In [261]:
!pip install inverness
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In [104]:
import inverness
model = inverness.Model('model_all_v7/').load(['fun','meta','phraser','dictionary','tfidf','lsi','dense_ann'])
load done in 2.94 seconds
In [105]:
from IPython.core.display import display, HTML
from matplotlib import pyplot as plt
from tqdm import tqdm
import pandas as pd
import re
pd.set_option('display.max_rows', 100)
In [106]:
def score_text(text, criteria):
""""""
total = 0
value = 1
for c in criteria:
if type(c) in (int,float):
value = c
else:
c = c.replace('_',r'\b')
matches = re.findall(c,text,re.I)
total += value if matches else 0
#total += value*len(matches)
return total
def score_results(i_d_lists, criteria, mark=None):
""""""
results = []
for i,d in zip(*i_d_lists):
doc = model.get_doc(i)
text = model.doc_to_text(doc).replace('\n',' ').replace('\r',' ')
s = score_text(text, criteria)
html = highlight(text, criteria, style_by_group_id, default_style)
rec = s,d,i,html,doc
results += [rec]
results.sort(key=lambda x:(-x[0],x[1]))
return results
# TODO ??? tqdm
def score_queries(queries, criteria, K=50):
""""""
by_score = []
for query in queries:
q = model.text_to_dense(query)
i_d = model.dense_ann_query(q,K)
results = score_results(i_d, criteria)
score = agg_results(results)
by_score += [(score,query)]
by_score.sort()
return by_score
def highlight(text, criteria, styles={}, default='w=bold'):
""""""
group_id = 0
for c in criteria:
if type(c) in (int,float):
group_id += 1
else:
c = c.replace('_',r'\b')
c = f'({c}\\w*)'
style = styles.get(group_id,default)
style_props = []
for prop in style.split(','):
k,_,v = prop.partition('=')
if k=='w':
style_props += [f'font-weight:{v}']
if k=='fg':
style_props += [f'foreground-color:{v}']
if k=='bg':
style_props += [f'background-color:{v}']
before = f'<span style="{";".join(style_props)}">'
after = '</span>'
text = re.sub(c, before+'\\1'+after, text, flags=re.I)
# TODO default
return text
# L2 score
def agg_results(results):
""""""
scores = [x[0] for x in results]
return sum([x*x for x in scores])**0.5
# TODO break title into multiple lines
def plot_results(results,title=''):
""""""
scores = [x[0] for x in results]
scores.sort(reverse=True)
plt.plot(scores)
if title: plt.title(title)
score = agg_results(results)
plt.figtext(0.4, 1, f"L2 score: {score:.02f}")
plt.show()
# TEST
#highlight_old("this is a test of this function",['thi',5,'_is'],mark=[1])
#highlight("this is a test of this function",['thi',5,'_is'],styles={0:'w=bold',1:'bold,bg=#FF0000,fg=#0000FF'})
#highlight("this is a test of this function",['thi',5,'_is'])
In [257]:
criteria = [
50,'mechanical','ventilat',
2,'adjust','_age','_years','_old',
2,'_surviv','discharge','extubate','alive',
2,'nonsurviv','_died','dead','death','mortality','complication',
5,'Kaplan.Meier','APACHE','SOFA','RIFLE','Glasgow.Coma','GCS','SAPS','_RESP_','RSBI','1000.person_',
2,'figure','_fig[.]','_table',
2,'outcome','result','occurr','cohort','median',
1,'duration','time','_day','patients','_stay','_week'
]
style_by_group_id = {1:'w=bold',2:'bg=#FFFF00',3:'bg=#00FF00',4:'bg=#FFAAAA',5:'bg=#FFCC00',6:'bg=#FFAAFF',7:'bg=#00FFFF'}
default_style = ''
# https://www.mdcalc.com/covid-19
In [258]:
K = 50
queries = [
'Outcomes data for COVID-19 after mechanical ventilation adjusted for age',
'results after mechnical ventilation discharged dead died',
'results after mechnical ventilation discharged dead died survived survivors adjusted age years old',
'results after mechnical ventilation discharged died survived survivors extubated adjusted',
'results after mechnical ventilation discharged dead died survived survivors adjusted age years old',
'results after mechnical ventilation discharged died survived extubated adjusted',
'results after mechnical ventilation discharged died survived extubated adjusted age',
'outcomes after mechnical ventilation discharged died survived extubated adjusted',
'results outcomes after mechnical ventilation discharged died survived extubated adjusted age',
'results outcomes after mechnical ventilation discharged died survived extubated',
'results outcomes mechnical ventilation discharged died survived extubated',
'results outcomes after mechnical ventilation discharged died survived extubated adjusted',
]
for score,query in score_queries(queries, criteria, K):
print(f"{score:10.02f} -- {query}")
58.02 -- results after mechnical ventilation discharged dead died survived survivors adjusted age years old
58.02 -- results after mechnical ventilation discharged dead died survived survivors adjusted age years old
446.41 -- results after mechnical ventilation discharged died survived extubated adjusted age
546.58 -- results outcomes after mechnical ventilation discharged died survived extubated adjusted age
603.41 -- Outcomes data for COVID-19 after mechanical ventilation adjusted for age
690.27 -- results after mechnical ventilation discharged dead died
704.74 -- results outcomes after mechnical ventilation discharged died survived extubated
718.88 -- results outcomes mechnical ventilation discharged died survived extubated
726.37 -- outcomes after mechnical ventilation discharged died survived extubated adjusted
731.40 -- results after mechnical ventilation discharged died survived extubated adjusted
753.34 -- results after mechnical ventilation discharged died survived survivors extubated adjusted
756.94 -- results outcomes after mechnical ventilation discharged died survived extubated adjusted
In [241]:
query = 'results outcomes after mechnical ventilation \n discharged died survived extubated adjusted'
In [259]:
K = 500
q = model.text_to_dense(query)
i_d_lists = model.dense_ann_query(q, K)
results = score_results(i_d_lists, criteria, mark)
plot_results(results, title=query)
In [260]:
N = 20
for score,dist,i,html,doc in results[:N]:
display(HTML(f"{score} :: {dist:.03f} :: {i}<br>{html}"))
153 :: 0.208 :: 164967
