The effect of statin therapy on mortality in critically ill patients is controversial, with some studies suggesting a benefit and others suggesting no benefit or even potential harm. The objective of this study was to evaluate the association between statin therapy during intensive care unit (ICU) admission and all-cause mortality in critically ill patients.
This was a nested cohort study within two randomised controlled trials conducted in a tertiary care ICU. All 763 patients who participated in the two trials were included in this study. Of these, 107 patients (14%) received statins during their ICU stay. The primary endpoint was all-cause ICU and hospital mortality. Secondary endpoints included the development of sepsis and severe sepsis during the ICU stay, the ICU length of stay, the hospital length of stay, and the duration of mechanical ventilation. Multivariate logistic regression was used to adjust for clinically and statistically relevant variables.
Statin therapy was associated with a reduction in hospital mortality (adjusted odds ratio [aOR] = 0.60, 95% confidence interval [CI] 0.36-0.99). Statin therapy was associated with lower hospital mortality in the following groups: patients >58 years of age (aOR = 0.58, 95% CI 0.35-0.97), those with an acute physiology and chronic health evaluation (APACHE II) score >22 (aOR = 0.54, 95% CI 0.31-0.96), diabetic patients (aOR = 0.52, 95% CI 0.30-0.90), patients on vasopressor therapy (aOR = 0.53, 95% CI 0.29-0.97), those admitted with severe sepsis (aOR = 0.22, 95% CI 0.07-0.66), patients with creatinine ≤100 μmol/L (aOR = 0.14, 95% CI 0.04-0.51), and patients with GCS ≤9 (aOR = 0.34, 95% CI 0.17-0.71). When stratified by statin dose, the mortality reduction was mainly observed with statin equipotent doses ≥40 mg of simvastatin (aOR = 0.53, 95% CI 0.28-1.00). Mortality reduction was observed with simvastatin (aOR = 0.37, 95% CI 0.17-0.81) but not with atorvastatin (aOR = 0.80, 95% CI 0.84-1.46). Statin therapy was not associated with a difference in any of the secondary outcomes.
Statin therapy during ICU stay was associated with a reduction in all-cause hospital mortality. This association was especially noted in high-risk subgroups. This potential benefit needs to be validated in a randomised, controlled trial.
In this issue of Critical Care, Dutch investigators report that, in a cohort of patients with sepsis/septic shock admitted to three different intensive care units (ICUs), low central venous oxygen saturation (ScvO2) was uncommon at the time of ICU admission, and hospital mortality was <30%. Their findings, taken together with those of recent reports from Australia and New Zealand (ANZ), raise serious concerns about the utility of early goal directed therapy (EGDT) outside the context of the original trial. Despite inclusion of EGDT into the Surviving Sepsis Guidelines, in response to growing uncertainty, ANZ and US investigators will soon begin randomization of patients into two large multicentre trials comparing EGDT to standard therapy. Until such studies are completed, basing international treatment guidelines on a single centre study performed in what may turn out to be a highly atypical environment would seem premature.
Studies have shown that statins have pleiotropic effects on inflammation and coagulation; which may affect the risk of developing venous thromboembolism (VTE). The objective of this study was to evaluate the association between statin therapy during intensive care unit (ICU) stay and the incidence of VTE in critically ill patients.
This was a post-hoc analysis of a prospective observational cohort study of patients admitted to the intensive care unit between July 2006 and January 2008 at a tertiary care medical center. The primary endpoint was the incidence of VTE during ICU stay up to 30 days. Secondary endpoint was overall 30-day hospital mortality. Propensity score was used to adjust for clinically and statistically relevant variables.
Of the 798 patients included in the original study, 123 patients (15.4%) received statins during their ICU stay. Survival analysis for VTE risk showed that statin therapy was not associated with a reduction of VTE incidence (crude hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.28-1.54, P = 0.33 and adjusted HR 0.63, 95% CI 0.25-1.57, P = 0.33). Furthermore, survival analysis for hospital mortality showed that statin therapy was not associated with a reduction in hospital mortality (crude HR 1.26, 95% CI 0.95-1.68, P = 0.10 and adjusted HR 0.98, 95% CI 0.72-1.36, P = 0.94).
Our study showed no statistically significant association between statin therapy and VTE risk in critically ill patients. This question needs to be further studied in randomized control trials.
Venous thromboembolism; Outcome assessment; Intensive care; Hospital mortality; Propensity scores; Statins
Patients who survive admission to the intensive care unit (ICU) commonly complain of fatigue, weakness, and poor functional status. This study sought to determine the utilization of inpatient physical therapy for patients recovering from critical illness.
