In emerging countries such as Brazil, organizational factors, including the implementation of protocols, are potential targets to improve patient outcomes and resource use in ICUs.

Organizational aspects, namely the implementation of protocols and presence of clinical pharmacists in the ICU, and close collaboration between oncologists and ICU teams are targets to improve mortality and resource use in critically ill patients with cancer.

The HIV group presented in baseline conditions, a shift of cardiac sympathovagal balance, an exacerbated response of the LF component during the tilt test, and an ineffective cardiac vagal response to the cold-face test suggesting sympathetic and parasympathetic dysfunction. AIDS patients receiving HAART did not present these autonomic alterations.

BackgroundPatients ≥80 years of age are increasingly being admitted to the intensive care unit (ICU). The impact of relevant variables, such comorbidities and performance status, on short-term outcomes in the very elderly is largely unknown. Few studies address the calibration of illness severity scores (SAPS3 score) within this population. We investigated the risk factors for hospital mortality in critically ill patients ≥80 years old, emphasizing performance status and comorbidities, and assessed the calibration of SAPS3 scores in this population.Methods1129 very elderly patients admitted to a tertiary ICU in Brazil during a two-year period were retrospectively included in this study. Demographic features, reasons for admission, illness severity, comorbidities (including the Charlson Comorbidity Index) and a simplified performance status measurement were obtained. After univariate analysis, a multivariate model was created to evaluate the factors that were associated with hospital mortality. Alternatively, a conditional inference tree with recursive partitioning was constructed. Calibration of the SAPS3 scores and the multivariate model were evaluated using the Hosmer-Lemeshow test and a calibration plot. Discrimination was assessed using a receiver operating characteristics curve.ResultsOn multivariate analysis after stepwise regression, only the SAPS3 score (OR 1.08, 95% CI 1.06-1.10), Charlson Index (OR 1.16, 95% CI 1.07-1.27), performance status (OR 1.61, 95% CI 1.05-2.64 for partially dependent patients and OR 2.39, 95% CI 1.38-4.13 for fully dependent patients) and a non-full code status (OR 11.74, 95% CI 6.22-22.160) were associated with increased hospital mortality. Conditional inference tree showed that performance status and Charlson Index had the greatest influence on patients with less severe disease, whereas a non-full code status was prominent in patients with higher illness severity (SAPS3 score >61). The model obtained after logistic regression that included the before mentioned variables demonstrated better calibration and greater discrimination capability (AUC 0.86, 95% CI 0.83-0.89 versus AUC 0.81, 95% CI 0.78-0.84, respectively; p < 0.001) than the SAPS3 score alone.ConclusionsPerformance status and comorbidities are important determinants of short-term outcome in critically ill elderly patients ≥80 years old. The addition of simple background information may increase the calibration of the SAPS3 score in this population.

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BackgroundEnterovirus and herpes simplex viruses are common causes of lymphocytic meningitis. The purpose of this study was to analyse the impact of the use molecular testing for Enteroviruses and Herpes simplex viruses I and II in all suspected cases of viral meningitis.MethodsFrom November 18, 2008 to November 17, 2009 (phase II, intervention), all patients admitted with suspected viral meningitis (with pleocytosis) had a CSF sample tested using a nucleic acid amplification test (NAAT). Data collected during this period were compared to those from the previous one-year period, i.e. November 18, 2007 to November 17, 2008 (phase I, observational), when such tests were available but not routinely used.ResultsIn total, 2,536 CSF samples were assessed, of which 1,264 were from phase I, and 1,272 from phase II. Of this total, a NAAT for Enterovirus was ordered in 123 cases during phase I (9.7% of the total phase I sample) and in 221 cases in phase II (17.4% of the total phase II sample). From these, Enterovirus was confirmed in 35 (28.5%, 35/123) patients during phase I and 71 (32.1%, 71/221) patients during phase II (p = 0.107). The rate of diagnosis of meningitis by HSV I and II did not differ between the groups (13 patients, 6.5% in phase I and 13, 4.7% in phase II) (p = 1.0), from 200 cases in phase I and 274 cases in phase II.ConclusionsThe number of cases diagnosed with enteroviral meningitis increased during the course of this study, leading us to believe that the strategy of performing NAAT for Enterovirus on every CSF sample with pleocytosis is fully justified.

ObjectiveTo evaluate the impact of body mass index on the short-term prognosis of non-surgical critically ill patients while controlling for performance status and comorbidities.MethodsWe performed a retrospective analysis on a two-year single-center database including 1943 patients. We evaluated the impact of body mass index on hospital mortality using a gradient-boosted model that also included comorbidities and was assessed by Charlson’s comorbidity index, performance status and illness severity, which was measured by the SAPS3 score. The SAPS3 score was adjusted to avoid including the same variable twice in the model. We also assessed the impact of body mass index on the length of stay in the hospital after intensive care unit admission using multiple linear regressions.ResultsA low value (< 20kg/m2) was associated with a sharp increase in hospital mortality. Mortality tended to subsequently decrease as body mass index increased, but the impact of a high body mass index in defining mortality was low. Mortality increased as the burden of comorbidities increased and as the performance status decreased. Body mass index interacted with the impact of SAPS3 on patient outcome, but there was no significant interaction between body mass index, performance status and comorbidities. There was no apparent association between body mass index and the length of stay at the hospital after intensive care unit admission.ConclusionBody mass index does appear to influence the shortterm outcomes of critically ill medical patients, who are generally underweight. This association was independent of comorbidities and performance status.

IntroductionHigher mortality for patients admitted to intensive care units (ICUs) during the weekends has been occasionally reported with conflicting results that could be related to organisational factors. We investigated the effects of ICU organisational and staffing patterns on the potential association between weekend admission and outcomes in critically ill patients.MethodsWe included 59 614 patients admitted to 78 ICUs participating during 2013. We defined ‘weekend admission’ as any ICU admission from Friday 19:00 until Monday 07:00. We assessed the association between weekend admission with hospital mortality using a mixed logistic regression model controlling for both patient-level (illness severity, age, comorbidities, performance status and admission type) and ICU-level (decrease in nurse/bed ratio on weekend, full-time intensivist coverage, use of checklists on weekends and number of institutional protocols) confounders. We performed secondary analyses in the subgroup of scheduled surgical admissions.ResultsA total of 41 894 patients (70.3%) were admitted on weekdays and 17 720 patients (29.7%) on weekends. In univariable analysis, weekend admitted patients had higher ICU (10.9% vs 9.0%, P<0.001) and hospital (16.5% vs 13.5%, P<0.001) mortality. After adjusting for confounders, weekend admission was not associated with higher hospital mortality (OR 1.05, 95% CI 0.99 to 1.12, P=0.095). However, a ‘weekend effect’ was still observed in scheduled surgical admissions, as well as in ICUs not using checklists during the weekends. For unscheduled admissions, no ‘weekend effect’ was observed regardless of ICU’s characteristics. For scheduled surgical admissions, a ‘weekend effect’ was present only in ICUs with a low number of implemented protocols and those with a reduction in the nurse/bed ratio and not applying checklists during weekends.ConclusionsICU organisational factors, such as decreased nurse-to-patient ratio, absence of checklists and fewer standardised protocols, may explain, in part, increases in mortality in patients admitted to the ICU mortality on weekends.