Natriuretic Peptides to Predict Short-Term Mortality in Patients With Sepsis: A Systematic Review and Meta-analysis.

Data are conflicting regarding the optimal cutoffs of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) to predict short-term mortality in patients with sepsis. We conducted a comprehensive search of several databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus) for English-language reports of studies evaluating adult patients with sepsis, severe sepsis, and septic shock with BNP/NT-proBNP levels and short-term mortality (intensive care unit, in-hospital, 28-day, or 30-day) published from January 1, 2000, to September 5, 2017. The average values in survivors and nonsurvivors were used to estimate the receiver operating characteristic curve (ROC) using a parametric regression model. Thirty-five observational studies (3508 patients) were included (median age, 51-75 years; 12%-74% males; cumulative mortality, 34.2%). A BNP of 622 pg/mL had the greatest discrimination for mortality (sensitivity, 0.695 [95% CI, 0.659-0.729]; specificity, 0.907 [95% CI, 0.810-1.003]; area under the ROC, 0.766 [95% CI, 0.734-0.797]). An NT-proBNP of 4000 pg/mL had the greatest discrimination for mortality (sensitivity, 0.728 [95% CI, 0.703-0.753]; specificity, 0.789 [95% CI, 0.710-0.867]; area under the ROC, 0.787 [95% CI, 0.766-0.809]). In prespecified subgroup analyses, identified BNP/NT-proBNP cutoffs had higher discrimination if specimens were obtained 24 hours or less after admission, in patients with severe sepsis/septic shock, in patients enrolled after 2010, and in studies performed in the United States and Europe. There was inconsistent adjustment for renal function. In this hypothesis-generating analysis, BNP and NT-proBNP cutoffs of 622 pg/mL and 4000 pg/mL optimally predicted short-term mortality in patients with sepsis. The applicability of these results is limited by the heterogeneity of included patient populations.

Temporal trends, predictors, and outcomes of acute kidney injury and hemodialysis use in acute myocardial infarction-related cardiogenic shock.

BACKGROUND: There are limited data on acute kidney injury (AKI) complicating acute myocardial infarction with cardiogenic shock (AMI-CS). This study sought to evaluate 15-year national prevalence, temporal trends and outcomes of AKI with no need for hemodialysis (AKI-ND) and requiring hemodialysis (AKI-D) following AMI-CS. METHODS: This was a retrospective cohort study from 2000-2014 from the National Inpatient Sample (20% stratified sample of all community hospitals in the United States). Adult patients (>18 years) admitted with a primary diagnosis of AMI and secondary diagnosis of CS were included. The primary outcome was in-hospital mortality in cohorts with no AKI, AKI-ND, and AKI-D. Secondary outcomes included predictors, resource utilization and disposition. RESULTS: During this 15-year period, 440,257 admissions for AMI-CS were included, with AKI in 155,610 (35.3%) and hemodialysis use in 14,950 (3.4%). Older age, black race, non-private insurance, higher comorbidity, organ failure, and use of cardiac and non-cardiac organ support were associated with the AKI development and hemodialysis use. There was a 2.6-fold higher adjusted risk of developing AKI in 2014 compared to 2000. Presence of AKI-ND and AKI-D was associated with a 1.3 and 1.7-fold higher adjusted risk of mortality. Compared to the cohort without AKI, AKI-ND and AKI-D were associated with longer length of stay (9±10, 12±13, and 18±19 days respectively; p<0.001) and higher hospitalization costs ($101,859±116,204, $159,804±190,766, and $265,875 ± 254,919 respectively; p<0.001). CONCLUSION: AKI-ND and AKI-D are associated with higher in-hospital mortality and resource utilization in AMI-CS.

Acute respiratory failure and mechanical ventilation in cardiogenic shock complicating acute myocardial infarction in the USA, 2000-2014.

BACKGROUND: There are limited epidemiological data on acute respiratory failure (ARF) in cardiogenic shock complicating acute myocardial infarction (AMI-CS). This study sought to evaluate the prevalence and outcomes of ARF in AMI-CS. METHODS: This was a retrospective study of AMI-CS admissions during 2000-2014 from the National Inpatient Sample. Administrative codes for ARF and mechanical ventilation (MV) were used to define the cohorts of no ARF, ARF without MV and ARF with MV. Admissions with a secondary diagnosis of AMI and with chronic MV were excluded. Outcomes of interest included in-hospital mortality, temporal trends of ARF prevalence and resource utilization. MEASUREMENTS AND MAIN RESULTS: During 2000-2014, 439,436 admissions for AMI-CS met the inclusion criteria. ARF and MV were noted in 57% and 43%, respectively. Admissions with non-ST-elevation AMI-CS, of non-White race and with non-private insurance received MV more frequently. Noninvasive ventilation and invasive MV increased from 0.4% and 39.2% (2000) to 3.6% and 46.4% (2014), respectively (p < 0.001). Coronary angiography and percutaneous coronary intervention were used less frequently in admissions receiving ARF with MV. Compared to admissions with no ARF, ARF without MV (adjusted odds ratio (aOR) 1.56 [95% confidence interval (CI) 1.53-1.59]; p < 0.001) and ARF with MV (aOR 2.50 [95% CI 2.47-2.54]; p < 0.001) were associated with higher in-hospital mortality. Admissions with ARF without MV had greater resource utilization and lesser discharges to home as compared to no ARF. CONCLUSIONS: In this contemporary AMI-CS cohort, the presence of ARF and MV use was noted in 57% and 43%, respectively, and was associated with higher in-hospital mortality.

