Combination therapy in type 2 diabetes mellitus: adding linagliptin to a stable regimen of metformin and a sulfonylurea.

Expert Opin Pharmacother. 2012 May 16;

Authors: Aronson R

Abstract
Linagliptin, the most recently approved drug of the dipeptidyl peptidase-4 (DPP-4) inhibitor class, is an oral agent used to improve glycemic control in type 2 diabetes mellitus (T2DM). By inhibiting the DPP-4 enzyme, these drugs slow the inactivation of the endogenous incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), in turn reducing blood glucose levels in a glucose-dependent manner. As well as significantly reducing glycosylated hemoglobin, the class has a good safety profile, with a low incidence of hypoglycemia, and is not associated with weight gain. From a practical point of view, they also have simple regimens, generally with once-daily oral administration, and can be used as monotherapy or in combination with other anti-diabetic drugs. Owens and colleagues have reported a 6-month study of linagliptin add-on therapy in patients who were receiving a stable regimen of metformin and a sulfonylurea, but needed additional glycemic control. Linagliptin was associated with significant improvement in glycemic control and was well-tolerated by patients, indicating that it provides a valuable option for a large number of patients with T2DM, especially for those who would prefer to add an oral therapy to a current regimen.

PMID: 22587735 [PubMed - as supplied by publisher]

Multidrug-resistant Pseudomonas aeruginosa bloodstream infections: risk factors and mortality.

Epidemiol Infect. 2011 Nov;139(11):1740-9

Authors: Tumbarello M, Repetto E, Trecarichi EM, Bernardini C, De Pascale G, Parisini A, Rossi M, Molinari MP, Spanu T, Viscoli C, Cauda R, Bassetti M

Abstract
We retrospectively studied patients diagnosed with P. aeruginosa bloodstream infections (BSIs) in two Italian university hospitals. Risk factors for the isolation of multidrug-resistant (MDR) or non-MDR P. aeruginosa in blood cultures were identified by a case-case-control study, and a cohort study evaluated the clinical outcomes of such infections. We identified 106 patients with P. aeruginosa BSI over the 2-year study period; 40 cases with MDR P. aeruginosa and 66 cases with non-MDR P. aeruginosa were compared to 212 controls. Independent risk factors for the isolation of MDR P. aeruginosa were: presence of central venous catheter (CVC), previous antibiotic therapy, and corticosteroid therapy. Independent risk factors for non-MDR P. aeruginosa were: previous BSI, neutrophil count <500/mm3, urinary catheterization, and presence of CVC. The 21-day mortality rate of all patients was 33·9%. The variables independently associated with 21-day mortality were presentation with septic shock, infection due to MDR P. aeruginosa, and inadequate initial antimicrobial therapy.

PMID: 21226988 [PubMed - indexed for MEDLINE]

Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses.

Am J Respir Crit Care Med. 2012 Apr 1;185(7):738-43

Authors: Garland A, Roberts D, Graff L

Abstract
RATIONALE: Around-the-clock intensivist presence in intensive care units (ICUs) has been promoted as necessary to optimize outcomes. Little data have addressed how it affects the multiple stakeholders in such care.
OBJECTIVES: To assess effects of around-the-clock intensivist presence on intensivists, patients, families, housestaff, and nurses.
METHODS: This 32-week, crossover pilot trial of two intensivist staffing models, performed in two Canadian ICUs, alternated 8-week blocks of two staffing models: the standard model, where one intensivist worked for 7 days, taking night call from home; and the shift work model, where one intensivist worked 7 day shifts, while other intensivists remained in the ICU at night.
MEASUREMENTS AND MAIN RESULTS: Surveys scaled from 0-100 points assessed outcomes for 24 intensivists (primary outcome: burnout); 119 families (satisfaction); 74 nurses (satisfaction with collaboration and communications, role conflict); and 34 housestaff (autonomy, supervision, and learning opportunities). Outcomes for 501 patients included mortality, length of stay, and resource use. Intensivists doing shift work experienced less burnout (-6.9 points; P = 0.04). Adjusted hospital mortality (odds ratio, 1.22; P = 0.44), ICU length of stay (-6 h; P = 0.46), and family satisfaction (0.9 points; P = 0.79) did not differ between staffing models. Under shift work staffing, nurses reported more role conflict (9 points; P < 0.001), whereas nighttime housestaff reported less autonomy, more supervision, but no difference in learning opportunities.
CONCLUSIONS: Shiftwork staffing was better for intensivists and most were receptive once they had experienced it. Although there were no evident negative outcomes for patients or families, further evaluation is needed to clarify how around-the-clock intensivist staffing influences the various stakeholders in ICU care, given power considerations in this study. Clinical trial registered with www.clinicaltrials.gov (NCT 01146691).

