, plasminogen activator inhibitor-1, and protein C) and markers of inflammation and coagulation were evaluated during the ICU stay. Sequential Organ Failure Assessment scores were assessed for 7 days after ICU admission to determine organ dysfunction. Variables were compared among five stratified groups according to the Sequential Organ Failure Assessment score (0-2, 3-5, 6-8, 9-12, and 13-24). Regression analysis and 95al Care Medicine.To develop hypotheses of patient and surrogate's rationale for decision-making. Design We pursued a qualitative study of patients with acute respiratory distress syndrome or sepsis and their surrogates. Fourteen patients and 28 surrogates were given semistructured interviews while in the ICU and again 30 days later. The interviews focused on goal outcomes for the ICU stay and why a patient or surrogate would want a specific intervention (e.g., intubation and cardiopulmonary resuscitation). Setting ICU of tertiary care academic hospital. Patients Fourteen acute respiratory distress syndrome or sepsis patients and 28 of their surrogates. Cyclosporin A in vivo Interventions None. Measurements and Main Results Interviews were analyzed using grounded theory and the constant comparative method on NVivo 10.0 (QSR International, Melbourne, Australia). We identified the following four typologies of decision-making rationale 1) "Timers"-determined decisions based on the length of time on life support; 2) "Natural Livers"-rejected interventions using a "machine"; 3) "Deferrers"-relied on physician for decision-making and prognosis; and 4) "Believers"-relied on a higher power for guidance. Conclusions Our hypothesized typologies need validation in a prospective observational trial. If validated, they may allow for better clinician communication. Copyright (c) 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.1) To show how to exploit the information contained in the trajectories of time-varying patient clinical data for dynamic predictions of mortality in the ICU; and 2) to demonstrate the additional predictive value that can be achieved by incorporating this trajectory information. Design Observational, retrospective study of patient medical records for training and testing of statistical learning models using different sets of predictor variables. Setting Medical ICU at the Yale-New Haven Hospital. Subjects Electronic health records of 3,763 patients admitted to the medical ICU between January 2013 and January 2015. Interventions None. Measurements and Main Results Six-hour mortality predictions for ICU patients were generated and updated every 6 hours by applying the random forest classifier to patient time series data from the prior 24 hours. The time series were processed in different ways to create two main models 1) manual extraction of the summary statistics used in the literature (min/max/median/first/laques can be used to automatically extract all relevant shape features for use in predictive modeling. The approach requires no additional data and can potentially be used to improve any risk model that uses some form of trajectory information. In this single-center study, the shapes of the clinical data trajectories convey information about ICU mortality risk beyond what is already captured by the summary statistics currently used in the literature. Copyright (c) 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.To examine the association between premorbid metformin exposure and mortality, hyperlactatemia, and organ dysfunction in sepsis. Data Sources PubMed and EMBASE (with Medline via Ovid) databases were searched for all studies of premorbid metformin exposure and sepsis published between January 1974 and August 2018. Study Selection Studies of at least 20 patients with sepsis that reported data on metformin use, mortality, and/or organ dysfunction were independently selected. Data Extraction Two reviewers abstracted data on study design, settings, study quality, participants, metformin exposure, mortality, initial lactate levels, and organ dysfunction. Risk of bias was independently assessed. Data Synthesis Eight observational studies fulfilled our criteria, comprising 4,144 patients with sepsis including 562 diabetics on metformin. Premorbid metformin exposure was associated with reduced mortality in sepsis (odds ratio, 0.57; 95% CI, 0.40-0.80). Between studies heterogeneity was low (i 2 = 43%; τ2 = 0.1; p = 0.09).
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