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The objective of this study was to refine the APACHE (Acute Physiology, Age, Chronic Health Evaluation) methodology in order to more accurately predict hospital mortality risk for critically ill hospitalized adults. We prospectively collected data on 17,440 unselected adult medical/surgical intensive care unit (ICU) admissions at 40 US hospitals (14 volunteer tertiary-care institutions and 26 hospitals randomly chosen to represent intensive care services nationwide). We analyzed the relationship between the patient's likelihood of surviving to hospital discharge and the following predictive variables: major medical and surgical disease categories, acute physiologic abnormalities, age, preexisting functional limitations, major comorbidities, and treatment location immediately prior to ICU admission. The APACHE III prognostic system consists of two options: (1) an APACHE III score, which can provide initial risk stratification for severely ill hospitalized patients within independently defined patient groups; and (2) an APACHE III predictive equation, which uses APACHE III score and reference data on major disease categories and treatment location immediately prior to ICU admission to provide risk estimates for hospital mortality for individual ICU patients. A five-point increase in APACHE III score (range, 0 to 299) is independently associated with a statistically significant increase in the relative risk of hospital death (odds ratio, 1.10 to 1.78) within each of 78 major medical and surgical disease categories. The overall predictive accuracy of the first-day APACHE III equation was such that, within 24 h of ICU admission, 95 percent of ICU admissions could be given a risk estimate for hospital death that was within 3 percent of that actually observed (r2 = 0.41; receiver operating characteristic = 0.90). Recording changes in the APACHE III score on each subsequent day of ICU therapy provided daily updates in these risk estimates. When applied across the individual ICUs, the first-day APACHE III equation accounted for the majority of variation in observed death rates (r2 = 0.90, p<0.0001).

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Summary

Critical illness may lead to altered bone turnover and associated adverse health outcomes. This systematic review found moderate evidence for a positive association between critical illness and increased bone turnover. Prospective cohort studies that identify the extent and risk factors for critical illness related bone loss are required.
Introduction

Intensive care patients face health issues that extend beyond their critical illness and result in significant morbidity and mortality. Critical illness may result in altered bone turnover due to associated immobilisation, inflammation, exposure to medications that effect bone and calcium metabolism, and endocrine dysfunction. The aim of this study was to synthesise the existing evidence for altered bone turnover in adults admitted to intensive care.
Methods

A literature search using MEDLINE and EMBASE was performed from 1965 to March 2013. Reviewed studies investigated the relationship between critical illness and evidence of altered bone turnover (bone turnover markers, bone mineral density, or fracture). Studies were rated upon their methodological quality, and a best-evidence synthesis was used to summarise the results.
Results

Four cohort and seven case–control studies were identified for inclusion, of which five studies were rated as being of higher methodological quality. Ten of the studies measured bone turnover markers, and one study fracture rate. Findings were consistent across studies, and best-evidence analysis resulted in a conclusion that moderate evidence exists for an association between critical illness requiring admission to intensive care and altered bone turnover.
Conclusion

A positive association between critical illness requiring intensive care admission and bone turnover exists, although data are limited, and the risk factors and the nature of the relationship are not yet understood. Prospective cohort studies that identify risk factors and extent of critical illness related bone turnover changes are required.

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Adult ICU patients routinely experience pain, both at rest and with routine ICU care such as procedures or wound care. Lack of treatment of pain can result in many complications including delirium. The PADIS Guidelines suggest that pain be routinely monitored in all adult ICU patients. Self- reporting is the gold standard for assessment of pain. Vital signs should not be used alone for assessment of pain in patients that are unable to communicate. The Behavioral Pain Scale (BPS) and the Critical‐Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain scales for assessing pain in adult, ICU patients unable to communicate pain.

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Severe covid-19 pneumonia has posed critical challenges for the research and medical communities. Older age, male sex, and comorbidities increase the risk for severe disease. For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS). Autopsy studies of patients who died of severe SARS CoV-2 infection reveal presence of diffuse alveolar damage consistent with ARDS but with a higher thrombus burden in pulmonary capillaries. When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to avoid intubation, and does not increase risk for disease transmission.
During invasive mechanical ventilation, low tidal volume ventilation and positive end expiratory pressure (PEEP) titration to optimize oxygenation are recommended. Dexamethasone treatment improves mortality for the treatment of severe and critical covid-19, while remdesivir may have modest benefit in time to recovery in patients with severe disease but shows no statistically significant benefit in mortality or other clinical outcomes. Covid-19 survivors, especially patients with ARDS, are at high risk for long term physical and mental impairments, and an interdisciplinary approach is essential for critical illness recovery.

Brief description of media:

Severe covid-19 pneumonia has posed critical challenges for the research and medical communities. Older age, male sex, and comorbidities increase the risk for severe disease. For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS). Autopsy studies of patients who died of severe SARS CoV-2 infection reveal presence of diffuse alveolar damage consistent with ARDS but with a higher thrombus burden in pulmonary capillaries. When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to avoid intubation, and does not increase risk for disease transmission.
During invasive mechanical ventilation, low tidal volume ventilation and positive end expiratory pressure (PEEP) titration to optimize oxygenation are recommended. Dexamethasone treatment improves mortality for the treatment of severe and critical covid-19, while remdesivir may have modest benefit in time to recovery in patients with severe disease but shows no statistically significant benefit in mortality or other clinical outcomes. Covid-19 survivors, especially patients with ARDS, are at high risk for long term physical and mental impairments, and an interdisciplinary approach is essential for critical illness recovery.