PMID: 22246176 [PubMed - indexed for MEDLINE]

Apolipoprotein M - a new biomarker in sepsis.

Crit Care. 2012 May 17;16(3):126

Authors: Christoffersen C, Nielsen LB

Abstract
ABSTRACT: Sepsis is one of the leading causes of mortality in non-cardiac intensive care units, and the need for markers of progression and severity are high. Also, treatment of sepsis is highly debated and potential new targets of treatment are of great interest. In the previous issue of Critical Care Kumaraswamy and colleagues have investigated whether plasma apolipoprotein M (apoM) is affected during different grades of sepsis, septic shock and systemic inflammatory response syndrome. Interestingly, plasma apoM was significantly decreased in all groups of patients with a relationship to severity of disease. This identifies apoM as a potential new biomarker in sepsis. It also underscores the possibility that altered high-density lipoprotein in sepsis patients can affect the course of disease. Thus, since apoM is the carrier of Sphingosine-1-P (S1P), a molecule with great influence on vascular barrier function, the study presented raises the interest and relevance for further studies of apoM and S1P in relation to sepsis and inflammation.

PMID: 22587809 [PubMed - as supplied by publisher]

Increased hospitalizations among sarcoidosis patients from 1998 to 2008: a population-based cohort study.

BMC Pulm Med. 2012 May 14;12(1):19

Authors: Gerke AK, Yang M, Tang F, Cavanaugh JE, Polgreen PM

Abstract
ABSTRACT: BACKGROUND: Diagnostic and treatment approaches for sarcoidosis have changed dramatically over the past decade. Yet, the most recent reports of trends in hospitalizations of sarcoidosis patients are over ten years old. The objectives of this study were to determine the incidence of sarcoidosis among hospitalized patients and to analyze recent trends and seasonality of hospitalizations in sarcoidosis patients. METHODS: We performed a retrospective cohort study of the Nationwide Inpatient Sample from 1998 through 2008. We identified all hospitalizations with a primary or secondary diagnosis of sarcoidosis (ICD-9-CM code 135). Incidence was modeled as a seasonal time series about a linear trend. RESULTS: Time series analysis of the monthly number of hospitalizations revealed a distinct positive linear trend. Over the study period, the number of hospitalized patients with sarcoidosis increased from 37,516 to 70,947 cases. Trends were most pronounced in patients older than 55 years (p < 0.0001), African Americans (p < 0.0001), females (p = 0.0289), and non-Medicaid populations (p < 0.0001). Hospitalizations are seasonal with highest incidence in January through March. CONCLUSIONS: Hospitalizations among sarcoidosis patients have almost doubled during the past decade, with disproportionate rate increases in African Americans, women, and older patients. The rate also increases among patients with insurance other than Medicaid. This study indicates the need for heightened surveillance of sarcoidosis patients given the unknown consequences of evolving treatment approaches. Our results point to a need for research investigating risk factors for hospitalization, including medications, co-morbidities, demographics, and socioeconomic status.