The overall ICU mortality rate was 74.2 % (n = 23). The median ICU and hospital lengths of stay were 9 (IQR: 4-16) and 12 (IQR: 4-16) days, respectively. The major causes of death were hypoxemic respiratory failure (52.2 %) and refractory septic shock (26.1 %). One patient died from sudden cardiac arrest after ICU discharge but while still in the hospital. Furthermore, one patient died within 1 year after discharge from the ICU because of septic shock related to an infected wound. Only one patient was lost to follow-up after hospital discharge. The SOFA score and Glasgow Coma Scale (GCS) increased markedly over the first 2 weeks in the ICU in the whole cohort, while other parameters of organ function remained largely unchanged (Additional file 3). Compared with those who were discharged alive from the ICU, nonsurvivors were older, had higher APACHE II and SOFA scores on admission to the ICU, and were more likely to require invasive mechanical ventilation and vasopressor therapy and to have been ventilated using highfrequency oscillation (Tables 1 and 2 , and Additional files 1 and 2). Nonsurvivors had a persistently low PaO2/FiO 2 throughout the first 2 weeks in the ICU, whereas survivors showed a slight increase over time (Fig. 2) . After adjustment for the severity of illness and the degree of organ dysfunction, the need for vasopressors was the only independent risk factor for death in the ICU (OR 18.33, 95 % confidence interval 1.11-302.1, P 0.04) (Additional file 4). Morbidity and mortality Characteristics of patients on admission to the intensive care unit APACHE acute physiology and chronic health evaluation, COPD chronic obstructive pulmonary disease, ICU intensive care unit, IQR interquartile range, NA not applicable, SD standard deviation, SOFA sequential organ failure assessment Box plot representing the time course of PaO2/FiO2 according to ICU outcome. *P < 0.005 compared to survivors
150 :: 0.224 :: 516403
The SOFA score and Glasgow Coma Scale (GCS) increased markedly over the first 2 weeks in the ICU in the whole cohort, while other parameters of organ function remained largely unchanged (Additional file 3). Compared with those who were discharged alive from the ICU, nonsurvivors were older, had higher APACHE II and SOFA scores on admission to the ICU, and were more likely to require invasive mechanical ventilation and vasopressor therapy and to have been ventilated using high-frequency oscillation (Tables 1 and 2, and Additional files 1 and 2). Nonsurvivors had a persistently low PaO2/FiO2 throughout the first 2 weeks in the ICU, whereas survivors showed a slight increase over time (Fig. 2). After adjustment for the severity of illness and the degree of organ dysfunction, the need for vasopressors was the only independent risk factor for death in the ICU (OR 18.33, 95 % confidence interval 1.11–302.1, P 0.04) (Additional file 4). Morbidity and mortality ::: Results Table 1: Characteristics of patients on admission to the intensive care unit APACHE acute physiology and chronic health evaluation, COPD chronic obstructive pulmonary disease, ICU intensive care unit, IQR interquartile range, NA not applicable, SD standard deviation, SOFA sequential organ failure assessment Table 2: Procedures and therapies ECMO extracorporeal membrane oxygenator, IQR interquartile range, RRT renal replacement therapy aComparisons done for frequencies bNorepinephrine cIntravenous hydrocortisone (200–300 mg per day) in four patients and methyprednisolone in four patients (maintenance therapy for underlying disease) Fig. 2: Box plot representing the time course of PaO2/FiO2 according to ICU outcome. *P < 0.005 compared to survivors
142 :: 0.289 :: 297634
Infections are a frequent complication after stroke. Pneumonia is the most frequent site of infection and is associated with lower survival and impaired neurologic outcome. Studies focusing on intensive care patients show the highest incidence of pneumonia, but are very heterogeneous in the severity of selected patients. To date, there is no study focusing exclusively on the epidemiology and prognostic impact of pneumonia in mechanically ventilated stroke patients. Furthermore, previous studies lack the adjustment for early decisions to forgo life-sustaining treatment (DFLST) which is a significant confounder in these patients. Patients and methods: We conducted a retrospective analysis of a large prospective multicenter database over a 20-year period (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) . We included all adult ischemic stroke patients admitted to the ICU who required invasive mechanical ventilation at ICU admission. The relation between the occurrence of pneumonia during ICU stay and 30-day mortality was investigated using a Cox proportional hazard model, adjusted on DFLST. Data are presented as median (interquartile range) or numbers (percentages). Results: We identified 195 patients (age 69 (61-76) years, male gender 132 (67.7%) patients) from 11 ICUs. On ICU admission, the Glasgow coma scale score (GCS) was 6 (3-, 0) and the Simplified Acute Physiology score 2 (SAPS 2) score was 56 (45-66). Patients required vasopressors in 92 (47.2%) cases and renal replacement therapy in 17 (8.7%) cases. DFLST occurred 5 (2-8) days after ICU admission in 65 (33.3%) patients. Withholding of care and withdrawal of care were observed in 31 (15.9%) and 34 (17.4%) cases, respectively. Survival at day 3six, 6 months and one year was 44%, 32, 6% and 29.7% respectively. During ICU stay, there were 90 pneumonia episodes, occurring at least once in 74 (37.9%) patients. Pneumonia caused sepsis and septic shock (SEPSIS-3 definition) in 40 (44.4%) and 33 (36.7%) cases respectively. After adjustment, the occurrence of pneumonia during ICU stay was not associated with 30-day mortality (figure 1). Conclusion: In this cohort of mechanically ventilated patients with acute ischemic stroke, pneumonia was a frequent complication but was not associated with 30-day mortality. Impact of pneumonia on functional outcomes in survivors should be investigated in further studies. Introduction:
135 :: 0.300 :: 284306
