Postdischarge health resource use in pediatric survivors of prolonged mechanical ventilation for acute respiratory illness.

We aimed to identify characteristics associated with postdischarge health resource use in children without medical complexity who survived an episode of prolonged mechanical ventilation for respiratory illness. We hypothesized that longer durations of mechanical ventilation, noncomplex chronic conditions, and severe acute respiratory distress syndrome (ARDS) would be associated with readmission or an Emergency Department (ED) visit. In this retrospective cohort, we evaluated children without a complex chronic condition who survived a respiratory illness requiring ≥3 days of mechanical ventilation and who had insurance eligibility within the Colorado All Payers Claims Database. We used insurance claims to characterize health resource use and multivariable logistic regression to identify characteristics associated with readmission or an ED visit during the postdischarge year. We evaluated 82 children, median age 12.8 months (interquartile range [IQR]: 4.0-24.1), 20 (24%) with a noncomplex chronic condition and 62 (76%) without any chronic conditions. Bronchiolitis (60%) and pneumonia/aspiration pneumonitis (17%) were the most common etiologies of respiratory failure and 47 (57%) patients had severe ARDS. Forty-six (56%) patients had an ED visit or readmission. Among the 18 readmitted patients, 16/18 (89%) readmissions were for respiratory illness. Forty (49%) patients had ≥2 outpatient pulmonary visits and 45 (55%) filled a pulmonary medication prescription. In analyses controlling for age, illness severity and mechanical ventilation duration, severe ARDS was predictive of ED visit or readmission (odds ratio [OR]: 5.53 [95% confidence interval [CI]: 1.79, 19.09]). Children who survive prolonged mechanical ventilation for respiratory disease experience high rates of postdischarge health resource use, particularly those surviving severe ARDS.

An exploratory assessment of serum biomarkers of post-cardiac arrest syndrome in children.

AIM: We hypothesized that serum biomarkers of inflammation including chemokine, cytokine, pituitary hormones, and growth factors following cardiac arrest in children would independently associate with 6-month neurologic outcome. METHODS: In this prospective observational single center study of children with in-hospital and out-of-hospital cardiac arrest surviving to intensive care unit admission, serum was obtained twice per 24 h period between 0 h and 96 h and once at approximately 196 h post-cardiac arrest. Inflammatory mediators, hormones, and growth factors were analyzed by Luminex Multiplex Bead Immunoassay. We recorded demographics, resuscitation characteristics, and Pediatric Cerebral Performance Category (PCPC) at 6 months. We analyzed the association and area under the curve (AUC) of biomarker levels with favorable (PCPC 1-3) or unfavorable (PCPC 4-6, or >1 increase from baseline) outcome. RESULTS: Forty-two children (50% female; median age of 2.5 [IQR: 0.4-10.2]) were enrolled and 18 (42%) died prior to 6-month follow up. Receiver operator curves for initial levels of ciliary neurotrophic factor (CNTF, AUC 0.84, 95% CI 0.73-0.96, p < 0.001) and interleukin (IL-17, AUC 0.84, 95% CI 0.73-0.97, p < 0.001) best classified favorable versus unfavorable 6-month outcome. In multivariable analysis, initial levels of CNTF and IL-17 remained associated with 6-month PCPC. Peak levels of interferon-γ-inducible protein 10 (IP-10), CNTF, and hepatocyte growth factor (HGF) were also independently associated with outcome. CONCLUSION: Increased serum concentrations of CNTF and IL-17 associated with unfavorable 6-month neurologic outcome of children surviving cardiac arrest. Further investigation of the prognostic utility and roles of CNTF and IL-17 in the pathophysiology of post-cardiac arrest syndrome are warranted. This project is registered with clinicaltrials.gov (NCT00797680) as "Duration of Hypothermia for Neuroprotection after Pediatric Cardiac Arrest: A Randomized, Controlled Trial".

Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States.

Community-acquired pneumonia (CAP) is a frequent cause of hospital admission and death among elderly patients, but there is little information on age- and sex-specific incidence, patterns of care (intensive care unit admission and mechanical ventilation), resource use (length of stay and hospital costs), and outcome (mortality). We conducted an observational cohort study of all Medicare recipients, aged 65 years or older, hospitalized in nonfederal U.S. hospitals in 1997, who met ICD-9-CM-based criteria for CAP. We identified 623,718 hospital admissions for CAP (18.3 per 1,000 population > or = 65 years), of which 26,476 (4.3%) were from nursing homes and of which 66,045 (10.6%) died. The incidence rose five-fold and mortality doubled as age increased from 65-69 to older than 90 years. Men had a higher mortality, both unadjusted (odds ratio [OR]: 1.21 [95% CI: 1.19-1.23]) and adjusted for age, location before admission, underlying comorbidity, and microbiologic etiology (OR: 1.15 [95% CI: 1.13-1.17]). Mean hospital length of stay and costs per hospital admission were 7.6 days and $6,949. For those admitted to the intensive care unit (22.4%) and for those receiving mechanical ventilation (7.2%), mean length of stay and costs were 11.3 days and $14,294, and 15.7 days and $23,961, respectively. Overall hospital costs were $4.4 billion (6.3% of the expenditure in the elderly for acute hospital care), of which $2.1 billion was incurred by cases managed in intensive care units. We conclude that in the hospitalized elderly, CAP is a common and frequently fatal disease that often requires intensive care unit admission and mechanical ventilation and consumes considerable health care resources. The sex differences are of concern and require further investigation.

Is the randomized, controlled trial in children an endangered species?

OBJECTIVE: To discuss the potential effects of current Food and Drug Administration (FDA) policy in the United States facilitating the approval of novel therapies for use in children (based on safety trials) on pediatric randomized, controlled trials in the pediatric intensive care unit setting. Method: The history of randomized, controlled trials, the FDA, and the events that led to this ruling are discussed. RESULTS: A recent FDA ruling ensures increased drug testing in children; however, it also opens the possibility for drug approval for use in children without any requirement for randomized, controlled trial testing of the efficacy of the drug on disease-specific outcomes. CONCLUSIONS: In light of the high degree of instability of pediatric intensive care unit patients, the frequent use of multiple drugs in a given patient with resultant drug-drug interactions, the risk of toxicity in critically ill infants and children with impaired drug metabolism, and age-dependent differences in physiology, clinicians must strive to be informed of the meaning of FDA approval or disapproval of the drugs they use for children.