Yaw Amoateng-Adjepong

Complications Associated with Sickle Cell Trait: A Brief Narrative Review

Sickle cell trait occurs in approximately 300 million people worldwide, with the highest prevalence of approximately 30% to 40% in sub-Saharan Africa. Long considered a benign carrier state with relative protection against severe malaria, sickle cell trait occasionally can be associated with significant morbidity and mortality. Sickle cell trait is exclusively associated with rare but often fatal renal medullary cancer. Current cumulative evidence is convincing for associations with hematuria, renal papillary necrosis, hyposthenuria, splenic infarction, exertional rhabdomyolysis, and exercise-related sudden death. Sickle cell trait is probably associated with complicated hyphema, venous thromboembolic events, fetal loss, neonatal deaths, and preeclampsia, and possibly associated with acute chest syndrome, asymptomatic bacteriuria, and anemia in pregnancy. There is insufficient evidence to suggest an independent association with retinopathy, cholelithiasis, priapism, leg ulcers, liver necrosis, avascular necrosis of the femoral head, and stroke. Despite these associations, the average life span of individuals with sickle cell trait is similar to that of the general population. Nonetheless, given the large number of people with sickle cell trait, it is important that physicians be aware of these associations.

Acute kidney injury criteria predict outcomes of critically ill patients

Objective:The Acute Kidney Injury Networks proposed definition for acute kidney injury (increment of serum creatinine ≥0.3 mg/dL or 50% from baseline within 48 hrs or urine output <0.5 mL/kg/hr for >6 hrs despite fluid resuscitation when applicable) predicts meaningful clinical outcomes. Design:Retrospective cohort study. Setting:A 350-bed community teaching hospital. Patients:The study population consisted of 471 patients with no recent history of renal replacement therapy who were admitted to the medical intensive care unit during 1 yr. Interventions:Medical records of all patients were reviewed using a data abstraction tool. Demographic information, diagnoses, risk factors for acute kidney disease, physiologic and laboratory data, and outcomes were recorded. Measurements and Main Results:Of 496 patients, 471 were not receiving renal replacement therapy in the weeks before medical intensive care unit admission; 213 had changes ≥.3 mg/dL in serum creatinine within 48 hrs and/or urine output of ≤.5 mL/kg/hr for >6 hrs. Detailed fluid challenge information was available for only 123 patients, who met acute kidney injury criteria, and three patients reversed after administration of ≥500 mL of intravenous fluid and/or blood products. All patients whose creatinine increased ≥50% also had increments ≥0.3 mg/dL. The 120 patients with acute kidney injury were older (mean ± se: 69.3 ± 1.7 vs. 62.9 ± 1.3, p < .01), were more ill (Acute Physiology and Chronic Health Evaluation II score 18.7 ± .6 vs. 13.3 ± .4, p < .01), and had multiple comorbidities (two or more organs, 65% vs. 51.3%, p < .01) compared with those without acute kidney injury. The mortality rate of patients who met criteria for acute kidney injury was significantly higher than that of patients who did not have acute kidney injury (45.8 vs. 16.4%, p < .01). In multivariate logistic regression analyses, acute kidney injury was an independent predictor of mortality (adjusted odds ratio 3.7, 95% confidence interval 2.2–6.1). Acute kidney injury was a better predictor of in-hospital mortality than was Acute Physiology and Chronic Health Evaluation II score, advanced age, or presence of nonrenal organ failures. Median hospital stay was twice as long in patients with acute kidney injury (14 vs. 7 days, p < .01), and only patients with acute kidney injury required hemodialysis during hospitalization. The oliguria criterion of acute kidney injury did not affect the odds of in-hospital mortality. Conclusions:The Acute Kidney Injury Network definition of acute kidney injury predicts hospital mortality, need for renal replacement therapy, and prolonged hospital stay in critically ill patients. An increment of serum creatinine ≥0.3 mg/dL in 48 hrs alone predicts clinical outcomes as well as the full Acute Kidney Injury Network definition.