Overall ICU and hospital mortality were 17% and 24%, respectively, without significant variation over the study period (Additional file 3: Table S3 ). The main causes of death were: multi-organ failure in 10 patients (42%), refractory ARDS in 5 patients (21%), and septic shock in Fig. 1 Imaging characteristics from lung CT. A 46-year-old woman was admitted to the ICU for acute respiratory failure. She underwent kidney transplantation 12 years ago. She reported fever and a typical chickenpox skin rash 5 days before admission. The onset of respiratory symptoms started 2 days before ICU admission and invasive mechanical ventilation was implemented at day 1. She developed a severe ARDS requiring prone positioning, neuromuscular blockers, and 14 days of invasive mechanical ventilation. Lung CT scan demonstrated diffuse bilateral nodules, patchy ground glass opacities, and interlobular septal thickening. A fiber bronchoscopy with bronchoalveolar lavage documented a Staphylococcus aureus co-infection. She received intravenous aciclovir 10 mg/kg/8 h during 15 days associated with 10 days of oxacilline and was discharge alive from the ICU 17 days after admission 4 patients (17%). One (4%) patient died from fulminant hepatic failure attributed to VZV infection and 1 (4%) patient died from brain edema. The cause of death was missing for 3 patients. By univariate analysis, factors associated with hospital mortality were: age (60 (49-72.5) vs. 36 (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44) (45) ; p < 0.0001), underlying immunosuppression (92% vs. 40%; p < 0.0001), SOFA score on day 1 (7 (5-10.75) vs. 4 (2-5.25) ; p = 0.0002), disseminated intravascular coagulation (42% vs. 4%; p = 0.0001), and empiric antibiotic treatment on ICU admission (91% vs. 53%; p < 0.0001) (Additional file 4: Table S2 , Additional file 5: Figure S2 , and Additional file 6: Figure S3 ). Treatments related to VZV pneumonia and outcome ICU management and outcome data Characteristics of the pulmonary involvement (n = 102)Macroscopic examination of the fluid was not reported in 12 cases BAL bronchoalveolar lavage, CT computed tomography, ICU intensive care unit, PCR polymerase chain reaction Risk factors associated with the need for invasive mechanical ventilation in patients with VZV pneumonia. OR odds ratio, SOFA Sequential Organ Failure Assessment Recurrent varicella-zoster virus infections in apparently immunocompetent children Reinfection with varicella-zoster virus in immunocompromised patients Varicella-zoster virus antibody avidity and IgG-subclass patterns in children with recurrent chickenpox Identifying cancer subjects with acute respiratory failure at high risk for intubation and mechanical ventilation Predictors of noninvasive ventilation failure in patients with hematologic malignancy and acute respiratory failure Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study Varicella-zoster virus pneumonitis Bacterial complications of primary varicella in children Corticosteroids in life-threatening varicella pneumonia Effect of corticosteroids on adult varicella pneumonia: cohort study and literature review Combining corticosteroids and acyclovir in the management of varicella pneumonia: a prospective study Corticosteroids as adjunctive therapy for severe Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. A double-blind, placebo-controlled trial A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. California Collaborative Treatment Group Efficacy and safety of corticosteroids for community-acquired pneumonia: a systematic review and meta-analysis The influence of corticosteroid treatment on the outcome of influenza A(H1N1pdm09)-related critical illness
132 :: 0.196 :: 2069893
In this analysis, a total of 175 patients were admitted to ICUs and received mechanical ventilation during the study period. Most of the patients were below 1 month (89% of the whole population) and 59% were boys. A total of 30 (17%) of this study population died after the date of mechanical ventilation with a median survival time of 16 days (IQR 7-37 days). The mortality rate was 9.9 per 1000-person years (95%, CI 6.96 to 14.25). The Kaplan-Meier survival curves for 30-day ICU mortality as shown in Figure 3. The curve shows that by the end of one month, 75% of patients on mechanical ventilation are still alive. The characteristic of the population as demonstrated in Table 3. The main source of the admission of those neonates was labor and delivery by C-section, with the mean gestational week being 32 (SD 5) weeks. Prematurity with respiratory problems (50%) was the main recorded cause of the initiation of mechanical ventilation, followed by respiratory distress syndrome (37%). The majority of admissions to ICUs were premature. Neonates who received mechanical ventilation within the first month of their life and who were born extremely preterm had a high mortality rate after the initiation of mechanical ventilation. A total of 169 (96%) of the neonates were intubated in ICU while only 3% had already been intubated before their ICU admission. Variables related to mechanical ventilation parameters on day one of mechanical ventilation are presented in Table 3. For the results of the univariate analysis of factors associated with mortality among this population, Table 4 shows that neonates who received mechanical ventilation within the first month of life and who were born extremely preterm had a high mortality rate after the initiation of mechanical ventilation. In addition, those neonates who had respiratory distress syndrome as the cause of initiating the mechanical ventilation had a high rate of mortality; however, the univariate analysis showed no significant association. Neonates who had congenital anomalies as the cause of receiving mechanical ventilation were more likely to have a lower survival rate (OR 13, 95% CI 2.68-62.8). Results Table 3: Demographic, clinical characteristics, and initial ventilator modes of the pediatric patients on the inanition of the mechanical ventilation in the ICU between 2016-2018 (N=175). Table 3: Demographic, clinical characteristics, and initial ventilator modes of the pediatric patients on the inanition of the mechanical ventilation in the ICU between 2016-2018 (N=175). Table 4: The univariate analysis of factors associated with mortality among adult patients who admitted to ICU and received mechanical ventilation between 2016-2018. Figure 3: Kaplan-Meier curves of the probability of survival overtime for pediatric mechanical ventilated patients (N=175) admitted to the intensive care unit between 2016-2108.
