Kaewput, Wisit

Background: Lactic acidosis is a heterogeneous condition with multiple underlying causes and associated outcomes. The use of multi-dimensional patient data to subtype lactic acidosis can personalize patient care. Machine learning consensus clustering may identify lactic acidosis subgroups with unique clinical profiles and outcomes. Methods: We used the Medical Information Mart for Intensive Care III database to abstract electronic medical record data from patients admitted to intensive care units (ICU) in a tertiary care hospital in the United States. We included patients who developed lactic acidosis (defined as serum lactate ≥ 4 mmol/L) within 48 h of ICU admission. We performed consensus clustering analysis based on patient characteristics, comorbidities, vital signs, organ supports, and laboratory data to identify clinically distinct lactic acidosis subgroups. We calculated standardized mean differences to show key subgroup features. We compared outcomes among subgroups. Results: We identified 1919 patients with lactic acidosis. The algorithm revealed three best unique lactic acidosis subgroups based on patient variables. Cluster 1 (n = 554) was characterized by old age, elective admission to cardiac surgery ICU, vasopressor use, mechanical ventilation use, and higher pH and serum bicarbonate. Cluster 2 (n = 815) was characterized by young age, admission to trauma/surgical ICU with higher blood pressure, lower comorbidity burden, lower severity index, and less vasopressor use. Cluster 3 (n = 550) was characterized by admission to medical ICU, history of liver disease and coagulopathy, acute kidney injury, lower blood pressure, higher comorbidity burden, higher severity index, higher serum lactate, and lower pH and serum bicarbonate. Cluster 3 had the worst outcomes, while cluster 1 had the most favorable outcomes in terms of persistent lactic acidosis and mortality. Conclusions: Consensus clustering analysis synthesized the pattern of clinical and laboratory data to reveal clinically distinct lactic acidosis subgroups with different outcomes.

Background: Lactic acidosis is the most common cause of anion gap metabolic acidosis in the intensive care unit (ICU), associated with poor outcomes including mortality. We sought to compare machine learning (ML) approaches versus logistic regression analysis for prediction of mortality in lactic acidosis patients admitted to the ICU. Methods: We used the Medical Information Mart for Intensive Care (MIMIC-III) database to identify ICU adult patients with lactic acidosis (serum lactate ≥4 mmol/L). The outcome of interest was hospital mortality. We developed prediction models using four ML approaches consisting of random forest (RF), decision tree (DT), extreme gradient boosting (XGBoost), artificial neural network (ANN), and statistical modeling with forward stepwise logistic regression using the testing dataset. We then assessed model performance using area under the receiver operating characteristic curve (AUROC), accuracy, precision, error rate, Matthews correlation coefficient (MCC), F1 score, and assessed model calibration using the Brier score, in the independent testing dataset. Results: Of 1919 lactic acidosis ICU patients, 1535 and 384 were included in the training and testing dataset, respectively. Hospital mortality was 30%. RF had the highest AUROC at 0.83, followed by logistic regression 0.81, XGBoost 0.81, ANN 0.79, and DT 0.71. In addition, RF also had the highest accuracy (0.79), MCC (0.45), F1 score (0.56), and lowest error rate (21.4%). The RF model was the most well-calibrated. The Brier score for RF, DT, XGBoost, ANN, and multivariable logistic regression was 0.15, 0.19, 0.18, 0.19, and 0.16, respectively. The RF model outperformed multivariable logistic regression model, SOFA score (AUROC 0.74), SAP II score (AUROC 0.77), and Charlson score (AUROC 0.69). Conclusion: The ML prediction model using RF algorithm provided the highest predictive performance for hospital mortality among ICU patient with lactic acidosis.