Effects of a Medical Intensivist on Patient Care in a Community Teaching Hospital

OBJECTIVE To determine the effect of adding a trained intensivist on patient care and educational outcomes in a community teaching hospital. MATERIAL AND METHODS We retrospectively reviewed outcomes for patients admitted to the medical intensive-care unit (MICU) of a 270-bed community teaching hospital between July 1992 and June 1994. Mortality rates and durations of stay were determined for the year before (BD, 1992 through 1993) and the first year after (AD, 1993 through 1994) introduction of a full-time director of critical care. Performance of resident trainees on a standardized critical-care examination was measured for the same periods. RESULTS Overall, 459 patients in the BD period were compared with 471 patients in the AD period. The mix of cases and severity of illness (acute physiology and chronic health evaluation or APACHE II scores) on admission were similar for the BD and AD periods. MICU mortality decreased from 20.9% during the BD to 14.9% during the AD period (P = 0.02), and in-hospital mortality decreased from 34.0% to 24.6% (P = 0.002). Disease-specific mortalities were lower during the AD period for most categories of illness. Detailed analysis of a subgroup of patients (those with pneumonia) demonstrated no differences in distribution of patients by gender, race, or acuity of illness (APACHE II scores). The mortality rate due to pneumonia decreased from 46% during the BD period to 31% during the AD period. This decrease was consistent across categories of APACHE II scores. From BD to AD periods, mean durations of total hospital stay decreased from 22.6 +/- 1.4 days to 17.7 +/- 1.0 days, and mean MICU stay decreased from 5.0 +/- 0.3 days to 3.9 +/- 0.3 days (P < 0.05). Critical-care in-service examination scores for 22 residents increased from 53.8 +/- 1.7% to 67.5 +/- 2.2% (P < 0.01), and AD scores were significantly higher than BD scores for residents at similar levels of training. CONCLUSION Addition of a medical intensivist was temporally associated with improved clinical and educational outcomes in our community teaching hospital.

Myocardial ischemia and weaning failure in patients with coronary artery disease: an update.

OBJECTIVE To determine the frequency and effects of weaning-related myocardial ischemia on weaning outcomes in patients with coronary artery disease. DESIGN Prospective cohort study. SETTING Medical and cardiac intensive care units of a 300-bed teaching community hospital. MEASUREMENTS AND MAIN RESULTS Three-lead ST segments, heart rate-systolic blood pressure products, and respiratory rate/tidal volume ratios were obtained for patients with coronary artery disease just before and during their initial trials of weaning from mechanical ventilation. ST segments were interpreted by a blinded cardiologist. Eighty-three patients with a mean age of 72.4 +/- 1.1 years (mean +/- SEM), a mean Acute Physiology and Chronic Health Evaluation II score of 16.4 +/- 0.8, and a mean duration of mechanical ventilation of 4.6 +/- 0.9 days were studied. Eight patients showed electrocardiographic evidence of ischemia during weaning, and seven of these patients failed to be liberated on their first day of weaning. The presence of ischemia significantly increased the risk of weaning failure (risk ratio, 2.1; 95% confidence interval, 1.4-3.1). The rate-pressure product for the group as a whole increased significantly during weaning, from 11.9 +/- 0.4 to 13.5 +/- 0.5 mm Hg x beats/min x 10(3) (p < .01). The increase in rate-pressure product tended to be greater in patients who became ischemic (12.8 +/- 0.9 to 17.3 +/- 2.0 mm Hg x beats/min x 10(3)) than in patients who were not ischemic during weaning (11.8 +/- 0.4 to 13.0 +/- 0.5 mm Hg x beats/min x 10(3); p = .05). The rate/volume ratio did not change significantly during weaning, but the rate/volume ratios after both 1 min (65.6 +/- 4.6 vs. 98.0 +/- 9.4 breaths/min/L; p < .05) and 30 mins (68.6 +/- 4.3 vs. 91.1 +/- 8.9 breaths/min/L; p < .05) of unassisted breathing were lower in successful than in unsuccessful patients. CONCLUSION Electrocardiographic evidence of myocardial ischemia occurs frequently and is associated with significantly increased risk of first-day weaning failure in patients with coronary artery disease.

Microalbuminuria in critically ill medical patients: prevalence, predictors, and prognostic significance.

ObjectiveTo ascertain the prevalence, predictors, and prognostic significance of microalbuminuria in critically ill patients. DesignProspective cohort study. SettingMedical intensive care unit of a community teaching hospital. PatientsAdmitted critically ill patients. Measurements and Main ResultsWe measured serial spot urine albumin-creatinine ratios in 104 critically ill patients, with a median age of 64.5 yrs and median Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores of 20.5 and 5.0, respectively. Sixty-nine percent of the patients had microalbuminuria or clinical proteinuria and 43.3% had an albumin-creatinine ratio ≥100 mg/g at admission. The acuity of illness, being non-White, and having diabetes mellitus were independent predictors of albumin-creatinine ratio ≥100 mg/g. The overall mortality rate was 26.9% (28/104). Patients with an albumin-creatinine ratio ≥100 mg/g were 2.7 times as likely to die compared with those with an albumin-creatinine ratio <100 mg/g, even after simultaneous adjustments for age, and APACHE II and SOFA scores (odds ratio, 2.7; 95% confidence interval, 1.1–7.2, p = .04). The association of albumin-creatinine ratio ≥100 mg/g with death was consistent across age, ethnicity, renal function, acuity of illness, and comorbid conditions. Among survivors, patients with an albumin-creatinine ratio ≥100 mg/g stayed approximately 5 days longer in the hospital (p = .0007). Overall, the albumin-creatinine ratio shared similar predictive characteristics with APACHE II and SOFA scores. ConclusionsThis study confirms a high prevalence of microalbuminuria in critically ill patients and suggests that an albumin-creatinine ratio ≥100 mg/g is an independent predictor of mortality and hospital stay.