PMID: 22584044 [PubMed - as supplied by publisher]

Long-term death and recurrence in patients with acute venous thromboembolism: The MASTER registry.

Thromb Res. 2012 May 12;

Authors: Verso M, Agnelli G, Ageno W, Imberti D, Moia M, Palareti G, Pistelli R, Cantone V,

Abstract
BACKGROUND: The long-term clinical outcome of VTE has been essentially assessed in cohorts of selected patients. The aim of this multicenter registry was to prospectively assess the long-term clinical outcome in a cohort of unselected patients with objectively confirmed acute VTE. MATERIALS AND METHODS: Death and VTE recurrence at 24months were the main study outcomes. Univariate and multivariate survival analyses were performed according to the Kaplan-Meyer and Cox proportional hazard model, respectively. RESULTS: 2119 patients with acute VTE were included in the registry: 1541 (72.7%) with deep vein thrombosis, 206 (9.7%) with pulmonary embolism and 372 (17.6%) with both. Information about death was available in 2021 patients (95.4%) and about recurrence in 1988 patients (93.8%). 167 patients (4.55% patient-year) died during follow-up. After adjusting for age, cancer (Hazard ratio [HR]: 7.2; 95%CI 4.8-10.8), long-term heparin treatment (HR: 2.5; 95%CI 1.8-3.5), in-hospital management of VTE (HR: 2.0; 95%CI 1.3-3.0), and ileo-caval thrombosis (HR: 1.7; 95%CI 1.2-2.4) were found to be independent predictors of death. 124 (3.63% patient-year) patients had a VTE recurrence during follow-up. In-hospital management of VTE (HR: 1.8; 95%CI 1.2-2.9), male gender (HR: 1.7; 95%CI 1.2-2.4) were independent risk factors for recurrent VTE. Cancer (HR: 1.6; 95%CI 1.0-2.8) showed a trend for increased risk of VTE recurrence (p=0.056). The reported rate of major bleeding was 2.5%. CONCLUSIONS: In a large cohort of unselected VTE patients, cancer, ileo-caval thrombosis, long-term heparin treatment and in-hospital management were associated with increased mortality during long-term follow-up. In-hospital management, male gender were associated with an increased risk of VTE recurrence.

PMID: 22583838 [PubMed - as supplied by publisher]

Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction.

Am Heart J. 2012 Mar;163(3):372-82

Authors: Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, Granger CB, Cairns CB, Glickman LT

Abstract
BACKGROUND: Current guidelines recommend an immediate (eg, <10 minutes) 12-lead electrocardiogram (ECG) to identify ST-elevation myocardial infarction (STEMI) among patients presenting to the emergency department (ED) with chest pain. Yet, one third of all patients with myocardial infarction do not have chest pain. Our objective was to develop a practical approach to identify patients, especially those without chest pain, who require an immediate ECG in the ED to identify STEMI.
METHODS: An ECG prioritization rule was derived and validated using classification and regression tree analysis among >3 million ED visits to 107 EDs from 2007 to 2008.
RESULTS: The final study population included 3,575,178 ED patient visits; of these, 6,464 (0.18%) were diagnosed with STEMI. Overall, 1,413 (21.9%) of patients with STEMI did not present to the ED with chest pain. Major predictors of those requiring an immediate ECG in the ED included age ?30 years with chest pain; age ?50 years with shortness of breath, altered mental status, upper extremity pain, syncope, or generalized weakness; and those with age ?80 years with abdominal pain or nausea/vomiting. When the ECG prioritization rule was applied to a validation sample, it had a sensitivity of 91.9% (95% CI 90.9%-92.8%) for STEMI and a negative predictive value 99.98% (95% CI 99.98%-99.98%).
CONCLUSION: A simple ECG prioritization rule based on age and presenting symptoms in the ED can identify patients during triage who are at high risk for STEMI and therefore should receive an immediate 12-lead ECG, often before they are seen by a physician.