132 :: 0.199 :: 1979939
In this analysis, a total of 175 patients were admitted to ICUs and received mechanical ventilation during the study period. Most of the patients were below 1 month (89% of the whole population) and 59% were boys. A total of 30 (17%) of this study population died after the date of mechanical ventilation with a median survival time of 16 days (IQR 7-37 days). The mortality rate was 9.9 per 1000-person years (95%, CI 6.96 to 14.25). The Kaplan-Meier survival curves for 30-day ICU mortality as shown in Figure 3 . The curve shows that by the end of one month, 75% of patients on mechanical ventilation are still alive. The characteristic of the population as demonstrated in Table 3 . The main source of the admission of those neonates was labor and delivery by C-section, with the mean gestational week being 32 (SD 5) weeks. Prematurity with respiratory problems (50%) was the main recorded cause of the initiation of mechanical ventilation, followed by respiratory distress syndrome (37%). The majority of admissions to ICUs were premature. Neonates who received mechanical ventilation within the first month of their life and who were born extremely preterm had a high mortality rate after the initiation of mechanical ventilation. A total of 169 (96%) of the neonates were intubated in ICU while only 3% had already been intubated before their ICU admission. Variables related to mechanical ventilation parameters on day one of mechanical ventilation are presented in Table 3 . For the results of the univariate analysis of factors associated with mortality among this population, Table 4 shows that neonates who received mechanical ventilation within the first month of life and who were born extremely preterm had a high mortality rate after the initiation of mechanical ventilation. In addition, those neonates who had respiratory distress syndrome as the cause of initiating the mechanical ventilation had a high rate of mortality; however, the univariate analysis showed no significant association. Neonates who had congenital anomalies as the cause of receiving mechanical ventilation were more likely to have a lower survival rate (OR 13, 95% CI 2.68-62.8). Demographic Demographic The univariate analysis of factors associated with mortality among adult patients who admitted to ICU and received mechanical ventilation between 2016-2018. Values are presented as numbers and percentage (%). CI -confidence interval mortality, as 72% such patients died in ICUs. Kaplan-Meier curves of the probability of survival overtime for pediatric mechanical ventilated patients (N=175) admitted to the intensive care unit between 2016-2108.
132 :: 0.278 :: 1258014
Patient delay was defined as the number of days from the onset of illness to hospital admission. Length of stay (for either hospital or ICU) was defined as the number of days from admission to discharge or death. Re-admission b7 days after discharge was considered as a continuous stay. ICU admission criteria included a quick deteriorating disease course with potential need for vasopressive therapy and/or mechanical ventilation. Organ failure was defined when ≥3 points on the SOFA scale were scored for a particular organ system [15] . Circulatory failure was defined as a mean arterial pressure (MAP) b65 mmHg, a decrease in MAP N20 mmHg relative to baseline, the need for vasopressive therapies or intravenous fluids (N40 mL/kg) for ≥24 h. Respiratory failure was defined as the need for any form of respiratory support, hepatic failure as a total bilirubin level N 20 μmol/L, central nerve system (CNS) failure as a Glasgow Coma Scale (GCS) b14 in the absence of sedatives, opioids or delirium. Hematological failure was defined as leukopenia, thrombocytopenia and/or anemia. Renal failure was defined as a twofold rise in serum creatinine level relative to baseline, 50% reduction of glomerular filtration rate (GFR) or a urine production b0.5 mL/kg/h for N12 h. Disease severity scores SAPS 2 and APACHE III were calculated in all ICU patients. Data collection and study design The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. on behalf of the working group on sepsis-related problems of the european society of intensive care medicine
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Duration of corticosteroid treatment was 21.2 ± 6.1 days (range 11-28). All but one patient improved lung function, were extubated, and discharged alive from the ICU. The ICU nonsurvivor was a 46-year-old male smoker with a history of alcohol abuse, admitted with septic shock and severe ARDS, negative H1N1 RT-PCR, dysfunction of five vital organs (APACHE II and SOFA scores 20 and 16, respectively), failed to improve lung injury score by day 7 of ARDS, and died on ICU day 15 with progression of MODS. One hospital nonsurvivor, a 60-year-old moderately obese (BMI [35) female with COPD, positive H1N1 RT-PCR, without shock at study entry, was extubated after 7 days of mechanical ventilation and died after ICU discharge as a result of cardiac arrest (electromechanical dissociation) preceded by sudden onset of severe dyspnea. Pulmonary embolism was suspected, but autopsy was not obtained. Hospital mortality in patients with and without shock was similar (12.5 vs. 20%). All hospital survivors were discharged home without oxygen supplementation and were alive at day 60. At the physician discretion, outpatient tapering was continued in all those with severe ARDS (5.3 ± 2.8 days) and in four without severe ARDS (3.4 ± 3.2 days). Results
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Duration of corticosteroid treatment was 21.2 ± 6.1 days (range 11–28). All but one patient improved lung function, were extubated, and discharged alive from the ICU. The ICU nonsurvivor was a 46-year-old male smoker with a history of alcohol abuse, admitted with septic shock and severe ARDS, negative H1N1 RT-PCR, dysfunction of five vital organs (APACHE II and SOFA scores 20 and 16, respectively), failed to improve lung injury score by day 7 of ARDS, and died on ICU day 15 with progression of MODS. One hospital nonsurvivor, a 60-year-old moderately obese (BMI >35) female with COPD, positive H1N1 RT-PCR, without shock at study entry, was extubated after 7 days of mechanical ventilation and died after ICU discharge as a result of cardiac arrest (electromechanical dissociation) preceded by sudden onset of severe dyspnea. Pulmonary embolism was suspected, but autopsy was not obtained. Hospital mortality in patients with and without shock was similar (12.5 vs. 20%). All hospital survivors were discharged home without oxygen supplementation and were alive at day 60. At the physician discretion, outpatient tapering was continued in all those with severe ARDS (5.3 ± 2.8 days) and in four without severe ARDS (3.4 ± 3.2 days). Results
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In the analysis of adult population, a total of 262 patients were admitted to ICUs and received mechanical ventilation during the study period. The mean age of those patients was 57 (SD 21) years, and the majority were male (64%). Of 262 patients, 98 patients died after receiving mechanical ventilation. Thus, the overall mortality for patients admitted to ICUs and receiving mechanical ventilation during the study period was 37%, with a median survival time in the ICU of 11 days (IQR 6-20 days). Because the average duration of mechanical ventilation was 11 days, the analysis was restricted to within 30 days of receiving mechanical ventilation. The mortality rate was 27.3 per 1000-person years (95% CI 22.4 to 33.2). The Kaplan-Meier survival curves for 30-day ICU mortality is shown in Figure 2. At the end of 30 days after receiving the mechanical ventilation, the overall survival rate was 82% after the fifth day and 75% after the tenth day of receiving the mechanical ventilation. Results Figure 2: Kaplan-Meier curves of the probability of survival over time for adult mechanical ventilated patients (N=262) admitted to the intensive care unit between 2016-2018.