Surveys were mailed to 984 physical therapists from across the United States. Each survey included questions concerning staffing and availability of physical therapists for ICU patients, and the utilization of physical therapy (PT) for six patient scenarios requiring ICU admission and mechanical ventilation.
Overall 482 physical therapists completed their survey. The majority of hospitals (89%) at which the physical therapists were employed require a physician consultation to initiate PT for ICU patients. Established hospital criteria for the initiation of PT in the ICU were present at only 10% of the hospitals. Community hospitals were more likely to routinely provide PT on weekends compared to academic hospitals (p=0.03). The likelihood of routine PT involvement varied significantly with the clinical scenario (highest 87% status post cerebrovascular accident, lowest 64% chronic obstructive pulmonary disease, p<0.001). The most common types of PT that would be performed on these critically ill patients were functional mobility retraining and therapeutic exercise. The type of PT identified by the physical therapists as having the most positive impact also significantly varied according to the clinical scenario (p<0.001).
PT is commonly administered to ICU patients during the recovery from critical illness in the United States. However the frequency and type of PT significantly varies based on the type of hospital and the clinical scenario.
Intensive care units; Physical Therapy; Critical Care; Rehabilitation
Recent publications suggest potential benefits from statins as a preventive or adjuvant therapy in sepsis. Whether ongoing statin therapy should be continued or discontinued in patients admitted in the intensive care unit (ICU) for sepsis is open to question.
We retrospectively compared patients with severe sepsis and septic shock in whom statin therapy had been discontinued or continued. The primary endpoint was the number of organ failure-free days at day 14. Secondary end-points included hospital mortality and safety. The association of statin continuation with outcome was evaluated for crude analysis and after propensity score matching and adjustment. We also measured plasma atorvastatin concentrations in a separate set of ICU septic patients continuing the drug.
Patients in whom statin therapy had been continued in the ICU (n = 44) had significantly more organ failure-free days (11 [6-14] vs. 6 [0-12], mean difference of 2.34, 95%CI from 0.47 to 5.21, P = 0.03) as compared to others (n = 32). However, there were important imbalances between groups, with more hospital-acquired infections, more need for surgery before ICU admission, and a trend towards more septic shock at ICU admission in the discontinuation group. The significant association of statin continuation with organ failure free days found in the crude analysis did not persist after propensity-matching or multivariable adjustment: beta coefficients [95% CI] of 2.37 [-0.96 to 5.70] (P = 0.20) and 2.24 [-0.43 to 4.91] (P = 0.11) respectively. We found particularly high pre-dose and post-dose atorvastatin concentrations in ICU septic patients continuing the drug.
Continuing statin therapy in ICU septic patients was not associated with reduction in the severity of organ failure after matching and adjustment. In addition, the very high plasma concentrations achieved during continuation of statin treatment advocates some caution.
statin; discontinuation; blood concentration; sepsis
Critically ill patients with 2009 H1N1 influenza are often treated in intensive care units (ICUs), representing significant risk of nosocomial transmission to critical care clinicians and other patients. Despite a large body of literature and guidelines recommending infection control practices, numerous barriers have been identified in ICUs, leading to poor compliance to the use of personal protective equipment (PPE). The use of PPE among critical care clinicians has not been extensively evaluated, especially during the pandemic influenza. This study examined the knowledge, attitudes, and self-reported behaviors, and barriers to compliance with the use of PPE among ICU healthcare workers (HCWs) during the pandemic influenza.
A survey instrument consisting of 36 questions was developed and mailed to all HCWs in 21 ICUs in 17 provinces in China. A total of 733 physicians, nurses, and other professionals were surveyed, and 650 (88.7%) were included in the analysis. Fifty-six percent of respondents reported having received training program of pandemic influenza before they cared for H1N1 patients, while 77% reported to have adequate knowledge of self and patient protection. Only 18% of respondents were able to correctly identify all components of PPE, and 55% reported high compliance (>80%) with PPE use during patient care. In multivariate analysis, vaccination for 2009 H1N1 influenza, positive attitudes towards PPE use, organizational factors such as availability of PPE in ICU, and patient information of influenza precautions, as well as reprimand for noncompliance by the supervisors were associated with high compliance, whereas negative attitudes towards PPE use and violation of PPE use were independent predictors of low compliance.
Knowledge and self-reported compliance to recommended PPE use among Chinese critical care clinicians is suboptimal. The perceived barriers should be addressed in order to close the significant gap between perception and knowledge or behavior.
To determine if prehospital statin use is associated with a lower risk of sepsis, ALI/ARDS, and mortality in critically ill patients. We also investigated the effect of combined prehospital use of both statins and aspirin.