Sex disparities in acute kidney injury complicating acute myocardial infarction with cardiogenic shock.

AIMS: To evaluate sex-specific disparities in acute kidney injury (AKI) complicating acute myocardial infarction-related cardiogenic shock (AMI-CS) in the United States. METHODS AND RESULTS: This was a retrospective cohort study from 2000 to 2014 from the National Inpatient Sample (20% sample of all hospitals in the United States). Patients >18 years admitted with a primary diagnosis of AMI and concomitant CS that developed AKI were included. The endpoints of interest were the prevalence, trends, and outcomes of men and women with AKI in AMI-CS. Multivariable hierarchical logistic regression was used to control for confounding, and a two-sided P < 0.05 was considered statistically significant. During this 15 year period, 440 257 admissions with AMI-CS met the inclusion criteria, with AKI noted in 155 610 (35.3%). Women constituted 36.3% of the cohort and were older, of non-White race, and with higher co-morbidity compared with men. Women with AKI less often received coronary angiography (59% vs. 66%), percutaneous coronary intervention (39% vs. 43%), mechanical circulatory support (39% vs. 48%), mechanical ventilation (49% vs. 54%), and haemodialysis (9% vs. 10%) compared with men (all P < 0.001). Adjusted in-hospital mortality was higher in women-odds ratio 1.16 (95% confidence interval 1.14-1.19); P < 0.001-compared with men. Women had shorter lengths of stay (12 ± 14 vs. 13 ± 14 days), lower hospital costs ($150 071 ± 180 796 vs. $181 260 ± 209 674), and were less often discharged to home (19% vs. 31%) (all P < 0.001). CONCLUSIONS: Women with AKI in AMI-CS received fewer cardiac and non-cardiac interventions, had higher in-hospital mortality, and were less often discharged to home compared with men.

Temporal trends and outcomes of prolonged invasive mechanical ventilation and tracheostomy use in acute myocardial infarction with cardiogenic shock in the United States.

BACKGROUND: There are limited data on prolonged invasive mechanical ventilation (IMV) and tracheostomy use in intubated acute myocardial infarction with cardiogenic shock (AMI-CS) patients. METHODS: Using the National Inpatient Sample, all admissions with AMI-CS requiring IMV between January 1, 2000, and December 31, 2014, were included. Prolonged IMV was defined as IMV use >96 h. Outcomes of interest included temporal trends in use of prolonged IMV and tracheostomy, in-hospital mortality, and resource utilization. RESULTS: In this 15-year period, 185,589 intubated AMI-CS admissions met the inclusion criteria. Prolonged IMV (>96 h) and tracheostomy use were noted in 68,544 (36.9%) and 10,645 (5.7%), respectively. Prolonged IMV and tracheostomy were used more commonly in younger patients. The cohort with prolonged IMV had higher organ failure and greater use of cardiac and non-cardiac organ support. Temporal trends showed a decline in prolonged IMV (adjusted odds ratio {aOR} 0.61 [95% confidence interval {CI} 0.57-0.65]) and tracheostomy use (aOR 0.80 [95% CI 0.70-0.90]) in 2014 compared to 2000. Prolonged IMV (aOR 0.45 [95% CI 0.44-0.47]; p < 0.001) and tracheostomy (aOR 0.28 [95% CI 0.27-0.29]; p < 0.001) were associated with lower in-hospital mortality with a decreasing trend between 2000 and 2014 in intubated AMI-CS admissions. Patients with prolonged IMV and tracheostomy use had nearly three-fold higher health care costs, and four-fold longer hospital stays. CONCLUSIONS: In this cohort of intubated AMI-CS admissions, prolonged IMV and tracheostomy showed a temporal decrease between 2000 and 2014. Prolonged IMV and tracheostomy use was associated with high resource utilization.

Use of corticosteroids in acute respiratory distress syndrome: Perspective from an Indian intensive care unit.