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The median SOFA score on day 1 was 4 (3–7). A chest CT was performed in 31 (30%) patients and was never normal. Common abnormalities were diffuse bilateral centrolobular nodules with tree-in-bud appearance (n = 14, 50%) and diffuse ground glass opacities (n = 11, 39%) (Fig. 1). Alveolar consolidations were also reported (n = 14, 50%). Fiberoptic bronchoscopy was performed in 35 (35%) patients and demonstrated vesicular lesions or ulcerations on bronchial mucosa in 13 (36%) cases. PCR for VZV in the bronchoalveolar lavage was tested in 24 patients and yielded a positive result in 96% of cases. Noninvasive mechanical ventilation was implemented in 29 (28%) patients, failing in 19 (66%) who were subsequently intubated. Invasive mechanical ventilation was used in 52 (51%) patients overall, of whom 42 (80.8%) fulfilled the ARDS criteria according to the Berlin definition (Table 3). Patients were intubated 1 (1–2) day after ICU admission. Three factors were independently associated with the need for invasive mechanical ventilation: SOFA score on day 1 (odds ratio (OR) 1.90 (1.33–2.70); p < 0.001), oxygen flow at ICU admission (OR 1.25 (1.08–1.45); p = 0.004), and early bacterial co-infection (OR 14.94 (2.00–111.8); p = 0.009) (Table 4 and Fig. 2). Vasopressors were required in 36 (35%) patients and renal replacement therapy in 24 (24%). Among the 102 patients, 40 (39%) patients had documented bacterial co-infection with 20 (50%) early infections (documented within 72 h after ICU admission) and 20 (50%) late infections. The primary sources of co-infections were the lungs (n = 24, 60%), bloodstream (n = 8, 20%), and skin (n = 4, 10%), with Staphylococcus aureus being the most often recovered pathogen (n = 12, 30%). The median ICU and hospital length of stay were 8 (4–16.75) days and 14 (9–33) days, respectively. Duration of mechanical ventilation was 14 (7–21) days. ICU management ::: Results Table 3: ICU management and outcome data Values are shown as n (%) or median (25th–75th percentiles) AKI acute kidney injury, ARDS acute respiratory distress syndrome, ECMO extra-corporeal lung oxygenation, ICU intensive care unit, VZV varicella-zoster virus Table 4: Multivariate analysis of factors associated with the need for invasive mechanical ventilation during ICU stay Results are presented for the imputed data Candidate predictors were: age, any comorbidity, underlying immunosuppression, SOFA score at day 1, oxygen flow at ICU admission, alveolar consolidation on chest X-ray, antibiotics at ICU admission, and early bacterial co-infection CI confidence interval, ICU intensive care unit, OR odds ratio, SOFA Sequential Organ Failure Assessment Fig. 1: Imaging characteristics from lung CT. A 46-year-old woman was admitted to the ICU for acute respiratory failure. She underwent kidney transplantation 12 years ago. She reported fever and a typical chickenpox skin rash 5 days before admission. The onset of respiratory symptoms started 2 days before ICU admission and invasive mechanical ventilation was implemented at day 1. She developed a severe ARDS requiring prone positioning, neuromuscular blockers, and 14 days of invasive mechanical ventilation. Lung CT scan demonstrated diffuse bilateral nodules, patchy ground glass opacities, and interlobular septal thickening. A fiber bronchoscopy with bronchoalveolar lavage documented a Staphylococcus aureus co-infection. She received intravenous aciclovir 10 mg/kg/8 h during 15 days associated with 10 days of oxacilline and was discharge alive from the ICU 17 days after admission Fig. 2: Risk factors associated with the need for invasive mechanical ventilation in patients with VZV pneumonia. OR odds ratio, SOFA Sequential Organ Failure Assessment
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In the analysis of adult population, a total of 262 patients were admitted to ICUs and received mechanical ventilation during the study period. The mean age of those patients was 57 (SD 21) years, and the majority were male (64%). Of 262 patients, 98 patients died after receiving mechanical ventilation. Thus, the overall mortality for patients admitted to ICUs and receiving mechanical ventilation during the study period was 37%, with a median survival time in the ICU of 11 days (IQR 6-20 days). Because the average duration of mechanical ventilation was 11 days, the analysis was restricted to within 30 days of receiving mechanical ventilation. The mortality rate was 27.3 per 1000-person years (95% CI 22.4 to 33.2). The Kaplan-Meier survival curves for 30-day ICU mortality is shown in Figure 2 . At the end of 30 days after receiving the mechanical ventilation, the overall survival rate was 82% after the fifth day and 75% after the tenth day of receiving the mechanical ventilation. Kaplan-Meier curves of the probability of survival over time for adult mechanical ventilated patients (N=262) admitted to the intensive care unit between 2016-2018.
