Person:

Camargo, Carlos

Background: We aimed to investigate mortality trends in hospitalized patients with septic shock in the US. To achieve this objective, we tested hypothesis that mortality decreased in patients identified by the code of septic shock while mortality did not change in those with septic shock identified by vasopressor use. Methods: We conducted a serial cross-sectional analysis using Nationwide Inpatient Sample database from 2005 through 2011. First, we identified all adult patients aged ≥18 years hospitalized for septic shock by the following criteria: 1) primary ICD-9 diagnosis of infection plus procedure code for vasopressor use, 2) primary ICD-9 diagnosis of infection plus septic shock in non-primary field, and 3) primary ICD-9 diagnosis of septic shock. Second, we stratified all identified patients by record of vasopressor use. The outcome of interest was year-to-year changes in the in-hospital all-cause mortality. Results: From 2005 to 2011, we identified 109,812 weighted hospitalizations with septic shock. Overall, there was a significant downward trend in in-hospital mortality (from 46 % in 2005 to 42 % in 2011; Ptrend = 0.003); the adjusted mortality also decreased significantly (OR for comparison of 2005 with 2011, 0.98; 95 % CI, 0.96–1.00; P < 0.001). In stratified analysis, the mortality trend was not significant in the subgroup with vasopressor use (from 42 % in 2005 to 40 % in 2011; Ptrend =0.57); similarly, the adjusted mortality did not change significantly (OR, 1.01; 95 % CI, 0.97–1.05; P =0.62). By contrast, there was a downward trend in mortality in the subgroup without vasopressor use (from 47 % in 2005 to 43 % in 2011; Ptrend =0.002); likewise, the adjusted mortality decreased significantly (OR, 0.97; 95 % CI, 0.95–0.99; P =0.002) Conclusions: From 2005 to 2011, we found a modest decrease in in-hospital mortality among patients identified with septic shock. However, in the subgroup with vasopressor use, we found no significant change in mortality. Our data challenge the conventional wisdom that mortality in this population has improved during the last decade. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1620-1) contains supplementary material, which is available to authorized users.

Purpose Recent studies propose TH2-mediated inflammation in patients with asthma–chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS). However, little is known about whether fractional exhaled nitric oxide (FeNO) differs between patients with ACOS and those with COPD alone. To address this knowledge gap, a nationally representative sample was analyzed to determine the difference in FeNO levels between patients with ACOS and those with COPD alone in the US population. Patients and methods This is a cross-sectional analysis of the National Health and Nutrition Examination Survey from 2007 through 2012. All subjects aged ≥40 years with COPD were identified. ACOS was defined as self-reported wheezing in past 12 months plus bronchodilator response (forced expiratory volume increase of >200 mL and >12%) or self-reported physician diagnosis of asthma. Results: A total of 197 subjects with COPD were identified in the National Health and Nutrition Examination Survey. Of these, 23% met the criteria of ACOS. The FeNO level was higher in subjects with ACOS compared with those with COPD alone in both unadjusted (mean 21.2 ppb vs 13.0 ppb; difference, 8.2 [95% CI, 0.2 to 16.2]; P=0.045) and adjusted (difference, 8.2 [95% CI, 0.9 to 15.5]; P=0.03) analyses. Although there was no significant difference among current smokers, the FeNO level was significantly higher in non-current smokers with ACOS than nonsmokers with COPD alone (mean 31.9 ppb vs 20.3 ppb; adjusted difference, 20.5 [95% CI, 4.4 to 36.6]; P=0.02). In a sensitivity analysis using an alternative definition of ACOS, the results did not change materially. The diagnostic value of FeNO to discriminate ACOS from COPD alone was not sufficient, with the area under the curve of 0.63 (95% CI, 0.54 to 0.72). Conclusion: By using nationally representative US data, it was found that 23% of COPD subjects met the ACOS criteria and also that the FeNO level was higher in subjects with ACOS compared with those with COPD alone, particularly in non-current smokers.

Background: Obesity and heart failure (HF) are important public health problems in the United States. Although studies have reported the association between obesity and higher chronic morbidity of HF, little is known about the relations of obesity with severity of HF exacerbation and in‐hospital mortality; therefore, we aimed to investigate the associations of obesity with severity of HF exacerbation and in‐hospital mortality. Methods and Results: This retrospective cohort study of adults hospitalized for HF exacerbation used population‐based data sets (the State Inpatient Databases) of 7 US states from 2012 to 2013. The outcomes were acute severity measures—use of positive pressure ventilation and hospital length of stay—and in‐hospital mortality. We determined the associations between obesity and these outcomes, including adjustment for sociodemographic factors and comorbidities. We identified 219 465 patients hospitalized for HF exacerbation. Of those, 37 539 (17.1%) were obese. Obese patients had a significantly higher risk of positive pressure ventilation use compared with nonobese patients (13.6% versus 8.8%), with a corresponding adjusted odds ratio of 1.61 (95% confidence interval, 1.55–1.68; P<0.001). Likewise, obese patients were more likely to have hospital length of stay of ≥4 days compared with nonobese patients (62.5% versus 56.7%), with an adjusted odds ratio of 1.40 (95% confidence interval, 1.37–1.44; P<0.001). In contrast, obese patients had significantly lower in‐hospital mortality compared with nonobese patients (1.7% versus 3.3%), with an adjusted odds ratio of 0.87 (95% confidence interval, 0.80–0.95; P=0.002). Conclusions: Based on large population‐based data sets of patients with HF exacerbation, obesity was associated with higher acute severity measures but lower in‐hospital mortality.

Introduction: Epidemiological surveillance data for emergency department (ED) visits by children are imperative to guide resource allocation and to develop health policies that advance pediatric emergency care. However, there are sparse population-based data on patient-level information (e.g., the number of children who present to the emergency department [ED]). In this context, we aimed to investigate both the patient- and visit-level rates of ED utilization by children. Methods: This was a retrospective cohort study using population-based multipayer data – state ED databases (SEDD) and state inpatient databases (SID) – from six geographically-dispersed U.S. states (California, Florida, Iowa, Nebraska, New York, and Utah) in 2010 and 2011. We identified all children aged <18 years who presented to the ED and described the patient-level ED visit rate, visit-level ED visit rate, and proportion of all ED visits made by children. We conducted the analysis using the 2011 SEDD and SID data. We also repeated the analysis using the 2010 data to determine the consistency of the results across different years. Results: In 2011, 2.9 million children with a patient identifier presented to EDs in the six U.S. states. At the patient-level, 15 out of every 100 children presented to an ED at least once per year. Of these children, 25% presented to EDs 2–3 times per year with an approximately 1.5-fold variation across the states (e.g., 19% in Utah vs. 28% in Florida). In addition, 5% presented to EDs ≥4 times per year. At the visit-level, 6.7 million ED visits were made by children in 2011 – 34 ED visits per 100 children annually. ED visits by children accounted for 22% of all ED visits (including both adults and children), with a relatively small variation across the states (e.g., 20% in New York vs. 24% in Nebraska). Analysis of the 2010 data gave similar results for the ED utilization by children. Conclusion: By using large population-based data, we found a substantial burden of ED visits at both patient- and visit-levels. These findings provide a strong foundation for policy makers and professional organizations to strengthen emergency care for children.