Outcomes of critically ill patients who received cardiopulmonary resuscitation.

RATIONALE Studies examining survival outcomes after in-hospital cardiopulmonary arrest (CPA) among intensive care unit (ICU) patients requiring medications for hemodynamic support are limited. OBJECTIVES To examine outcomes of ICU patients who received cardiopulmonary resusitation. METHODS We identified 49,656 adult patients with a first CPA occurring in an ICU between January 1, 2000 and August 26, 2008 within the National Registry of Cardiopulmonary Resuscitation. Survival outcomes of patients requiring hemodynamic support immediately before CPA were compared with those of patients who did not receive hemodynamic support (pressors), using multivariable logistic regression analyses to adjust for differences in demographics and clinical characteristics. Pressor medications included epinephrine, norepinephrine, phenylephrine, dopamine, dobutamine, and vasopressin. MEASUREMENTS AND MAIN RESULTS The overall rate of survival to hospital discharge was 15.9%. Patients taking pressors before CPA were less likely to survive to discharge (9.3 vs. 21.2%; P < 0.0001). After multivariable adjustment, patients taking pressors before pulseless CPA were 55% less likely to survive to discharge (adjusted odds ratio [OR], 0.45; 95% confidence interval [CI], 0.42-0.48). Age equal to or greater than 65 years (adjusted OR, 0.77; 95% CI, 0.73-0.82), nonwhite race (adjusted OR, 0.58; 95% CI, 0.54-0.62), and mechanical ventilation (adjusted OR, 0.60; 95% CI, 0.56-0.63) were also variables that could be identified before CPA that were independently associated with lower survival. More than half of survivors were discharged to rehabilitation or extended care facilities. Only 3.9% of patients who had CPA despite pressors were discharged home from the hospital, as compared with 8.5% of patients with a CPA and not taking pressors (adjusted OR, 0.53; 95% CI, 0.49-0.59). CONCLUSIONS Although overall survival of ICU patients was 15.9%, patients requiring pressors and who experienced a CPA in an ICU were half as likely to survive to discharge and to be discharged home than patients not taking pressors. This study provides robust estimates of CPR outcomes of critically ill patients, and may assist clinicians to inform consent for this procedure.

Rapid Reversal of Acute Kidney Injury and Hospital Outcomes: A Retrospective Cohort Study

BACKGROUND Acute kidney injury (AKI), defined as an increment in serum creatinine level of 0.3 mg/dL or greater in 48 hours, is associated with poor outcomes. The prognosis associated with an increased creatinine level, either on admission or that develops in the hospital (ie, AKI), that rapidly returns to normal is not known. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 6,033 patients admitted to medical wards of a community teaching hospital between 2005 and 2007. PREDICTOR AKI was defined as an increase in serum creatinine level of 0.3 mg/dL or greater within 48 hours. Increased serum creatinine level on admission was defined as serum creatinine greater than1.2 mg/dL on hospital admission in patients who did not subsequently meet criteria for AKI. Patients with a serum creatinine level of 1.2 mg/dL or less who had no increase of 0.3 mg/dL or greater within 48 hours during their hospital stay served as controls. OUTCOMES & MEASUREMENTS Mortality, length of stay, intensive care unit transfer, and discharge destination were outcomes of interest. RESULTS Of 6,033 patients, 735 had AKI. Of these, 443 (60%) had serum creatinine levels that subsequently decreased by 0.3 mg/dL or greater within 48 hours and 197 returned to normal levels within 48 hours. Overall, patients with AKI had significantly greater mortality rates (14.8%) than patients without AKI with increased serum creatinine levels on admission (2.5%) and controls (1.3%; P < 0.001). Patients with AKI with a serum creatinine level that returned to normal within 48 hours had substantially greater mortality rates (14.2%) than those who initially presented with an increased serum creatinine level on admission and subsequent serum creatinine level decrease of 0.3 mg/dL or greater to normal within 48 hours (2.5%; P < 0.01). LIMITATIONS Sample sizes of subgroups were small. Causes of AKI and increases in serum creatinine levels on admission were not assessed. CONCLUSIONS An increase in serum creatinine level of 0.3 mg/dL or greater during 48 hours of hospitalization predicts outcomes even if the value returns to normal. Patients who present to the hospital with an increased creatinine level that returns rapidly to normal have outcomes approaching those with serum creatinine levels consistently in the normal range.

