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Background: Previous studies demonstrated higher mortality for patients with a longer pre-intensive care unit (ICU) hospital length of stay (LOS), in well-resourced settings. Objectives: The study aimed to determine the association between pre-ICU hospital LOS and ICU outcomes in a resource-limited setting. We hypothesised that longer pre-ICU hospital LOS would be associated with higher ICU mortality. Methods: This was a retrospective cohort study measuring the association between pre-ICU hospital LOS and ICU outcomes using data extracted from a regional hospital ICU in KwaZulu-Natal, South Africa. Consecutive ICU admissions of all patients (medical and surgical) older than 18 years were included during the study period September 2014 to August 2018. A corrected sample size of 2 040 patients was identified. Multivariable logistic regression was used to assess the primary outcome of ICU mortality, and multivariable Cox proportional hazard regression was used for the secondary outcome of ICU LOS. Results: The median pre-ICU hospital LOS was 1 day (interquartile range (IQR) 0 - 2 days). The median length of ICU stay was 2.4 days (IQR 1.1 - 4.8 days) and the observed ICU mortality was 16% (n=327/2 040). Pre-ICU hospital LOS was not associated with ICU mortality in the unadjusted (odds ratio (OR) 1.00; 95% confidence interval (CI) 0.98 - 1.02; p=0.68; n=2 040) and fully adjusted logistic regression models (OR 1.00; 95% CI 0.98 - 1.03; p=0.90; n=1 981) using a complete case analysis for missing patient-level covariates. In Cox proportional hazard models, there was no association between pre-ICU hospital LOS and ICU LOS (hazard ratio 1.00; 95% CI 0.98 - 1.03; p=0.72; n=1 967), including when stratified by admission source. Conclusion: Pre-ICU hospital LOS was not associated with either ICU mortality or ICU LOS in a resource-limited setting. Future studies should aim to include multicentre data and evaluate long-term outcomes. Contributions of the study: The study was conducted in a resource-limited setting and found no association between prolonged LOS pre-ICU and patient outcomes. Several potential explanations for this observation have been explored. This important subject is pertinent to the appropriate use of limited resources and encourages future studies to evaluate this association and to consider longer-term outcomes (e.g. 30-day mortality) in future findings.
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Background: The Quick Sequential Organ Failure Assessment (qSOFA) score is a simple bedside tool validated outside of the intensive care unit (ICU) to identify patients with suspected infection who are at risk for poor outcomes. Objectives: To assess qSOFA at the time of ICU referral as a mortality prognosticator in adult medical v. surgical patients with suspected infection admitted to an ICU in a resource-limited regional hospital in South Africa (SA). Methods: We conducted a retrospective cohort study on adult medical or surgical patients that were admitted to an ICU in a resource-limited hospital in SA. We performed univariate and multivariable logistic regression and compared nested models using likelihood ratio test, and we calculated the area under the receiver operating characteristic curve (AUROC). Results: We recruited a total of 1 162 (medical n=283 and surgical n=875) participants in the study who were admitted to the ICU with suspected infection. qSOFA at the time of ICU referral was highly associated with but poorly discriminant of in-ICU mortality among medical (odds ratio (OR) 2.60, 95% confidence interval (CI) 1.19 - 5.71; p=0.02; AUROC 0.60; 95% CI 0.53 - 0.67; p=0.02) and surgical (OR 2.74; 95% CI 1.73-4.36; p<0.001; AUROC 0.60; 95% CI 0.55 - 0.65; p=0.04) patients. qSOFA model performance was similar between medical and surgical subgroups (p≥0.26). Addition of qSOFA to a baseline risk factor model including age, sex, and HIV status improved the model discrimination in both subgroups (medical AUROC 0.64; 95% CI 0.56 - 0.71; p=0.049; surgical AUROC 0.69; 95% CI 0.64 - 0.74; p<0.0001). Conclusion: qSOFA was highly associated with, but poorly discriminant for, poor outcomes among medical and surgical patients with suspected infection admitted to the ICU in a resource-limited setting. These findings suggest that qSOFA may be useful as a tool to identify patients at increased risk of mortality in these populations and in this context.
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Background: Sepsis is a major cause of morbidity and mortality, especially in critical care patients. Developing tools to identify patients who are at risk of poor outcomes and prolonged length of stay in intensive care units (ICUs) is critical, particularly in resource-limited settings. Objectives: To determine whether the quick sequential organ failure assessment (qSOFA) score based on bedside assessment alone was a promising tool for risk prediction in low-resource settings. Methods: A retrospective cohort of adult patients admitted to the intensive care unit (ICU) at Edendale Hospital in Pietermaritzburg, South Africa (SA), was recruited into the study between 2014 and 2018. The association of qSOFA with in-ICU mortality was measured using multivariable logistic regression. Discrimination was assessed using the area under the receiver operating characteristic curve and the additive contribution to a baseline model using likelihood ratio testing. Results: The qSOFA scores of 0, 1 and 2 were not associated with increased odds of in-ICU mortality (adjusted odds ratio (aOR) 1.24, 95% confidence interval (CI) 0.86 - 1.79; p=0.26) in patients with infection, while the qSOFA of 3 was associated with in-ICU mortality in infected patients (aOR 2.82; 95% CI 1.91 - 4.16; p<0.001). On the other hand, the qSOFA scores of 2 (aOR 3.25; 95% CI 1.91 - 5.53; p<0.001) and 3 (aOR 6.26, 95% CI 0.38 - 11.62, p<0.001) were associated with increased odds of in-ICU mortality in patients without infection. Discrimination for mortality was fair to poor and adding qSOFA to a baseline model yielded a statistical improvement in both cases (p<0.001). Conclusion: qSOFA was associated with, but weakly discriminant, for in-ICU mortality for patients with and without infection in a resource-limited, public hospital in SA. These findings add to the growing body of evidence that support the use of qSOFA to deliver low-cost, high-value critical care in resource-limited settings. Contributions of the study: This study expanded the data supporting the use of qSOFA in resource-limited settings beyond the emergency department or ward to include patients admitted to the ICU. Additionally, this study demonstrated stronger predictive abilities in a population of patients admitted with trauma without suspected or confirmed infection, thus providing an additional use of qSOFA as a risk-prediction tool for a broader population.
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The clinical applicability of screening surgically resected nonsmall cell lung cancer (NSCLC) tumour tissue and serum for activating epidermal growth factor receptor (EGFR) mutation is unknown. Furthermore, the comparative accuracy of inexpensive EGFR mutation tests, mutant-enriched (ME)-PCR and high-resolution melt (HRM) has not been determined. Lung tumour DNA from 522 surgically resected stage I-IV NSCLC and matched serum DNA from a subset of 64 subjects was analysed for EGFR mutations in exons 19 and 21 using ME-PCR and HRM. Additionally, 97 subjects had previous EGFR DNA sequencing data available for comparison. ME-PCR and HRM detected EGFR mutations in 5% (27 out of 522) of tumour samples. Compared to DNA sequencing, ME-PCR had a sensitivity of 100% and specificity of 99%, while HRM had 100% sensitivity and specificity. Six subjects with EGFR mutation tumours had matched serum, where ME-PCR detected mutations in three samples and HRM in two samples. In the cohort of never-smoker subjects, those with EGFR mutated tumours had worse survival compared with wild-type tumours (30 versus 49 months; p=0.017). ME-PCR and HRM have similar accuracy in detecting EGFR mutations but the prognostic implications of the mutations in resected NSCLC warrants further study.