Cross-sectional analysis of a prospective cohort
575 critically ill patients admitted to the medical or surgical ICU of an academic tertiary-care hospital
Measurements and Main Results
Of 575 patients, 149 (26%) were on statin therapy prior to hospitalization. A multivariable analysis including age, gender, current tobacco use, prehospital aspirin use, race, and APACHE II score revealed that patients on statin therapy prior to hospitalization were less likely to have or develop severe sepsis (OR 0.62, 95% CI 0.40 to 0.96) or ALI/ARDS (OR 0.60, 95% CI 0.36 to 0.99) during the first four ICU days. In-hospital mortality for patients with and without prehospital statin use (OR 1.06, 95% CI 0.62 to 1.83) was similar. Patients who had prehospital use of both statins and aspirin had the lowest rates of severe sepsis, ALI/ARDS and mortality.
Prehospital use of statins may be protective against the sepsis and ALI. This effect may be potentiated by prehospital aspirin use.
Acute Lung Injury; Acute Respiratory Distress Syndrome; Severe Sepsis; Sepsis; Statin; Aspirin; Inflammation
To study the relationship of Australian and New Zealand (ANZ) neonatologists' personal fear of death to their forgoing life‐sustaining treatment and hastening death in newborns destined for severe disability and newborns for whom further treatment is considered non‐beneficial or overly burdensome.
A self‐report questionnaire survey of ANZ neonatologists.
Neonatologists registered in the 2004 ANZ Directory of Neonatal Intensive Care Units.
78 of 138 (56%) neonatologists who responded to the study questionnaire.
Main outcome measures
Between‐group differences in the Multidimensional Fear of Death Scale.
In newborns for whom further treatment was deemed futile, 73 neonatologists reported their attitude to hastening death as follows: 23 preferred to hasten death by withdrawing minimal treatment, 35 preferred to hasten death with analgesia‐sedation, and 15 reported that hastening death was unacceptable. Analysis of variance showed a statistically significant difference between the three groups regarding fear of the dying process (F = 3.78, p = 0.028), fear of premature death (F = 3.28, p = 0.044) and fear of being destroyed (F = 3.20, p = 0.047). Post hoc comparisons showed that neonatologists who reported that hastening death was unacceptable compared with neonatologists who preferred to hasten death with analgesia‐sedation had significantly less fear of the dying process and fear of premature death, and significantly more fear of being destroyed.
ANZ neonatologists' personal fear of death and their attitude to hastening death when further treatment is considered futile are significantly related. Neonatologists' fear of death may influence their end‐of‐life decisions.
The use or misuse of statins in critically ill patients recently attracted the attention of intensive care clinicians. Indeed, statins are probably the most common chronic treatment before critical illness and some recent experimental and clinical data demonstrated their beneficial effects during sepsis, acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), or after aneurismal subarachnoidal hemorrhage (aSAH). Due to the heterogeneity of current studies and the lack of well-designed prospective studies, definitive conclusions for systematic and large-scale utilization in intensive care units cannot be drawn from the published evidence. Furthermore, the extent of statins side effects in critically ill patients is still unknown. For the intensive care clinician, it is a matter of individually identifying the patient who can benefit from this therapy according to the current literature. The purpose of this review is to describe the mechanisms of actions of statins and to synthesize the clinical data that underline the relevant effects of statins in the particular setting of critical care, in an attempt to guide the clinician through his daily practice.
Mevalonate; HMG-CoA reductase; Sepsis; Acute lung injury; Acute respiratory distress syndrome; Subarachnoid hemorrhage
Statins reduce risk of cardiovascular events and have beneficial pleiotropic effects; both may reduce mortality in critically ill patients. We examined whether statin use was associated with risk of death in general intensive care unit (ICU) patients.
Cohort study of 12,483 critically ill patients > 45 yrs of age with a first-time admission to one of three highly specialized ICUs within the Aarhus University Hospital network, Denmark, between 2001 and 2007. Statin users were identified through population-based prescription databases. We computed cumulative mortality rates 0-30 days and 31-365 days after ICU admission and mortality rate ratios (MRRs), using Cox regression analysis controlling for potential confounding factors (demographics, use of other cardiovascular drugs, comorbidity, markers of social status, diagnosis, and surgery).
