An international cohort study of birth outcomes associated with hospitalized acute respiratory infection during pregnancy.

OBJECTIVES: Findings during the 2009 pandemic suggest severe maternal infection with pandemic influenza had adverse perinatal health consequences. Limited data exist evaluating the perinatal health effects of severe seasonal influenza and non-influenza infections during pregnancy. METHODS: A retrospective cohort of pregnant women from Australia, Canada, Israel, and the United States was established using birth records to identify pregnancies and birth outcomes and hospital and laboratory testing records to identify influenza and non-influenza associated acute respiratory or febrile illness (ARFI) hospitalizations. ARFI hospitalized women were matched to non-hospitalized women (1:4) by country and season of conception. Log-binomial regression was used to estimate the relative risk (aRR) of preterm birth (PTB), small-for-gestational-age (SGA), and low birthweight (LBW) birth, adjusting for pre-existing medical conditions, maternal age, and parity. RESULTS: 950 pregnant women hospitalized with an ARFI were matched with 3,800 non-hospitalized pregnant women. Compared to non-hospitalized women, risk of PTB was greater among women hospitalized with influenza-associated ARFI (aRR: 1.57; 95% CI: 1.15-2.15) and non-influenza ARFI (aRR: 2.78; 95% CI: 2.12-3.65). Similar results were observed for LBW; there were no associations with SGA birth. CONCLUSIONS: ARFI hospitalization during pregnancy was associated with increased risk of PTB and LBW.

Incidence and long-term outcomes of critically ill adult patients with moderate-to-severe diabetic ketoacidosis: retrospective matched cohort study.

OBJECTIVE: The objective of this study was to describe the clinical outcomes and treatment intensity of adult intensive care unit (ICU) patients with moderate-to-severe diabetic ketoacidosis (DKA). We aimed also to compare their clinical course with matched non-DKA ICU controls and to identify prognostic factors for mortality and hospital readmission within 1 year. DESIGN: This is a retrospective matched cohort study. SETTING: The settings are 2 tertiary teaching hospitals in Edmonton, Canada. PATIENTS: Patients were adults with moderate-to-severe DKA admitted from January 2002 to December 2009. Control patients were defined as randomly selected age, sex, and Acute Physiology and Chronic Health Evaluation II score-matched nondiabetic ICU patients (1:4.5 matching ratio). Diabetic patients were stratified according to severity of exacerbation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: From 2002 to 2009, the incidence of DKA per 1000 admissions was 4.59 (95% confidence interval [CI], 3.64-5.71). Severe DKA was associated with higher Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores in the first 3 days of ICU stay as compared with moderate DKA. Mechanical ventilation was received in 39%, vasopressors in 17%, and renal replacement therapy in 12% of DKA patients, respectively. One-year mortality and readmission rates were 9% and 36%. By logistic regression, death and/or readmission occurring in 1 year was independently associated with insulin use (odds ratio, 4.79; 95% CI, 1.14-20.05) and treatment noncompliance (odds ratio, 3.33; 95% CI, 1.04-10.64). Compared with matched non-DKA patients, those with DKA had lower mortality and were more likely to be discharged home. CONCLUSIONS: Diabetic ketoacidosis necessitating ICU admission is associated with considerable resource utilization and long-term risk for death. Interventions aimed to improve compliance with therapy may prevent readmissions and improve the long-term outcome.

Risk factors and outcomes associated with acute kidney injury following ruptured abdominal aortic aneurysm.