Atypical antipsychotic medications are independently associated with severe obstructive sleep apnea.

Background:Atypical antipsychotic (AA) medications are widely prescribed for their Food and Drug Administration-approved uses (acute mania, bipolar mania, psychotic agitation, bipolar maintenance, etc) and off-label indications. Although AA medications are associated with substantial weight gain, their tranquilizing effects may independently contribute to risk of obstructive sleep apnea (OSA) perhaps, by a reduction in activity of hypoglossal or recurrent activity of laryngeal nerve on the upper motor airway musculature. Methods:We hypothesized that AA medications are associated with more severe OSA independent of weight and neck circumference. Medical intake data and polysomnographic studies of patients referred to community hospital sleep disorders center were analyzed retrospectively. Results:Mean age of patients was 49.1 years, 55.1% were male, and mean body mass index (BMI) was 33.8 kg/m2. Sixty-eight patients (8.1%) were taking AA at the time of polysomnography. There were no differences in age, sex, neck circumference and BMI of AA versus non-AA patients. The mean (SE) apnea-hypopnea index values were 29.2 (3.5)/h in AA patients and 21.3 (0.8)/h in non-AA patients (P = 0.03). Thirty-four percent of AA patients had severe OSA (apnea-hypopnea index > 30/h) compared with 23% of non-AA patients (P = 0.04). When adjusted for BMI, sex, and use of benzodiazepines and sleeping aids, the odds ratios of severe OSA in AA patients were 1.9 times in non-AA patients (95% confidence interval, 1.1-3.3). Conclusions:Atypical antipsychotic medication use may increase the risk of more severe OSA independent of weight and neck circumference.

Anemia Prevalence in a Home Visit Geriatric Population

OBJECTIVES Ascertain anemia prevalence in the home visit geriatric population. DESIGN Retrospective chart review. SETTING A geriatric home visit program of a community-based teaching hospital. PARTICIPANTS Non-institutionalized elderly patients referred to the geriatric home visit program from March 1, 2003, through October 1, 2006. MEASUREMENTS Demographic, diagnostic, and hemoglobin data were abstracted. Anemia was defined using the WHO criteria of hemoglobin (Hb) less than 13 g/dL in men and less than 12 g/dL in women. RESULTS The cohort consisted of 244 patients, predominantly white (88%), women (77%), and with a median age of 85 years. Anemia prevalence was 39.6% (95% CI: 32.6-46.9): 44.7% (95% CI: 30.2-59.9) in the men and 37.9% (95% CI: 30.0-46.4%) in the women. There was no statistically significant difference in anemia prevalence by race, known diagnosis of dementia, or by any other comorbidity. Majorities (86.8%) of the anemias were normocytic, 10.5% were microcytic, and 2.6% had macrocytosis. About 36.4% had nutrient deficiencies, 13.6% had anemia of chronic disease, 9.1% had myelodysplastic syndrome, and the etiology remained unknown for 40.9%. CONCLUSION Anemia prevalence in the homebound geriatric population is high, about 4 times the National Health and Nutrition Examination Survey (NHANES III) estimate for the free-living, community-dwelling elderly. It mirrors the high prevalence in the nursing home population.

Recurrent bilateral spontaneous pneumothorax complicating chemotherapy for metastatic sarcoma.

We present the case of a 63-year-old woman with metastatic, high-grade pleomorphic sarcoma who had recurrent, bilateral pneumothorax while on a regimen of doxorubicin and dacarbazine. We postulate that her doxorubicin-based chemotherapy induced rapid cell lysis and necrosis of peripherally located, metastatic pulmonary nodules, leading to the pneumothoraces. Other potential mechanisms include bronchopleural fistula, rupture of dilated alveoli distal to a stenosis, chemotherapy-induced impairment of repair processes, and persistent local infection. Pneumothoraces related to pulmonary metastases tend to be refractory to conventional therapy and necessitate surgical intervention to prevent recurrences.