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In univariable analyses, indicators of disease severity (SOFA score, SAPS-II score), transferral from another hospital to the study hospital, length of ICU stay, overall length of hospital stay until discharge from ICU (including ICU stay) and mechanical ventilation at discharge from ICU were significantly associated with the number of days hospitalized during the first year after ICU (Table 3). There was no significant association with any of the sociodemographic variables. Analytical results ::: Results Table 3: Univariable negative binomial regression analyses of days of hospitalization after discharge from ICU IRR incidence rate ratio, SE standard error, 95% CI 95% confidence interval, SAPS-II Simplified Acute Physiology Score-II, SOFA sequential organ failure assessment, GCS Glasgow Coma Scale aDerived from educational and professional levels [36] bIncluding stay in transferring hospital
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We analyzed nine patients (six male), who had a median age of 39 (21 to 72) years, APACHE II score 14 (5 to 23) and SOFA score 9 (6 to 15). All patients had a pulmonary origin of their ARDS and were on their fi rst day of ventilation. At baseline patients had a PaO 2 /FiO 2 ratio of 141 (71 to 280), compliance of 32 (17 to 43) ml/cmH 2 O, and PEEP of 12 (10 to 16) cmH 2 O. In the Vt arms 4 and 6 ml/kg, Vts were 260 (210 to 300) and 350 (310 to 400) ml, respectively (P <0.01), respiratory rates were 37 (31 to 42) and 25 (21 to 28) breaths per minute (P <0.01), and PaO 2 levels were 84 (54 to 148) and 83 (61 to 162) mmHg (P = 0.3). PEEP and FiO 2 were kept constant. PaCO 2 did not signifi cantly increase with Vt 4 but repeated O/C (delta nonaerated tissue) consistently decreased ( Figure 1 ). Introduction Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are associated with signifi cant morbidity and mortality. Mechanical ventilation is the cornerstone of supportive therapy. However, the optimal strategy of ventilation and adjunctive therapies are still evolving. There is evidence to support the use of volume-limited and pressure-limited lung-protective ventilation but practice variability in the clinical management is still a concern mainly in sicker patients. and hospital outcome have not found a consistent outcome association. We hypothesized that severity of hypoxemia on admission after optimal ventilation may predict hospital outcome if the ARDS patients are categorised based on the primary etiology: pulmonary ARDS (ARDS p ) and extra pulmonary ARDS (ARDS exp ). Our aim was therefore to ascertain the relationship between hospital outcome and the severity of hypoxemia in patients with early ARDS (days 1 to 3 following admission) after categorising based on etiology. Results Venet F et al.: Intensive Care Med 2009, 35:678-686.
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The current study shows that comorbidity phenotypes of COPD is associated with short term outcome and ICU mortality following exacerbation. under this nosological framework. Most of these carry prognostic information with a potential impact on the clinical decisions that could be made during the management of these patients. The aim of the study is to assess the frequency of patients admitted for hypercapnic respiratory failure without prior pulmonary diagnosis, and assign a final diagnosis with emphasis on morbid overlaps. Patients and methods: In consecutive patients admitted in the ICU for hypercapnic respiratory failure demographic and clinical data pertaining to current and prior hospitalisations were recorded. Patients were managed for the acute episode, and when they were considered for ICU discharge, the following was performed-pulmonary CT scan with particular emphasis on emphysema and fibrosis patterns, spirometry for the diagnosis of obstructive lung disease, transthoracic cardiac echography, and nocturnal polygraphy for the diagnosis of sleep apnea syndrome (AHI ≥ 5). Results: During the study period, 107 patients (mean age 66 ± 6 years, 63% male) were consecutively admitted for severe hypercapnic respiratory failure requiring ventilatory support. NIV was started in 83% patients with a failure rate 20%. Table 1 reports the pulmonary diseases eventually adjudicated at admission, and at ICU discharge. Conclusion: Reliable information on actual lung diseases of patients admitted for hypercapnic respiratory failure is often lacking at ICU admission. Our study highlights the frequency of COPD, bronchiectasis, and obesity-hypoventilation syndrome in these patients. Overlaps are frequently present in these patients with a need for characterization of their evolutionary genius in the short and long term. Introduction: Despite the wide spread use of home mechanical ventilation (HMV) to treat chronic hypercapnic respiratory failure, compliance with HMV among patients has seldom been systematically studied. Evaluating outcomes for ICU survivors requiring home mechanical ventilation is also interesting. The aim was to determine patients' compliance to home mechanical ventilation indicated at discharge and to determine patients' outcomes and quality of life within three months after discharge. Patients and methods: It is a retros pective observational study conducted in a 9-bed medical ICU. All consecutive patients discharged from ICU with home mechanical ventilation between January, 1st 2015 and of December, 31st 2017 were included. Data collected involved patients' demographics, past history and underlying diseases, functional state, clinical, paraclinical, therapeutic and ICU stay course characteristics. At discharge, data on types, modes and indications of home mechanical ventilation, were gathered. Compliance reports were obtained from providers after one to three months of use. Vital status and quality of life as assessed by the St. Georges Hospital on Respiratory Problems (SGRQ), were estimated via phone calls at three months after discharge. Results: Among a to tal of 717 ICU admitted patients, 635 required mechanical ventilation. 