PMID: 22424007 [PubMed - indexed for MEDLINE]

Downstream procedures and outcomes after stress testing for chest pain without known coronary artery disease in the United States.

Am Heart J. 2012 Mar;163(3):454-61

Authors: Mudrick DW, Cowper PA, Shah BR, Patel MR, Jensen NC, Peterson ED, Douglas PS

Abstract
BACKGROUND: Millions of Americans with suspected coronary artery disease undergo noninvasive cardiac stress testing annually. Downstream procedures and subsequent outcomes among symptomatic patients without known coronary disease referred for stress testing are not well characterized in contemporary community practice.
METHODS: We examined administrative insurance billing data from a national insurance provider from November 2004 through June 2007. After excluding patients with prior cardiac disease or chest pain evaluation, we identified 80,676 people age 40 to 64 years with outpatient cardiac stress testing within 30 days after an office visit for chest pain. We evaluated rates of invasive coronary angiography, coronary revascularization, and cardiovascular events after stress testing.
RESULTS: Within 60 days, only 8.8% of stress test patients underwent cardiac catheterization and only 2.7% underwent revascularization; within 1 year, only 0.5% died and had myocardial infarction or stroke. There were marked geographic variations in 1-year rates of catheterization (3.8%-14.8%) and revascularization (1.2%-3.0%) across 20 hospital referral regions.
CONCLUSIONS: In this large national cohort of middle-aged patients without previously coded cardiac diagnosis who were referred for stress testing after outpatient chest pain evaluation, few proceeded to invasive angiography or revascularization, and subsequent cardiovascular events were infrequent.

PMID: 22424017 [PubMed - indexed for MEDLINE]

Design of the Rule Out Myocardial Ischemia/Infarction Using Computer Assisted Tomography: a multicenter randomized comparative effectiveness trial of cardiac computed tomography versus alternative triage strategies in patients with acute chest pain in the emergency department.

Am Heart J. 2012 Mar;163(3):330-8, 338.e1

Authors: Hoffmann U, Truong QA, Fleg JL, Goehler A, Gazelle S, Wiviott S, Lee H, Udelson JE, Schoenfeld D,

Abstract
Although early cardiac computed tomographic angiography (CCTA) might improve the management of emergency department (ED) patients with acute chest pain, it could also result in increased testing, costs, and radiation exposure. ROMICAT II was a randomized comparative effectiveness trial enrolling patients 40 to 74 years old without known coronary artery disease who presented to the ED with chest pain but without ischemic electrocardiographic (ECG) changes or elevated initial troponin and who required further risk stratification. Overall, 1000 patients at 9 sites within the United States were randomized to either CCTA as the first diagnostic test following serial biomarkers or to standard of care, which included no testing or functional testing such as exercise ECG, stress radionuclide imaging, or stress echocardiography. Test results were provided to ED physicians, yet patient management was not driven by a study protocol in either arm. Data were collected on diagnostic testing, cardiac events, and cost of medical care for the index hospitalization and during the following 28 days. The primary end point was length of hospital stay. Secondary end points were cumulative radiation exposure, resource utilization, and costs of competing strategies. Tertiary end points were institutional, physician, and patient characteristics associated with primary and secondary outcomes. Rate of missed acute coronary syndrome within 28 days was the safety end point. The ROMICAT II will provide rigorous data on whether CCTA is more efficient than standard of care in the management of patients with acute chest pain at intermediate risk for acute coronary syndrome.

PMID: 22424002 [PubMed - indexed for MEDLINE]

Rhabdomyolysis.

Br J Hosp Med (Lond). 2012 Feb;73(2):C30-2

Authors: de Wolff JF

Abstract
Rhabdomyolysis is the destruction of a significant amount of striated muscle, leading to disruptions in fluid balance, electrolytes and renal function. It may have either traumatic (such as crush injury) or non-traumatic causes. Diagnosis is typically made through the timely determination of the serum creatine kinase activity in a patient with a suggestive history or clinical features. Treatment is supportive, with generous intravenous hydration and correction of electrolyte abnormalities. Sometimes haemofiltration or dialysis is required, but the renal prognosis is generally good.