BACKGROUND: Current data describing the epidemiology of acute kidney injury (AKI) following repair of ruptured abdominal aortic aneurysm (rAAA) are limited and long-term outcomes are largely unknown. Our objectives were to describe the incidence rate, risk factors, clinical course and long-term outcomes of AKI following rAAA repair. METHODS: Retrospective population-based cohort study of all referrals undergoing emergency repair of rAAA in Northern Alberta from January 1, 2002 to December 31 2009. Demographic, clinical, physiologic and laboratory data were extracted. AKI was defined and classified according to the AKIN criteria. RESULTS: In total, 140 patients survived to receive emergent rAAA repair. Post-operative AKI occurred in 75.7% of patients (n = 106), 78.3% (n = 83) of which occurred during the initial 24 hours of ICU admission. AKIN stage 1, 2, and 3 occurred in 47 (33.6%), 36 (25.7%) and 23 (16.4%), respectively, with 19 patients receiving renal replacement therapy (RRT). Several clinical and biochemical patient factors were associated with incident AKI, including baseline estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² (odds ratio [OR] 2.94; 95% CI, 1.15-7.51, p = 0.03), need for mechanical ventilation (OR 22.7; 95% CI, 7.0-72.1, p < 0.0001) and vasoactive therapy (OR 9.9; 95% CI, 3.0-32.2, p < 0.0001) and higher mean APACHE II scores (25.7 [8.2] vs. 16.3 [4.9], p < 0.0001). AKI was associated with a higher ICU (28.3% vs. 0%; p = 0.0008) and in-hospital case-fatality rate (35.9% vs. 0%, p = 0.0001). Of 102 survivors to discharge, 65.7% (n = 67) recovered to baseline kidney function. In multivariable analysis, greater severity of AKI (OR 5.01; 95% CI, 2.34-10.7, p < 0.001) and lower baseline eGFR (OR 0.96; 95% CI, 0.93-0.99, p = 0.03) were associated with non-recovery. AKI remained independently associated with 1-year mortality after adjusting for age, sex, comorbidity, and illness severity (OR 5.21; 95% CI, 1.04-26.2, p = 0.045; AUC 0.83; H-L GoF, p = 0.26). Among survivors at 1-year, only 63.4% (n = 55) had complete kidney recovery. CONCLUSIONS: Following rAAA repair, AKI is a common complication independently associated with long-term post-operative mortality. A significant proportion of AKI sufferers in this setting fail to recover to baseline kidney function.

Laboratory based surveillance of travel-related Shigella sonnei and Shigella flexneri in Alberta from 2002 to 2007.

Between 2002 and 2007, travel related cases of Shigella sonnei and S. flexneri in Alberta, Canada were acquired from Central America, the Indian subcontinent and North America. Of this group, resistance to ciprofloxacin and nalidixic acid was identified in isolates from patients who had travelled to the Indian subcontinent. This study provides a Canadian perspective to a growing body of literature linking ciprofloxacin and nalidixic acid resistance to travel to the Indian subcontinent.Shigella is a common cause of diarrheal illness in North America with a rate of 2.0 per 100,000 in Canada 1 and a rate of 3.2 per 100,000 in the United States 23. Imported cases of Shigella infections have been reported in developed countries following travel to a foreign or developing country 45 and may be impacted by factors including socio-economic factors 6, food distribution networks 5 and microbiologic factors 7. Across multiple geographic regions, high rates of antimicrobial resistance to multiple agents (e.g. sulfonamides, tetracycline, chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole) have limited the choices for empiric antimicrobial therapy required to manage Shigella infections and reduce fecal excretion of the bacteria 8910 with descriptions of shifting species dominance and changes in antimicrobial susceptibility 1011. Generally, Shigella flexneri and Shigella sonnei are the dominant species and are heavily impacted by changes in antimicrobial susceptibility 1213.This study identifies the global regions associated with travel-related cases of S. flexneri and S. sonnei in Alberta, Canada and compares antibiotic resistance patterns of these isolates for 2002 to 2007 inclusive.Specimens collected 2002-2007 (inclusive) from S. flexneri and S. sonnei infections in Alberta, Canada were included for study. Data collected at time of specimen submission included: date of specimen collection, outbreak association if present, travel history and antibiogram (data source-ProvLab Information Systems; Communicable Disease Report at Alberta Health and Wellness). Outbreaks were defined by public health officials as ≥ 2 epidemiologically related cases. Each outbreak was assigned a unique incident number. Repeat isolates received within six months of original case infections were excluded. Only one representative case for each outbreak was included, unless the isolates had different antibiotic susceptibility patterns. Based on travel history the origin of an isolate was grouped into corresponding regions and continents. Regions included in the study represented major travel destinations for individuals living in Canada. Domestic exposures were defined as "travel within North America."