1882 (14.3%) ICU patients were current statin users. Statin users had a reduced risk of death within 30 days of ICU admission [users: 22.1% vs. non-users 25.0%; adjusted MRR = 0.76 (95% confidence interval (CI): 0.69 to 0.86)]. Statin users also had a reduced risk of death within one year after admission to the ICU [users: 36.4% vs. non-users 39.9%; adjusted MRR = 0.79 (95% CI: 0.73 to 0.86)]. Reduced risk of death associated with current statin use remained robust in various subanalyses and in an analysis using propensity score matching. Former use of statins and current use of non-statin lipid-lowering drugs were not associated with reduced risk of death.
Preadmission statin use was associated with reduced risk of death following intensive care. The associations seen could be a pharmacological effect of statins, but unmeasured differences in characteristics of statin users and non-users cannot be entirely ruled out.
To determine the degree of interinstitutional transfusion practice variation and reasons why red cells are administered in critically ill patients.
Multicentre cohort study combined with a cross-sectional survey of physicians requesting red cell transfusions for patients in the cohort.
The cohort included 5298 consecutive patients admitted to six tertiary level intensive care units in addition to administering a survey to 223 physicians requesting red cell transfusions in these units.
Haemoglobin concentrations were collected, along with the number and reasons for red cell transfusions plus demographic, diagnostic, disease severity (APACHE II score), intensive care unit (ICU) mortality and lengths of stay in the ICU.
Twenty five per cent of the critically ill patients in the cohort study received red cell transfusions. The overall number of transfusions per patient-day in the ICU averaged 0.95 ± 1.39 and ranged from 0.82 ± 1.69 to 1.08 ± 1.27 between institutions (P < 0.001). Independent predictors of transfusion thresholds (pre-transfusion haemoglobin concentrations) included patient age, admission APACHE II score and the institution (P < 0.0001). A very significant institution effect (P < 0.0001) persisted even after multivariate adjustments for age, APACHE II score and within four diagnostic categories (cardiovascular disease, respiratory failure, major surgery and trauma) (P < 0.0001). The evaluation of transfusion practice using the bedside survey documented that 35% (202 of 576) of pre-transfusion haemoglobin concentrations were in the range of 95-105 g/l and 80% of the orders were for two packed cell units. The most frequent reasons for administering red cells were acute bleeding (35%) and the augmentation of O2 delivery (25%).
There is significant institutional variation in critical care transfusion practice, many intensivists adhering to a 100g/l threshold, and opting to administer multiple units despite published guidelines to the contrary. There is a need for prospective studies to define optimal practice in the critically ill.
red cells; transfusions; haemoglobin; intensive care
The role of statins in the primary and secondary prevention of cardiovascular events is well known. An important adverse event associated with statin treatment is myopathy; intensive physical effort in patients treated with statins increases the risk of muscle injury/myopathy. In this article we discuss the benefits and risks associated with statin treatment in patients undergoing cardiac rehabilitation after acute coronary syndromes and/or coronary revascularization procedures. In our opinion, the benefits of the secondary prevention of coronary heart disease achieved with statins seem to outweigh the hazards associated with statin therapy. The careful selection of patients for both treatment with statins and the gradual intensification of physical training in the course of cardiac rehabilitation appears to constitute an important element of the therapeutic approach.
statins; myopathy; early cardiac rehabilitation
Proven efficacious therapies are sometimes underused in patients with chronic cardiac conditions, resulting in suboptimal outcomes. We evaluated whether evidence summaries, which were either unsigned or signed by local opinion leaders, improved the quality of secondary prevention care delivered by primary care physicians of patients with coronary artery disease.
We performed a randomized trial, clustered at the level of the primary care physician, with 3 study arms: control, unsigned statements or opinion leader statements. The statements were faxed to primary care physicians of adults with coronary artery disease at the time of elective cardiac catheterization. The primary outcome was improvement in statin management (initiation or dose increase) 6 months after catheterization.
We enrolled 480 adults from 252 practices. Although statin use was high at baseline (n = 316 [66%]), most patients were taking a low dose (mean 32% of the guideline-recommended dose), and their low-density lipoprotein (LDL) cholesterol levels were elevated (mean 3.09 mmol/L). Six months after catheterization, statin management had improved in 79 of 157 patients (50%) in the control arm, 85 of 158 (54%) patients in the unsigned statement group (adjusted odds ratio [OR] 1.18, 95% CI 0.71–1.94, p = 0.52) and 99 of 165 (60%) patients in the opinion leader statement group (adjusted OR 1.51, 95% CI 0.94–2.42, p = 0.09). The mean fasting LDL cholesterol levels after 6 months were similar in all 3 study arms: 2.35 (standard deviation [SD] 0.86) mmol/L in the control arm compared with 2.24 (SD 0.73) among those in the opinion leader group (p = 0.48) and 2.19 (SD 0.68) in the unsigned statement group (p = 0.32).