PMID: 22504713 [PubMed - indexed for MEDLINE]

Quality of care for myocardial infarction at academic and nonacademic hospitals.

Am J Med. 2012 Apr;125(4):365-73

Authors: Belle L, Labarère J, Fourny M, Drouet E, Mulak G, Dujardin JJ, Vilarem D, Bonnet P, Hanssen M, Simon T, Ferrières J, Danchin N,

Abstract
BACKGROUND: Whether academic hospitals provide better quality of care for patients with acute myocardial infarction is widely debated. The aim of this study was to compare processes of care and mortality between academic and nonacademic hospitals in the contemporary era of acute myocardial infarction management.
METHODS: We analyzed the original data from a prospective cohort study of 3059 patients, including 1714 with ST-segment elevation and 1345 with non-ST-segment elevation myocardial infarction, enrolled at 39 and 183 academic and nonacademic hospitals, respectively, in France.
RESULTS: Unadjusted 1-year mortality for academic and nonacademic hospitals was 10% versus 15% for patients with ST-segment elevation myocardial infarction (P=.01) and 13% versus 14% for patients with non-ST-segment elevation myocardial infarction (P=.75). Patients treated in academic or nonacademic hospitals with percutaneous coronary intervention capability were more likely to receive reperfusion and recommended drug therapies than those treated in nonacademic hospitals without percutaneous coronary intervention capability. After adjusting for baseline characteristics, the hazards of death associated with admission to nonacademic hospitals with and without percutaneous coronary intervention capability relative to academic hospitals were 1.13 (95% confidence interval [CI], 0.79-1.62) and 1.65 (95% CI, 1.09-2.49) for those with ST-segment elevation myocardial infarction and 0.95 (95% CI, 0.66-1.36) and 1.06 (95% CI, 0.72-1.58) for those with non-ST-segment elevation myocardial infarction, respectively. Further adjustment for receipt of acute reperfusion and recommended drug therapies eliminated all differences in mortality between the study groups.
CONCLUSION: Admission to academic hospitals was associated with a more frequent use of recommended therapies, conveying a survival advantage for patients with ST-segment elevation myocardial infarction.

PMID: 22444102 [PubMed - indexed for MEDLINE]

Prospective Evaluation of Subjects With Chronic Asymptomatic Pancreatic Hyperenzymemia.

Am J Gastroenterol. 2012 May 15;

Authors: Amodio A, Manfredi R, Katsotourchi AM, Gabbrielli A, Benini L, Mucelli RP, Vantini I, Frulloni L

Abstract
OBJECTIVES:Chronic asymptomatic pancreatic hyperenzymemia (CAPH) has been described since 1996 as a benign disease. Recent studies described pathological findings at magnetic resonance cholangiopancreatography with secretin stimulation (s-MRCP) in more than half of the CAPH subjects. The aim of this study was to investigate the frequency and clinical relevance of s-MRCP findings in patients with CAPH.METHODS:Subjects prospectively enrolled from January 2005 to December 2010 underwent s-MRCP and biochemical tests routinely performed.RESULTS:Data relative to 160 subjects (94 males, 66 females, age 49.6±13.6 years) were analyzed. In all, 51 (32%) subjects had hyperamylasemia, 9 (6%) hyperlipasemia, and 100 (62%) an increase in both enzyme levels. The time between the first increased dosage of serum pancreatic enzymes and our observation was 3.3±3.9 years (range: 1-15). Familial pancreatic hyperenzymemia was observed in 26 out of 133 subjects (19.5%). Anatomic abnormalities of the pancreatic duct system at s-MRCP were found in 24 out of 160 subjects (15%). Pathological MRCP findings were present in 44 subjects (27.5%) before and in 80 subjects (50%) after secretin administration (P<0.0001). Five subjects (3.1%) underwent surgery, 3 for pancreatic endocrine tumor, 1 for pancreatic adenocarcinoma, and 1 for intraductal papillary-mucinous neoplasia (IPMN) involving the main pancreatic duct, and 18 patients (11.3%) needed a follow-up (17 for IPMN and 1 for endocrine tumor).CONCLUSIONS:Alterations of the pancreatic duct system at s-MRCP in subjects with CAPH can be observed in 50% of the subjects and are clinically relevant in 14.4% of cases.Am J Gastroenterol advance online publication, 15 May 2012; doi:10.1038/ajg.2012.125.