BACKGROUND: Acute respiratory distress syndrome (ARDS) causes overwhelming inflammation, which serves as a potential target for corticosteroids. Despite extensive Western literature, there are no Indian studies evaluating steroids in ARDS. METHODS: This was a retrospective study at an Indian intensive care unit (ICU) on ARDS patients. Demographic, clinical, laboratory, and imaging parameters were collected. Patients were divided into cohorts based on steroid use, and some received high-dose (2 mg/kg/day), whereas others received low-dose (1 mg/kg/day) steroids. Primary outcomes were in-hospital mortality and secondary outcomes included need for and duration of invasive mechanical ventilation (IMV), IMV-free days, ICU length of stay (LOS), and total LOS. Two-tailed p < 0.05 was considered statistically significant. RESULTS: During the 20-month period, 95 patients [median age 37 (30-47) years; 48 (50.5%) males] met our inclusion criteria. Steroid use was noted in 48 (50.5%) patients [11 (22.9%) low-dose and 37 (77.1%) high-dose]. Baseline characteristics of the cohorts, including ARDS severity indices, were comparable. Of these 95 patients, 70 (73.7%) had sepsis, but microbiological diagnosis was positive only in 17 (17.9%) patients. Steroid use did not significantly influence mortality [odds ratio (OR) 0.6 (0.3-1.4)] or need for IMV [OR 1.0 (0.4-2.6)]. There were no differences in outcomes of IMV-free days, ICU LOS, or total LOS. These outcomes were comparable between the high-dose and low-dose steroid users. CONCLUSIONS: Steroid use and comparison of low-dose vs. high-dose steroids did not influence outcomes associated with ARDS in the Indian population.

Association of hyponatremia with in-hospital outcomes in infective endocarditis: A 5-year review from an Indian Intensive Care Unit.

Hyponatremia is commonly noted with cardiovascular disorders, but its role in infective endocarditis (IE) is limited to being a marker of increased morbidity in IE patients with intravenous drug use. This was a 5-year retrospective review from an Indian Intensive Care Unit (ICU). Patients >18 years with IE and available serum sodium levels were included in the study. Pediatric and pregnant patients were excluded from the study. Hyponatremia was defined as admission sodium <135 mmol/L. Detailed data were abstracted from the medical records. Primary outcomes were need for invasive mechanical ventilation, ICU length of stay, and in-hospital mortality. Secondary outcomes included development of acute kidney injury, acute decompensated heart failure (ADHF), acute respiratory distress syndrome, stroke, and severe sepsis in the ICU. Two-tailed P < 0.05 was considered statistically significant. Between January 2010 and December 2014, 96 patients with IE were admitted to the ICU with 85 (88.5%) (median age 46 [34.5-55] years, 51 [60.0%] males) meeting our inclusion criteria. The comorbidities, echocardiographic, and microbiological characteristics were comparable between patients with hyponatremia (56; 65.9%) and eunatremia (29; 34.1%). Median sodium in the hyponatremic cohort was 131 mmol/L (127.25-133) compared to the eunatremic cohort 137 mmol/L (135-139) (P < 0.001). The primary outcomes were not different between the two groups. Hyponatremia was associated more commonly with ADHF (12 [21.4%] vs. 0; P = 0.007) during the ICU stay. Hyponatremia is commonly seen in IE patients and is not associated with worse hospital outcomes. ADHF was seen more commonly in the hyponatremic patients in comparison to those with eunatremia.

Development of vascular complications and bladder carcinoma in diabetics using pioglitazone: A five-year Indian review.

BACKGROUND: Pioglitazone has better cardiovascular outcomes and a questionable relationship with bladder carcinoma in diabetes mellitus, type II (DM-2). We sought to evaluate the role of pioglitazone in the Indian population. METHODS: This is a retrospective study at an academic medical center in India. All DM-2 patients in 2008 with a new prescription of pioglitazone were age- and gender-matched with non-users. We excluded patients with gestational DM or DM type I. They were followed forward for five years and demographic data, micro- and macro-vascular complications, mortality, and bladder carcinoma were recorded. Two-tailed p ≤ 0.05 was considered statistically significant. RESULTS: Two cohorts of 260 patients, with mean age of 58 ± 11 years with 413 (79.4%) males, were followed for five years. Pioglitazone users had higher hypertension, obesity, DM-2 family history (all p < 0.003), and use of insulin and oral hypoglycemics (all p < 0.0001) in comparison to non-users. HbA1c was not different between groups. Over five years, pioglitazone users had lesser retinopathy and myocardial infarctions (all p < 0.01). Five cases of bladder carcinoma were noted, all in the pioglitazone group, however without statistical significance. Baseline variables, including mean daily pioglitazone dose, were not statistically different between patients with and without bladder carcinoma. Nephropathy and MI were independent predictors for development of bladder carcinoma within pioglitazone users. CONCLUSIONS: Pioglitazone users had significantly lesser myocardial infarctions and retinopathy despite more difficult to control DM 2. In an age- and gender-matched cohort of users and non-users, pioglitazone did not contribute to development of bladder cancer in the Indian population.