Faxed evidence reminders for primary care physicians, even when endorsed by local opinion leaders, were insufficient to optimize the quality of care for adults with coronary artery disease. ClinicalTrials.gov trial register no. NCT00175240.
Strong working relationships between pharmacists and physicians are needed to optimize patient care. Understanding attitudes and barriers to collaboration between pharmacists and physicians may help with delivery of primary health care services. The objective of this study was to capture the opinions of family physicians and community pharmacists in Newfoundland and Labrador (NL) regarding collaborative practice.
Two parallel surveys were offered to all community pharmacists and family physicians in NL. Surveys assessed the following: attitudes and experience with collaborative practice, preferred communication methods, perceived role of pharmacists, areas for more collaboration and barriers to collaborative practice. Results for both groups were analyzed separately, with comparisons between groups to compare responses with similar questions.
Survey response rates were 78.6% and 7.1% for pharmacists and physicians, respectively. Both groups overwhelmingly agreed that collaborative practice could result in improved patient outcomes and agreed that major barriers were lack of time and compensation and the need to deal with multiple pharmacists/physicians. Physicians indicated they would like more collaboration for insurance approvals and patient counselling, while pharmacists want to assist with identifying and managing patients’ drug-related problems. Both groups want more collaboration to improve patient adherence.
Both groups agree that collaborative practice can positively affect patient outcomes and would like more collaboration opportunities. However, physicians and pharmacists disagree about the areas where they would like to collaborate to deliver care. Changes to reimbursement models and infrastructure are needed to facilitate enhanced collaboration between pharmacists and physicians in the community setting.
Clinical studies conducted in intensive care units are associated with logistical and ethical challenges. Diseases investigated are precipitous and life-threatening, care is highly technological, and patients are often incapacitated and decision-making is provided by surrogates. These investigations increasingly involve collection of genetic data. The manner in which the exigencies of critical illness impact attitudes regarding genetic data collection is unstudied. Given interest in understanding stakeholder preferences as a foundation for the ethical conduct of research, filling this knowledge gap is timely. The conduct of opinion research in the critical care arena is novel. This brief report describes the development of parallel patient/surrogate decision-maker quantitative survey instruments for use in this environment. Future research employing this instrument or a variant of it with diverse populations promises to inform research practices in critical illness gene variation research.
genetic research; critical illness; intensive care unit; surveys; systematic review
Intensive care unit (ICU) patients and family members repeatedly note accurate and timely communication from health care providers to be crucial to high-quality ICU care. Practice guidelines recommend improving communication. However, few data, particularly in surgical ICUs, exist on health care provider opinions regarding whether communication is effective.
To evaluate ICU clinician perceptions regarding adequacy of communication regarding prognosis, we developed a survey and administered it to a cross section of surgical ICU nurses, surgical ICU physicians, nurse practitioners (NPs), and surgeons.
Surgeons had a high satisfaction with communication regarding prognosis for themselves (90%), ICU nurses (85%), and ICU physicians and NPs (85%). ICU nurses noted high satisfaction with personal (82%) and ICU physician and NP (71%) communication, but low (2%) satisfaction with that provided by surgeons. ICU physicians and NPs noted high satisfaction with personal (74%) and ICU nurse (88%) communication, but lower (23%) satisfaction with that provided by surgeons. ICU nurses were the most likely (75%) to report speaking to patients and patient families regarding prognosis, followed by surgeons (40%), and then ICU physicians and NPs (33%). Surgeons noted many opportunities to speak to ICU nurses and ICU physicians and NPs about patient prognosis and noted that comments were often valued. ICU physicians and NPs and ICU nurses noted many opportunities to speak to each other but fewer opportunities to communicate with surgeons. ICU physicians and NPs thought that their comments were valued by ICU nurses but less valued by surgeons. ICU nurses thought that their comments were less valued by ICU physicians and NPs and surgeons.
ICU nurses, surgeons, and ICU intensivists and NPs varied widely in their satisfaction with communication relating to prognosis. Clinician groups also varied in whether they thought that they had opportunities to communicate prognosis and whether their concerns were valued by other provider groups. These results hint at the nuanced and complicated relationships present in surgical ICUs. Further validation studies and further evaluations of patient and family member perspectives are needed.
Hyperglycemia is common in critically ill patients and is associated with increased morbidity and mortality. Strict glycemic control improves outcomes in some adult populations and may have similar effects in children. While glycemic control has become standard care in adults, little is known regarding hyperglycemia management strategies used by pediatric critical care practitioners. We sought to assess both the beliefs and practice habits regarding glycemic control in pediatric intensive care units (ICUs) in the United States (US).