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The Confusion Assessment Method (CAM) was created in 1990, and it was intended to be a bedside assessment tool usable by non-psychiatrists by Dr. Sharon Inouye to assess for delirium.6 The CAM-ICU is an adaptation of this tool for use in ICU patients (e.g., critically ill patients on or off the ventilator). Delirium is defined in terms of four diagnostic features, and is deemed positive when Feature 1 and Feature 2 and either Feature 3 or 4 are present (see CAM-ICU schematic on
next page). The CAM-ICU is one of the recommended ICU delirium screening tools.

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We tend to make sense of sickness by ascribing levels to it, like medals in Olympic boxing: There’s featherweight “I’m under the weather,” a welterweight “ghastly ill.” And then there’s the super heavyweight, an opponent that actually scares you. Few people have to face off with this kind of illness. I have. Which may be why, as I scan through the daily news about the coronavirus, I tend to skip the stats on how many have died, the ventilators we don’t have, the politics, the quarantines, the jobs lost, even the bread-baking. Instead, I find myself drifting into the minds of those souls strapped to gurneys in the hallway, encased in a macramé of tubes and wires, fighting for each breath. These are the ones facing the super heavyweight. Some of them will die. But the ones I think about are the ones who will survive. Because I’ve been there. I know that getting off the ventilator won’t be the end of the story. And I know that not being sick doesn’t mean you’re well.

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The CPOT includes evaluation of four different behaviors (facial expressions, body movements, muscle tension, and compliance with the ventilator for mechanically ventilated patients or vocalization for nonintubated patients) rated on a scale of zero to two with a total score ranging from 0 to 8. The CPOT is feasible, easy to complete, and simple to understand.

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In this review, a panel of experts in the field of VAP from four European societies has tried to provide an overview of the most important aspects under debate. In order to stimulate further research and discussion, presentation of the main topics was focussed on the breaking current knowledge. The issue of attributable mortality, which is also a matter of controversy, will not be addressed in this review. Each section of the review has been written in an attempt to answer three main questions: 1) what is not controversial, 2) what is still controversial and 3) what should be investigated? The following topics were reviewed: clinical diagnosis, bacteriological and histological aspects, aetiology, diagnostic techniques, antimicrobial treatment and prevention.

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Esophageal variceal hemorrhage (EVH) is a serious and expensive sequela of chronic liver disease, leading to increased utilization of resources. Today, endoscopic sclerotherapy (ES) and endoscopic ligation (EL) are the accepted, community standards of endoscopic treatment of patients with EVH. However, there are no published studies comparing the economic costs of treating EVH using these interventions. As part of a prospective, randomized trial comparing ES and EL for the treatment of EVH, we estimated the direct costs of health care utilization and cost-effectiveness for the prevention of variceal rebleeding and patient survival at 1-year follow-up. Treatment groups were similar in incidence of variceal rebleeding (41.9% vs. 42.9%), variceal obliteration (41.9% vs. 40.0%), hospital days, blood transfusions, shunt requirements, and survival (71.0% vs. 60.0%). There were significantly more treatment failures for active bleeding using EL (42% vs. 0%; P =.027) and esophageal stricture formation in the ES-treated patients (19.4% vs. 2.9%; P = 0.03). Median total direct cost outcomes were similar between groups (EL = $9,696 and ES = $13,197; P =.46). EL and ES had similar cost/variceal rebleeding prevented ($28,678 vs. $29,093) and cost/survival ($27,313 vs. $23,804). In the subgroup of active bleeders, ES had a substantially lower cost/survival ($28,523 vs. $51,696). We conclude that resource utilization was similar between treatment groups and that the choice of endoscopic therapy for EVH must still rely on clinical grounds. Further studies comparing costs and resource utilization in this patient population are needed.

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Record Status
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.
Health technology
The study examined an in-home paediatric asthma disease management programme (ADMP) provided by respiratory therapists. The ADMP consisted of eight home visits for assessment, environmental review and patient education. A detailed description of all aspects of the programme was provided.

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Aim: To examine the effects of mechanical ventilation on the quality of sleep in patients in the intensivecare unit (ICU) using recent and relevant literature.Methods: To verify the examined objective, the results of the analysis of available original scientificworks have been used including defined inclusion/exclusion criteria and search strategy. Appropriate worksfound were analysed further. The applied methodology was in line with the general principles of Evidence-Based Medicine. The following literary databases were used: CINAHL, Medline and gray literature: GoogleScholar.Results:A total of 91 trials were found. Eleven of these relevant to the follow-up analysis wereselected: all trials were carried out under real ICU conditions and the total of 192 patients were included inthe review. There is an agreement within all trials that sleep in patients requiring mechanical ventilation isdisturbed. Most reviewed trials have shown that mechanical ventilation is probably not the main factorcausing sleep disturbances, but an appropriate ventilation strategy can significantly help to improve itsquality by reducing the frequency of the patient-ventilator asynchrony.Conclusion: Based on the analysis, it appears that an appropriate ventilation mode setting can have abeneficial effect on the quality of sleep in ICU patients.Keywords: mechanical ventilation, quality of sleep, intensive care unit