Objective The lung injury prediction score (LIPS) identifies patients at risk for ARDS in the emergency department (ED) but it has not been validated in non-ED hospitalized patients. We aimed to evaluate whether LIPS identifies non-ED hospitalized patients at risk of developing ARDS at the time of critical care contact. Design Retrospective study. Setting Five academic medical centers. Patients Nine hundred consecutive patients (≥18 y/o) with at least one ARDS risk factor at the time of critical care contact. Interventions None. Measurements and Main Results LIPS was calculated using the worst values within the 12 hours before initial critical care contact. Patients with ARDS at the time of initial contact were excluded. ARDS developed in 124 (13.7%) patients a median of 2 days (IQR 2–3) after critical care contact. Hospital mortality was 22% and was significantly higher in ARDS than non-ARDS patients (48% vs. 18%, p<0.001). Increasing LIPS was significantly associated with development of ARDS (OR 1.31, 95%CI 1.21–1.42) and the composite outcome of ARDS or death (OR 1.26, 95%CI 1.18–1.34). A LIPS ≥ 4 was associated with the development of ARDS (OR 4.17, 95%CI 2.26–7.72), composite outcome of ARDS or death (OR 2.43, 95%CI 1.68–3.49), and ARDS after accounting for the competing risk of death (HR 3.71, 95%CI 2.05–6.72). For ARDS development, the LIPS has an AUROC of 0.70 and a LIPS ≥ 4 has 90% sensitivity (misses only 10% of ARDS cases), 31% specificity, 17% positive predictive value, and 95% negative predictive value. Conclusions In a cohort of non-ED hospitalized patients, the LIPS and LIPS ≥ 4 can identify patients at increased risk of ARDS and/or death at the time of critical care contact but it does not perform as well as in the original ED cohort.

Infection with Enterococcus hirae has rarely been reported in humans but is not uncommon in mammals and birds. We describe a case of Enterococcus hirae bacteremia associated with acute pancreatitis, acute cholecystitis, and septic shock responsive to antibiotic therapy and supportive critical care management. Unique aspects of this case of Enterococcus hirae bacteremia are its association with acute pancreatitis and its geographical origin. To our knowledge, this is the first report of Enterococcus hirae bacteremia occurring in a patient in the United States. Although human infection with this organism appears to be rare, all cases reported to date describe bacteremia associated with severe and life-threatening illness. Thus, physicians need to be cognizant of the clinical significance of this heretofore little recognized pathogen.

BackgroundBronchodilators are a mainstay of treatment for patients with airflow obstruction. We hypothesized that patients with obesity and no objective documentation of airflow obstruction are inappropriately treated with bronchodilators.MethodsSpirometric results and medical records of all patients with body mass index >30 kg/m2 who were referred for testing between March 2010 and August 2011 were analyzed.Results155 patients with mean age of 52.6 ± (SE)1.1 y and BMI of 38.7 ± 0.7 kg/m2 were studied. Spirometry showed normal respiratory mechanics in 62 (40%), irreversible airflow obstruction in 36 (23.2%), flows suggestive of restriction in 35 (22.6%), reversible obstruction, suggestive of asthma in 11 (7.1%), and mixed pattern (obstructive and restrictive) in 6 (3.9%). Prior to testing, 45.2% (28 of 62) of patients with normal spirometry were being treated with medications for obstructive lung diseases and 33.9% (21 of 62) continued them despite absence of airflow obstruction on spirometry. 60% (21 of 35) of patients with a restrictive pattern in their spirometry received treatment for obstruction prior to spirometry and 51.4% (18 of 35) continued bronchodilator therapy after spirometric testing. There was no independent association of non-indicated treatment with spirometric results, age, BMI, co-morbidities or smoking history. All patients with airflow obstruction on testing who were receiving bronchodilators before spirometry continued to receive them after testing.ConclusionA substantial proportion of patients with obesity referred for pulmonary function testing did not have obstructive lung disease, but were treated nonetheless, before and after spirometry demonstrating absence of airway obstruction.

Ventilator parameters may impact patients' comfort substantially. Future studies may help identify evidence-based methodology for gauging comfort following changes in ventilator settings and the settings that are most likely to positively impact various groups of patients.