We surveyed 30 US pediatric ICUs from January to May 2009. Surveys were conducted by phone between the investigators and participating centers and consisted of a 22-point questionnaire devised to assess physician perceptions and center-specific management strategies regarding glycemic control.
ICUs included a cross section of centers throughout the US. Fourteen out of 30 centers believe all critically ill hyperglycemic adults should be treated, while 3/30 believe all critically ill children should be treated. Twenty-nine of 30 believe some subsets of adults with hyperglycemia should be treated, while 20/30 believe some subsets of children should receive glycemic control. A total of 70%, 73%, 80%, 27%, and 40% of centers believe hyperglycemia adversely affects outcomes in cardiac, trauma, traumatic brain injury, general medical, and general surgical pediatric patients, respectively. However, only six centers use a standard, uniform approach to treat hyperglycemia at their institution. Sixty percent of centers believe hypoglycemia is more dangerous than hyperglycemia. Seventy percent listed fear of management-induced hypoglycemia as a barrier to glycemic control at their center.
Considerable disparity exists between physician beliefs and actual practice habits regarding glycemic control among pediatric practitioners, with few centers reporting the use of any consistent standard approach to screening and management. Physicians wishing to practice glycemic control in their critically ill pediatric patients may want to consider adopting center-wide uniform approaches to improve safety and efficacy of treatment.
There is lack of evidence to guide thromboprophylaxis in the pediatric intensive care unit (PICU). We aimed to assess current prescribing practice for pharmacologic thromboprophylaxis in critically ill children.
PICUs in the United States and Canada with at least 10 beds.
Cross-sectional self-administered survey of pediatric intensivists using adolescent, child and infant scenarios.
PICU clinical directors or section heads.
Measurements and Main Results
Physician leaders from 97 of 151 (64.2%) PICUs or their designees responded to the survey. In mechanically ventilated children, 42.3% of the respondents would usually or always prescribe thromboprophylaxis for the adolescent but only 1.0% would prescribe it for the child and 1.1% for the infant. Considering all PICU patients, 3.1%, 32.0% and 44.2% of respondents would never prescribe thromboprophylaxis for the adolescent, child and infant scenarios, respectively. These findings were significant (P<.001 for the adolescent versus child and infant; P=.002 for child versus infant). Other patient factors that increased the likelihood of prescribing prophylaxis to a critically ill child for all 3 scenarios were the presence of hypercoagulability, prior deep venous thrombosis or a cavopulmonary anastomosis. Prophylaxis was less likely to be prescribed to patients with major bleeding or an anticipated invasive intervention. Low molecular weight heparin was the most commonly prescribed drug.
In these scenarios, physician leaders in PICUs were more likely to prescribe thromboprophylaxis to adolescents compared to children or infants, but they prescribed it less often in adolescents than is recommended by evidence-based guidelines for adults. The heterogeneity in practice we documented underscores the need for rigorous randomized trials to determine the need for thromboprophylaxis in critically ill adolescents and children.
venous thromboembolism; anticoagulants; prevention; risk factor; intensive care
Clinical trials have shown that statin therapy reduces cardiovascular morbidity and mortality in patients with coronary artery disease (CAD), even among patients with low-density lipoprotein (LDL) levels <100mg/dL. We sought to determine the extent to which patients with obstructive CAD in routine outpatient care are treated with statins, nonstatins, or no lipid lowering therapy.
Methods and Results
Within the American College of Cardiology's Practice Innovation and Clinical Excellence (PINNACLE) outpatient registry, we examined rates of treatment with statin and non-statin medications in 38,775 outpatients with obstructive CAD (history of myocardial infarction or coronary revascularization) and without documented contraindications to statin therapy. Among these patients, 30,160 (77.8%) were prescribed statins, 2042 (5.3%) were treated only with non-statin lipid lowering medications, and 6573 (17.0%) were untreated. Lack of medical insurance was associated with no statin treatment, while male sex, coexisting hypertension, and a recent coronary revascularization were associated with statin treatment. Among those not on any lipid lowering therapy, LDL levels were available for 51.2% (3365/6573). Among these untreated patients, LDL levels were <100 mg/dL in 1794 (53.3%) patients and ≥100 mg/dL in 1571 (46.7%) patients.