66(10.4%) patients were discharged with HMV, 38(57.6%) via non-invasive ventilation and 28(42.4%) on tracheostomy (TPPV). They were 61.5 ± 14.4 mean age. They had predominantly chronic respiratory failure, 60(91%) + 45(68.2%), COPD 35(58.3%), mMRC score at III and IV + 18(27.3%), already on HMV, 34(51.5%) patients had at least two comorbidities with Charlson comorbidity index at 2 [1] [2] [3] [4] . On admission, mean SAPSII, 26 ± 11 with a median ICU stay at 15[10-27] days. After discharge, compliance reports were obtained, only for 20(26%) patients. Respectively, mean percentage daily use of home NIV and TPPV (≥ 4 h per day) were respectively, 92 ± 11% and 96 ± 6%. Twelve patients (18.2%) were readmitted. Mortality at three months was estimated at 19(28.8%). Health related quality of life assessed by SGQR showed a significant impairment, mean total score, 47 ± 7 + (symptoms score, 27 ± 16 + activities score, 44 ± 18 + impacts score, 52 ± 8) compared to population norms (total score, 12 + symptoms score, 16 + activity score, 16 + impacts score, 8) . Conclusion: Factors associated with Aspergillosis-positive lower respiratory tract specimen culture in multivariate analysis Service de Médecine Intensive et Réanimation, Hôpital Delafontaine Emmanuelle Guérin -emmanuelle.guerin@aphp.fr Annals of Intensive Care Intensive Cardiac Care Unit, Cardiology department
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Introduction Contrary to wards that manage usually chronic or acute pain (algology, gerontology, surgery, recovery room, and so forth), a comparison of the fi ve most popular self-report pain tools (vertical and horizontal Visual Analog Scale (VAS-V, VAS-H), 0 to 10 oral Numeric Rating Scale (NRS-O), 0 to 10 visual enlarged NRS (NRS-V), Verbal Descriptor Scale (VDS)) has never been evaluated in an ICU setting. Methods Consecutive patients admitted to a medical-surgical ICU during 1 year were included when alert (RASS >-2) and able to follow simple commands. Exclusion criteria: previous self-report pain assessment without the presence of an investigator. Pain assessment using the fi ve scales in random order either at baseline (T1) and after (T2) administration of an analgesic, or during a nociceptive procedure, in absence of pain at baseline. Evaluated parameters: psychometric properties of scales (feasibility, validity, responsiveness and preference). Nonparametric tests were used for statistical analysis (Statview 5.0). Data are expressed as median (25th to 75th). Results All basal levels were below the expected values. Following enteral administration, pharmacological levels were already reached in 5 minutes, with a serum peak after 16 minutes (half-absorption time: 3 minutes 17 seconds). The maximum serum level observed was 11,040 pg/ml and the disappearance rate indicated a half-elimination time of 1 hour 34 minutes. Serum melatonin levels decreased signifi cantly after midnight; pharmacological levels were maintained up to 10 hours following administration. No excessive sleepiness was reported in this patient group. Conclusions Critically ill patients exhibited reduced melatonin secretion, as reported in the literature. Despite the critical illness, the oral bioavailability was satisfactory: serum levels after oral administration showed basically unchanged intestinal absorption, while the disappearance rate was slower than reported elsewhere in healthy volunteers. Introduction The aim of our study is to describe clinical progress, need for mechanical ventilation (MV), complications and mortality of patients with delirium tremens (DT) admitted to our ICU. Methods Patients with a diagnosis of DT admitted to a medical ICU of a tertiary hospital from January 2001 to December 2008 were included. We recorded: admission diagnosis, pathologies associated with DT, APACHE II score, treatment, need for MV and duration, complications, length of stay in the ICU and total hospital stay, mortality and survival at 2 years. Results There were 50 cases of DT. Median age 45 years, 96% male. Reasons for hospital admission: DT (68%), seizures (36%), sepsis (16%), brain injury (10%). Reasons for admission to the ICU: DT (54%), DT and seizures (26%), DT and brain injury (10%), DT and sepsis (8%), DT and other (2%). Median APACHE II score was 9 (range: 8 to 13). Seventy-four percent of the patients were controlled with no need for MV with a midazolam infusion of 45 to 50 μg/kg/hour and haloperidol of 17 to 30 μg/kg/hour. Twenty-eight per cent (14 patients) required MV, of them 78% had DT and other associated pathology on admission (Figure 1 ). From a total of 28 patients admitted with DT and no associated pathology, only four needed MV. The median time on MV was 2 days (range: 1 to 9). Complications were present in 22%: ventilation-associated pneumonia, and other infectious conditions. Total hospital length of stay 14 days ((SD: 11), 5.5 days in the ICU (SD: 9). The registered hospital mortality was 4%. Rate of survival at 2 years was 84%, from these 72% had continuous visits to emergency (≥5 consultations in 2 years) for episodes related to alcohol withdrawal or complications associated with chronic alcohol abuse. Conclusions Venet F et al.: Intensive Care Med 2009, 35:678-686.