PMID: 22584217 [PubMed - as supplied by publisher]

The determinants of hospital mortality among patients with septic shock receiving appropriate initial antibiotic treatment.

Crit Care Med. 2012 May 11;

Authors: Labelle A, Juang P, Reichley R, Micek S, Hoffmann J, Hoban A, Hampton N, Kollef M

Abstract
OBJECTIVE:: To identify the determinants of hospital mortality among patients with septic shock receiving appropriate initial antibiotic treatment. DESIGN:: A retrospective cohort study of hospitalized patients with blood culture positive septic shock (January 2002-December 2007). SETTING:: Barnes-Jewish Hospital, a 1,250-bed urban teaching hospital. PATIENTS:: Four hundred thirty-six consecutive patients with septic shock and a positive blood culture. INTERVENTIONS:: Data abstraction from computerized medical records. MEASUREMENTS AND MAIN RESULTS:: Septic shock was associated with bloodstream infection due to Gram-negative bacteria (59.2%) and Gram-positive bacteria (40.8%). Two hundred twenty-four patients (51.4%) died during their hospitalization. The presence of infection attributed to antibiotic-resistant bacteria was similar for patients who survived and expired (22.6% vs. 20.1%; p = .516). Multivariate logistic regression analysis demonstrated that infection acquired in the intensive care unit (adjusted odds ratio 1.99; 95% confidence interval 1.52-2.60; p = .011) and increasing Acute Physiology and Chronic Health Evaluation II scores (one-point increments) (adjusted odds ratio 1.11; 95% confidence interval 1.09-1.14; p < .001) were independently associated with a greater risk of hospital mortality, whereas infection with methicillin-susceptible Staphylococcus aureus (adjusted odds ratio 0.32; 95% confidence interval 0.20-0.52; p = .017) was independently associated with a lower risk of hospital mortality. Patients infected with methicillin-susceptible Staphylococcus aureus infections were statistically younger and had lower Charlson comorbidity and Acute Physiology and Chronic Health Evaluation II scores compared to patients with non-methicillin-susceptible Staphylococcus aureus infections. CONCLUSIONS:: Among patients with septic shock who receive appropriate initial antibiotic treatment, acquisition of infection in the intensive care unit and severity of illness appear to be the most important determinants of clinical outcome.

PMID: 22584765 [PubMed - as supplied by publisher]

Derivation of a cardiac arrest prediction model using ward vital signs.

Crit Care Med. 2012 May 11;