Despite robust clinical trial evidence, a substantial number of patients with obstructive CAD remain untreated with statins. A small proportion were treated with non-statin therapy, while 1 in 6 patients were simply untreated, of which half had LDL values <100mg/dl. These findings illustrate important opportunities to improve lipid management in outpatients with obstructive CAD.
coronary artery disease; lipids; cholesterol reduction; statins
Information about Medical Emergency Teams (METs) in Australia and New Zealand (ANZ) is limited to local studies and a cluster randomised controlled trial (the Medical Emergency Response and Intervention Trial [MERIT]). Thus, we sought to describe the timing of the introduction of METs into ANZ hospitals relative to relevant publications and to assess changes in the incidence and rate of intensive care unit (ICU) admissions due to a ward cardiac arrest (CA) and ICU readmissions.
We used the Australian and New Zealand Intensive Care Society database to obtain the study data. We related MET introduction to publications about adverse events and MET services. We compared the incidence and rate of readmissions and admitted CAs from wards before and after the introduction of an MET. Finally, we identified hospitals without an MET system which had contributed to the database for at least two years from 2002 to 2005 and measured the incidence of adverse events from the first year of contribution to the second.
The MET status was known for 131 of the 172 (76.2%) hospitals that did not participate in the MERIT study. Among these hospitals, 110 (64.1%) had introduced an MET service by 2005. In the 79 hospitals in which the MET commencement date was known, 75% had introduced an MET by May 2002. Of the 110 hospitals in which an MET service was introduced, 24 (21.8%) contributed continuous data in the year before and after the known commencement date. In these hospitals, the mean incidence of CAs admitted to the ICU from the wards changed from 6.33 per year before to 5.04 per year in the year after the MET service began (difference of 1.29 per year, 95% confidence interval [CI] -0.09 to 2.67; P = 0.0244). The incidence of ICU readmissions and the mortality for both ICU-admitted CAs from wards and ICU readmissions did not change. Data were available to calculate the change in ICU admissions due to ward CAs for 16 of 62 (25.8%) hospitals without an MET system. In these hospitals, admissions to the ICU after a ward CA decreased from 5.0 per year in the first year of data contribution to 4.2 per year in the following year (difference of 0.8 per year, 95% CI -0.81 to 3.49; P = 0.3).
Approximately 60% of hospitals in ANZ with an ICU report having an MET service. Most introduced the MET service early and in association with literature related to adverse events. Although available in only a quarter of hospitals, temporal trends suggest an overall decrease in the incidence of ward CAs admitted to the ICU in MET as well as non-MET hospitals.
Statins are the revolutionary drugs in the cardiovascular pharmacotherapy. But they also possess several adverse effects like myopathy with elevation of hepatic transaminases (>3 times the upper limit of normal) or creatine kinase (>10 times the upper limit of normal) and some rare side-effects, including peripheral neuropathy, memory loss, sleep disturbances, and erectile dysfunction. Due to these adverse effects, patients abruptly withdrew statins without consulting physicians. This abrupt discontinuation of statins is termed as statin intolerance. Statin-induced myopathy constitutes two third of all side-effects from statins and is the primary reason for statin intolerance. Though statin intolerance has considerably impacted cardiovascular outcomes in the high-risk patients, it has been well effectively managed by prescribing statins either as alternate-day or once weekly dosage regimen, as combination therapy with a non-statin therapy or and by dietary intervention. The present article reviews the causes, clinical implications of statin withdrawal and management of statin intolerance.
Adverse effects of stains; myopathy; rhabdomyolysis; statins; statin intolerance
Purpose of review
Interest in international comparisons of critical illness is growing, but the utility of these studies is questionable. This review examines the challenges of international comparisons and highlights areas where international data provide information relevant to clinical practice and resource allocation.
International comparisons of ICU resources demonstrate that definitions of critical illness and Intensive Care Unit (ICU) beds vary due to differences in ability to provide organ support and variable staffing. Despite these limitations, recent international data provide key information to understand the pros and cons of different availability of ICU beds on patient flow and outcomes, and also highlight the need to ensure long-term follow-up due to heterogeneity in discharge practices for critically ill patients. With increasing emphasis on curbing costs of healthcare, systems that deliver lower cost care provide data on alternative options, such as regionalization, flexible allocation of beds, and bed rationing.
Differences in provision of critical care can be leveraged to inform decisions on allocation of ICU beds, improve interpretation of clinical outcomes, and assess ways to decrease costs of care. International definitions of key components of critical care are needed to facilitate research and ensure rigorous comparisons.
Critical Care; Epidemiology; Healthcare Delivery; International Perspectives
To measure family practice patients’ adherence to statin medications and to identify factors associated with adherence to these medications.
Cross-sectional study using a mailed self-report survey sent to 400 patients.
Two academic family practice clinics in Halifax, NS.