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The median time from illness onset (ie, before admission) to discharge was 22·0 days (IQR 18·0-25·0), whereas the median time to death was 18·5 days (15·0-22·0; table 2). 32 patients required invasive mechanical ventilation, of whom 31 (97%) died. The median time from illness onset to invasive mechanical ventilation was 14·5 days (12·0-19·0). Extracorporeal membrane oxygenation was used in three patients, none of whom survived. Sepsis was the most frequently observed complication, followed by respiratory failure, ARDS, heart failure, and septic shock (table 2). Half of non-survivors experienced a secondary infection, and ventilator-associated pneumonia occurred in ten (31%) of 32 patients requiring invasive mechanical ventilation. The frequency of complications were higher in non-survivors than survivors (table 2) . In univariable analysis, odds of in-hospital death was higher in patients with diabetes or coronary heart disease (table 3) . Age, lymphopenia, leucocytosis, and elevated ALT, lactate dehydrogenase, high-sensitivity cardiac troponin I, creatine kinase, d-dimer, serum ferritin, IL-6, prothrombin time, creatinine, and procalcitonin were also associated with death (table 3) . Results Treatments and outcomes Risk factors associated with in-hospital death Risk factors associated with in-hospital death
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Between September 2009 and March 2011, we included 40 adult critically ill patients with confirmed H1N1 infection: 24/40 (60 %) in UZL and 16/40 (40 %) in UZA (Table 1). The total number of admissions during the study period was 5,260. Eighteen of 40 (45 %) patients had H1N1 in the 2009 season, while 22/40 (55 %) had H1N1 in the 2010 season. H1N1 infection was diagnosed during ICU stay in 31/40 (78 %) patients, while H1N1 was diagnosed shortly before ICU admission in 9/40 (22 %) patients. The patients had mean age of 49 ± 14 years, and 23/40 (58 %) were men. On admission, the mean APACHE II score was 23 ± 8 and the median SOFA score was 11 (5–13), reflecting a high severity of illness and a high incidence of MODS. Thirty-five patients (88 %) were mechanically ventilated for median duration of 11 (5–13) days. Seven patients (18 %) received CS during ICU stay as rescue therapy for “late ARDS.” Twenty-one (52 %) patients needed rescue therapy with NO ventilation for refractory hypoxemia, and 11 (28 %) of these patients received ECMO. Other baseline factors are described in Table 1. Patient characteristics ::: Results Table 1: Overview of the characteristics of all patients All = the combination of known IPA risk factors: COPD, cirrhosis, hematological disease (hemato), solid organ transplant (Tx) recipient or any other illness necessitating immunosuppressive therapy (other) IPA invasive pulmonary aspergillosis, APACHE Acute Physiology and Chronic Evaluation Score, SOFA Sequential Organ Failure Assessment, BMI body mass index, COPD chronic obstructive pulmonary disease, CS corticosteroids, NO/HFOV nitric oxide/high-frequency oscillation ventilation, ECMO extracorporeal membrane oxygenation, ICU intensive care unit * p < 0.05 a4/14 patients received corticosteroids (CS) as outpatients prior to ICU admission, 5/14 received CS in hospital prior to ICU admission, and 5/14 received CS as outpatients and in hospital prior to ICU admission Table 1: Overview of the characteristics of all patients All = the combination of known IPA risk factors: COPD, cirrhosis, hematological disease (hemato), solid organ transplant (Tx) recipient or any other illness necessitating immunosuppressive therapy (other) IPA invasive pulmonary aspergillosis, APACHE Acute Physiology and Chronic Evaluation Score, SOFA Sequential Organ Failure Assessment, BMI body mass index, COPD chronic obstructive pulmonary disease, CS corticosteroids, NO/HFOV nitric oxide/high-frequency oscillation ventilation, ECMO extracorporeal membrane oxygenation, ICU intensive care unit * p < 0.05 a4/14 patients received corticosteroids (CS) as outpatients prior to ICU admission, 5/14 received CS in hospital prior to ICU admission, and 5/14 received CS as outpatients and in hospital prior to ICU admission
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Results: Overall, 219 patients were included. 138 (63%) were of male gender and median age was of 55 (IQR 44–64). Acute myeloid leukemia (30.1%) and non-Hodgkin lymphoma (22.8%) were the most frequent malignancies. 134 patients were neutropenic at study inclusion (62%), and 53 were allogeneic stem cell recipients (24.2% + including 64.2% who suffered from Graft-versus-Host Disease) and 22 receiving antifungal prophylaxis (10%). Median SOFA score at admission was 9 [7–12] and median time before introduction of invasive mechanical ventilation was 1 [0–3] day. 154 patients (70.3%) had positive serum galactomannan and 136 (62.1%) a positive culture. ICU and 6-months mortality remained unchanged during the 20-years study period, being respectively 58.4% and 80.1% (Figure 1A). Need for invasive mechanical ventilation, at admission or following failure of non-invasive techniques, was associated with a high mortality rate (Figure 1B). Use of Voriconazole (HR 0.67, IC95 0.48–0.94) and focal radiologic pulmonary infiltrate (HR 0.58, IC95 0.41–0.80) were independently associated with better survival by multivariable analysis adjusted on day-1 SOFA score (HR 1.1, IC95%1.06–1.15). Correspondence: Emmanuel Pardo - pardo.emmanuel@gmail.com ::: 1CHU Saint-Antoine, Paris, FRANCE; 2Hôpital Saint-Louis, Paris, FRANCE; 3Institut Paoli-Calmettes, Marseille, FRANCE; 4Institut Gustave Roussy, Villejuif, FRANCE; 5Hôpital Albert Calmette, Lille, FRANCE ::: Emmanuel Pardo (speaker)1, Virginie Lemiale2, Djamel Mokart3, Annabelle Stoclin4, Anne-SophieMoreau5, Lionel Kerhuel2, Etienne Ghrenassia 2, Laure Calvet2, Audrey De Jong2, Sandrine Valade2, Eric Mariotte2, Lara Zafrani2, Michael Darmon2, Elie Azoulay2 ::: CO-09 Invasive Pulmonary Aspergillosis in Critically Ill Patients with Hematological Malignancies ::: Oral communications: Doctors
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Introduction Ventilator-associated pneumonia (VAP) is a frequently occurring nosocomial infection in ICU patients and has been associated with increased morbidity, prolonged duration of ventilation and ICU stay and increased costs for healthcare. It was shown that early diagnosis of VAP and immediate initiation of appropriate antibiotics is associated with reduced morbidity and mortality. The aim of this study is to evaluate the potential ability of a screening test based on the clinical pulmonary infection score (CPIS) to identify and treat patients with VAP. Methods All fi les belonging to patients between 18 and 80 years old admitted to the ICU and supported by mechanical ventilation for longer than 48 hours were evaluated retrospectively. Demographic data of the patients, the time of mechanical ventilation, duration of the ICU stay and results (survival or death) were recorded. The CPIS was calculated after 48 hours for the diagnosis of VAP. The patients with CPIS >5 intubated were evaluated VAP(+) and the others with CPIS ≤5 were thought VAP(-). The diagnosis of VAP was bacteriologically confi rmed with the culture of endotracheal aspirate. Statistical evaluations were done according to the results on the day of intubation and the results on days 2, 3, 5, 8 and 10 after intubation. Scores of APACHE II and CRP levels were also recorded on the same days. References
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