Background: Lower patient survival has been observed in sickle cell disease (SCD) patients who go on to receive a kidney transplant. This study aimed to assess the post-transplant outcomes of SCD kidney transplant recipients in the contemporary era. Methods: We used the OPTN/UNOS database to identify first-time kidney transplant recipients from 2010 through 2019. We compared patient and allograft survival between recipients with SCD (n = 105) vs. all other diagnoses (non-SCD, n = 146,325) as the reported cause of end-stage kidney disease. We examined whether post-transplant outcomes improved among SCD in the recent era (2010–2019), compared to the early era (2000–2009). Results: After adjusting for differences in baseline characteristics, SCD was significantly associated with lower patient survival (HR 2.87; 95% CI 1.75–4.68) and death-censored graft survival (HR 1.98; 95% CI 1.30–3.01), compared to non-SCD recipients. The lower patient survival and death-censored graft survival in SCD recipients were consistently observed in comparison to outcomes of recipients with diabetes, glomerular disease, and hypertension as the cause of end-stage kidney disease. There was no significant difference in death censored graft survival (HR 0.99; 95% CI 0.51–1.73, p = 0.98) and patient survival (HR 0.93; 95% CI 0.50–1.74, p = 0.82) of SCD recipients in the recent versus early era. Conclusions: Patient and allograft survival in SCD kidney recipients were worse than recipients with other diagnoses. Overall SCD patient and allograft outcomes in the recent era did not improve from the early era. The findings of our study should not discourage kidney transplantation for ESKD patients with SCD due to a known survival benefit of transplantation compared with remaining on dialysis. Urgent future studies are needed to identify strategies to improve patient and allograft survival in SCD kidney recipients. In addition, it may be reasonable to assign risk adjustment for SCD patients.

Background: This study aimed to determine the rates of inpatient palliative care service use and assess the impact of palliative care service use on in-hospital treatments and resource utilization in hospital admissions for hepatorenal syndrome. Methods: Using the National Inpatient Sample, hospital admissions with a primary diagnosis of hepatorenal syndrome were identified from 2003 through 2014. The primary outcome of interest was the temporal trend and predictors of inpatient palliative care service use. Logistic and linear regression was performed to assess the impact of inpatient palliative care service on in-hospital treatments and resource use. Results: Of 5571 hospital admissions for hepatorenal syndrome, palliative care services were used in 748 (13.4%) admissions. There was an increasing trend in the rate of palliative care service use, from 3.3% in 2003 to 21.1% in 2014 (p < 0.001). Older age, more recent year of hospitalization, acute liver failure, alcoholic cirrhosis, and hepatocellular carcinoma were predictive of increased palliative care service use, whereas race other than Caucasian, African American, and Hispanic and chronic kidney disease were predictive of decreased palliative care service use. Although hospital admission with palliative care service use had higher mortality, palliative care service was associated with lower use of invasive mechanical ventilation, blood product transfusion, paracentesis, renal replacement, vasopressor but higher DNR status. Palliative care services reduced mean length of hospital stay and hospitalization cost. Conclusion: Although there was a substantial increase in the use of palliative care service in hospitalizations for hepatorenal syndrome, inpatient palliative care service was still underutilized. The use of palliative care service was associated with reduced resource use.

Background: Antidepressants are one of the most prescribed medications, particularly for patients with mental disorders. Nevertheless, there are still limited data regarding the risk of ventricular arrhythmia (VA) and sudden cardiac death (SCD) associated with these medications. Thus, we performed systemic review and meta-analysis to characterize the risks of VA and SCD among patients who used common antidepressants. Methods: A literature search for studies that reported risk of ventricular arrhythmias and sudden cardiac death in antidepressant use from MEDLINE, EMBASE, and Cochrane Database from inception through September 2020. A random-effects model network meta-analysis model was used to analyze the relation between antidepressants and VA/SCD. Surface Under Cumulative Ranking Curve (SUCRA) was used to rank the treatment for each outcome. Results: The mean study sample size was 355,158 subjects. Tricyclic antidepressant (TCA) patients were the least likely to develop ventricular arrhythmia events/sudden cardiac deaths at OR 0.24, 0.028–1.2, OR 0.32 (95% CI 0.038–1.6) for serotonin and norepinephrine reuptake inhibitors (SNRI), and OR 0.36 (95% CI 0.043, 1.8) for selective serotonin reuptake inhibitors (SSRI), respectively. According to SUCRA analysis, TCA was on a higher rank compared to SNRI and SSRI considering the risk of VA/SCD. Conclusion: Our network meta-analysis demonstrated the low risk of VA/SCD among patients using antidepressants for SNRI, SSRI and especially, TCA. Despite the relatively lowest VA/SCD in TCA, drug efficacy and other adverse effects should be taken into account in patients with mental disorders.