Authors: Churpek MM, Yuen TC, Park SY, Meltzer DO, Hall JB, Edelson DP

Abstract
OBJECTIVE:: Rapid response team activation criteria were created using expert opinion and have demonstrated variable accuracy in previous studies. We developed a cardiac arrest risk triage score to predict cardiac arrest and compared it to the Modified Early Warning Score, a commonly cited rapid response team activation criterion. DESIGN:: A retrospective cohort study. SETTING:: An academic medical center in the United States. PATIENTS:: All patients hospitalized from November 2008 to January 2011 who had documented ward vital signs were included in the study. These patients were divided into three cohorts: patients who suffered a cardiac arrest on the wards, patients who had a ward to intensive care unit transfer, and patients who had neither of these outcomes (controls). INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Ward vital signs from admission until discharge, intensive care unit transfer, or ward cardiac arrest were extracted from the medical record. Multivariate logistic regression was used to predict cardiac arrest, and the cardiac arrest risk triage score was calculated using the regression coefficients. The model was validated by comparing its accuracy for detecting intensive care unit transfer to the Modified Early Warning Score. Each patient's maximum score prior to cardiac arrest, intensive care unit transfer, or discharge was used to compare the areas under the receiver operating characteristic curves between the two models. Eighty-eight cardiac arrest patients, 2,820 intensive care unit transfers, and 44,519 controls were included in the study. The cardiac arrest risk triage score more accurately predicted cardiac arrest than the Modified Early Warning Score (area under the receiver operating characteristic curve 0.84 vs. 0.76; p = .001). At a specificity of 89.9%, the cardiac arrest risk triage score had a sensitivity of 53.4% compared to 47.7% for the Modified Early Warning Score. The cardiac arrest risk triage score also predicted intensive care unit transfer better than the Modified Early Warning Score (area under the receiver operating characteristic curve 0.71 vs. 0.67; p < .001). CONCLUSIONS:: The cardiac arrest risk triage score is simpler and more accurately detected cardiac arrest and intensive care unit transfer than the Modified Early Warning Score. Implementation of this tool may decrease rapid response team resource utilization and provide a better opportunity to improve patient outcomes than the modified early warning score.

PMID: 22584764 [PubMed - as supplied by publisher]

Randomized trial of automated, electronic monitoring to facilitate early detection of sepsis in the intensive care unit.

Crit Care Med. 2012 May 11;

Authors: Hooper MH, Weavind L, Wheeler AP, Martin JB, Gowda SS, Semler MW, Hayes RM, Albert DW, Deane NB, Nian H, Mathe JL, Nadas A, Sztipanovits J, Miller A, Bernard GR, Rice TW

Abstract
OBJECTIVE:: To determine whether automated identification with physician notification of the systemic inflammatory response syndrome in medical intensive care unit patients expedites early administration of new antibiotics or improvement of other patient outcomes in patients with sepsis. DESIGN:: A prospective randomized, controlled, single center study. SETTING:: Medical intensive care unit of an academic, tertiary care medical center. PATIENTS:: Four hundred forty-two consecutive patients admitted over a 4-month period who met modified systemic inflammatory response syndrome criteria in a medical intensive care unit. INTERVENTION:: Patients were randomized to monitoring by an electronic "Listening Application" to detect modified (systemic inflammatory response syndrome) criteria vs. usual care. The listening application notified physicians in real time when modified systemic inflammatory response syndrome criteria were detected, but did not provide management recommendations. MEASUREMENTS AND MAIN RESULTS:: The median time to new antibiotics was similar between the intervention and usual care groups when comparing among all patients (6.0 hr vs. 6.1 hr, p = .95), patients with sepsis (5.3 hr vs. 5.1 hr; p = .90), patients on antibiotics at enrollment (5.2 hr vs. 7.0 hr, p = .27), or patients not on antibiotics at enrollment (5.2 hr vs. 5.1 hr, p = .85). The amount of fluid administered following detection of modified systemic inflammatory response syndrome criteria was similar between groups whether comparing all patients or only patients who were hypotensive at enrollment. Other clinical outcomes including intensive care unit length of stay, hospital length of stay, and mortality were not shown to be different between patients in the intervention and control groups. CONCLUSIONS:: Realtime alerts of modified systemic inflammatory response syndrome criteria to physicians in one tertiary care medical intensive care unit were feasible and safe but did not influence measured therapeutic interventions for sepsis or significantly alter clinical outcomes.

PMID: 22584763 [PubMed - as supplied by publisher]