A total of 284 patients aged 40 or older who were prescribed statin medications by their family physicians, either for the first time or as a renewal during a 20-month period.
MAIN OUTCOME MEASURES
Level of adherence to statin medications as measured by patients’ self-report on the Morisky scale; association between high adherence on the Morisky scale and 38 patient-reported factors.
Response rate was 82.5%. Average age of patients was 65 years, 57% were men, 62% had been on statin medications for more than 2 years, and 97% reported that their family physicians managed their cholesterol levels. More than 63% of patients reported high adherence as measured by the Morisky scale. On multiple logistic regression, being older than 65, taking 4 to 6 other prescribed medications, and having a lifestyle that included regular exercise or a healthy diet were significant independent predictors of high adherence scores on the Morisky scale.
Almost two-thirds (63%) of patients who were prescribed statins by their family physicians reported high adherence to the medications. Strategies to improve adherence would best be directed at patients who are younger or taking fewer than 4 or more than 6 other prescribed medications. Patients should be encouraged to maintain a lifestyle of regular exercise and a healthy diet, as this was associated with better adherence to statin medications.
The penetration rate of Electronic Health Record (EHR) systems in health care is increasing. However, many different EHR-systems are used with varying ePrescription designs and functionalities. The aim of the present study was to evaluate experienced ePrescribers' attitudes towards ePrescribing for suggesting improvements.
Physicians (n = 431) from seven out of the 21 Swedish health care regions, using one of the six most widely implemented EHR-systems with integrated electronic prescribing modules, were recruited from primary care centers and hospital clinics of internal medicine, orthopaedics and surgery. The physicians received a web survey that comprised eight questions on background data and 19 items covering attitudes towards ePrescribing. Forty-two percent (n = 199) of the physicians answered the questionnaire; 90% (n = 180) of the respondents met the inclusion criteria and were included in the final analysis.
A majority of the respondents regarded their EHR-system easy to use in general (81%), and for the prescribing of drugs (88%). Most respondents believed they were able to provide the patients better service by ePrescribing (92%), and regarded ePrescriptions to be time saving (91%) and to be safer (83%), compared to handwritten prescriptions. Some of the most frequently reported weaknesses were: not clearly displayed price of drugs (43%), complicated drug choice (21%), and the perception that it was possible to handle more than one patient at a time when ePrescribing (13%). Moreover, 62% reported a lack of receipt from the pharmacy after successful transmission of an ePrescription. Although a majority (73%) of the physicians reported that they were always or often checking the ePrescription a last time before transmitting, 25% declared that they were seldom or never doing a last check. The respondents suggested a number of improvements, among others, to simplify the drug choice and the cancellation of ePrescriptions.
The Swedish physicians in the group studied were generally satisfied with their specific EHR-system and with ePrescribing as such. However, identified weaknesses warrant improvements of the EHR-systems as well as of their implementation in the individual health care organisation.
During the first winter of exposure, the H1N1 2009 influenza virus placed considerable strain on intensive care unit (ICU) services in Australia and New Zealand (ANZ). We assessed the impact of the H1N1 2009 influenza virus on ICU services during the second (2010) winter, following the implementation of vaccination.
A prospective, cohort study was conducted in all ANZ ICUs during the southern hemisphere winter of 2010. Data on demographic and clinical characteristics, including vaccination status and outcomes, were collected. The characteristics of patients admitted during the 2010 and 2009 seasons were compared.
From 1 June to 15 October 2010, there were 315 patients with confirmed influenza A, of whom 283 patients (90%) had H1N1 2009 (10.6 cases per million inhabitants; 95% confidence interval (CI), 9.4 to 11.9) which was an observed incidence of 33% of that in 2009 (P < 0.001). The maximum daily ICU occupancy was 2.4 beds (95% CI, 1.8 to 3) per million inhabitants in 2010 compared with 7.5 (95% CI, 6.5 to 8.6) in 2009, (P < 0.001). The onset of the epidemic in 2010 was delayed by five weeks compared with 2009. The clinical characteristics were similar in 2010 and 2009 with no difference in the age distribution, proportion of patients treated with mechanical ventilation, duration of ICU admission, or hospital mortality. Unlike 2009 the incidence of critical illness was significantly greater in New Zealand (18.8 cases per million inhabitants compared with 9 in Australia, P < 0.001). Of 170 patients with known vaccination status, 26 (15.3%) had been vaccinated against H1N1 2009.
During the 2010 ANZ winter, the impact of H1N1 2009 on ICU services was still appreciable in Australia and substantial in New Zealand. Vaccination failure occurred.