Chronic kidney disease (CKD) is a common clinical problem affecting more than 800 million people with different kidney diseases [...]

SUMMARY Background This study aimed to determine the incidence, as well as evaluate risk factors, and impact of gastrointestinal bleeding on outcomes and resource use in patients admitted for salicylate poisoning. Methods We used the National Inpatient Sample to construct a cohort of patients hospitalized primarily for salicylate poisoning from 2003 to 2014. We compared clinical characteristics, in-hospital treatments, outcomes and resource use between salicylate poisoning patients with and without gastrointestinal bleeding. Results Of 13 805 hospital admissions for salicylate poisoning, gastrointestinal bleeding occurred in 482 (3.5%) admissions. The risk factors for gastrointestinal bleeding included older age, history of atrial fibrillation and cirrhosis. After adjusting for difference in baseline characteristics, patients with gastrointestinal bleeding required more gastric lavage, gastrointestinal endoscopy, invasive mechanical ventilation and red blood cell transfusion. Gastrointestinal bleeding was significantly associated with increased risk of anemia, circulatory, liver and hematological failure but was not significantly associated with increased in-hospital mortality. The length of hospital stay and hospitalization cost was significantly higher in patients with gastrointestinal bleeding. Conclusion Gastrointestinal bleeding occurred in about 4% of patients admitted for salicylate poisoning. Gastrointestinal bleeding was associated with higher morbidity and resource use but not mortality.

Background: This study aimed to evaluate the risk factors for circulatory shock and its impact on outcomes in patients hospitalized for salicylate intoxication. Methods: We used the National Inpatient Sample to identify patients hospitalized primarily for salicylate intoxication from 2003–2014. Circulatory shock was identified based on hospital diagnosis code for any type of shock or hypotension. We compared clinical characteristics, in-hospital treatments, outcomes, and resource use between patients with and without circulatory shock associated with salicylate intoxication. Results: Of 13,805 hospital admissions for salicylate intoxication, circulatory shock developed in 484 (4%) admissions. Risk factors for development of circulatory shock included older age, female sex, concurrent psychotropic medication overdose, anemia, congestive heart failure, volume depletion, rhabdomyolysis, seizure, gastrointestinal bleeding, and sepsis. Circulatory shock was significantly associated with increased odds of any organ failure and in-hospital mortality. Length of hospital stay and hospitalization cost was significantly higher in patients with circulatory shock. Conclusion: Approximately 4% of patients admitted for salicylate intoxication developed circulatory shock. Circulatory shock was associated with worse clinical outcomes and increased resource use.

Background: This study aimed to evaluate thrombotic microangiopathy’s (TMA) incidence, risk factors, and impact on outcomes and resource use in hospitalized patients with systemic lupus erythematosus (SLE). Methods: We used the National Inpatient Sample to construct a cohort of hospitalized patients with SLE from 2003–2014. We compared clinical characteristics, in-hospital treatments, outcomes, and resource use between SLE patients with and without TMA. Results: Of 35,745 hospital admissions for SLE, TMA concurrently presented or developed in 188 (0.5%) admissions. Multivariable analysis showed that age ≥ 40 years and Hispanics were significantly associated with decreased risk of TMA, whereas Asian/Pacific Islanders and history of chronic kidney disease were significantly associated with increased risk of TMA. TMA patients required more kidney biopsy, plasmapheresis, mechanical ventilation, and renal replacement therapy. TMA was significantly associated with increased risk of in-hospital mortality and acute conditions including hemoptysis, glomerulonephritis, encephalitis/myelitis/encephalopathy, hemolytic anemia, pneumonia, urinary tract infection, sepsis, ischemic stroke, seizure, and acute kidney injury. The length of hospital stays and hospitalization cost was also significantly higher in SLE with TMA patients. Conclusion: TMA infrequently occurred in less than 1% of patients admitted for SLE, but it was significantly associated with higher morbidity, mortality, and resource use.