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BACKGROUND: Timely ventilator liberation can prevent morbidities associated with invasive mechanical ventilation in the pediatric ICU (PICU). There currently exists no standard benchmark for duration of invasive mechanical ventilation in the PICU. This study sought to develop and validate a multi-center prediction model of invasive mechanical ventilation duration to determine a standardized duration of invasive mechanical ventilation ratio. METHODS: This was a retrospective cohort study using registry data from 157 institutions in the Virtual Pediatric Systems database. The study population included encounters in the PICU between 2012-2021 involving endotracheal intubation and invasive mechanical ventilation in the first day of PICU admission who received invasive mechanical ventilation for > 24 h. Subjects were stratified into a training cohort (2012-2017) and 2 validation cohorts (2018-2019/2020-2021). Four models to predict the duration of invasive mechanical ventilation were trained using data from the first 24 h, validated, and compared. RESULTS: The study included 112,353 unique encounters. All models had observed-to-expected (O/E) ratios close to one but low mean squared error and R² values. The random forest model was the best performing model and achieved an O/E ratio of 1.043 (95% CI 1.030-1.056) and 1.004 (95% CI 0.990-1.019) in the validation cohorts and 1.009 (95% CI 1.004-1.016) in the full cohort. There was a high degree of institutional variation, with single- unit O/E ratios ranging between 0.49-1.91. When stratified by time period, there were observ- able changes in O/E ratios at the individual PICU level over time. CONCLUSIONS: We derived and validated a model to predict the duration of invasive mechanical ventilation that performed well in aggregated predictions at the PICU and the cohort level. This model could be beneficial in quality improvement and institutional benchmarking initiatives for use at the PICU level and for tracking of performance over time. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The goal of this study was to determine the incidence, prognostic performance, and generalizability of the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) organ dysfunction criteria using electronic health record (EHR) data. Additionally, we sought to compare the performance of the PODIUM criteria with the organ dysfunction criteria proposed by the 2005 International Pediatric Sepsis Consensus Conference (IPSCC). METHODS: Retrospective observational cohort study of critically ill children at 2 medical centers in the United States between 2010 and 2018. We assessed prevalence of organ dysfunction based on the PODIUM and IPSCC criteria for each 24-hour period from admission to 28 days. We studied the prognostic performance of the criteria to discriminate in-hospital mortality. RESULTS: Overall, 22 427 PICU admissions met inclusion criteria, and in-hospital mortality was 2.3%. The cumulative incidence of each PODIUM organ dysfunction ranged from 15% to 30%, with an in-hospital mortality of 6% to 10% for most organ systems. The number of concurrent PODIUM organ dysfunctions demonstrated good-to-excellent discrimination for inhospital mortality (area under the curve 0.87-0.93 for day 1 through 28) and compared favorably to the IPSCC criteria (area under the curve 0.84-0.92, P < .001 to P = .06). CONCLUSIONS: We present the first evaluation of the PODIUM organ dysfunction criteria in 2 EHR databases. The use of the PODIUM organ dysfunction criteria appears promising for epidemiologic and clinical research studies using EHR data. More studies are needed to evaluate the PODIUM criteria that are not routinely collected in structured format in EHR databases. [ABSTRACT FROM AUTHOR]

During the innate immune response against infections, Natural Killer (NK) cells are as important effector cells as are Cytotoxic T lymphocytes (CTL) generated after antigenic stimulation in the adaptative response. NK cells increase in numbers, after viral infection or vaccination. We investigated the NK cell and CD8 T lymphocyte status in 55 dengue infected patients. The NK (CD56+CD3-) and CD56+ T cell (CD56+CD3+) rates rise during the acute phase of disease. The majority of NK cells from dengue patients display early markers for activation (CD69, HLA-DR, and CD38) and cell adhesion molecules (CD44, CD11a) during the acute phase of disease. The intracellular cytotoxic granule, TIA-1, is also up-regulated early in NK cells. Most of these markers appear also on CD8+ T lymphocytes but during the late acute phase. Circulating IL-15 is elevated in a significant number of patients during early acute infection and its values were statistically correlated with NK frequencies and cytotoxic markers on NKs. We have therefore shown that dengue virus infection is very likely stimulating a cytotoxic response that may be efficient in controlling the virus in synergism with CD8+ T lymphocytes. Interestingly, the heightened CD56+CD3-, CD56+CD3+, CD56+TIA-1+ and CD56+CD11a+ cell rates are associated with mild dengue clinical manifestations and might indicate a good prognosis of the disease. [ABSTRACT FROM AUTHOR]

Purpose Glaucoma patients are known to have an underlying vascular dysfunction and General anesthesia ( GA) significantly decreases blood pressure, which might decrease ocular perfusion. This study was conducted to investigate the effects of GA on ophthalmic flow velocities and blood pressure. Methods Prospective, case-control study. Glaucoma patients were scheduled for trabeculectomy or drainage device implantation; non-glaucomatous patients undergoing vitrectomy for macular hole or epiretinal membrane peeling were recruited as control subjects. Color Doppler imaging of the ophthalmic artery ( OA) was performed immediately before and 1 minute after GA induction. The following parameters were analyzed: OA blood velocities and resistivity index, as well as cardiovascular parameters (diastolic and systolic blood pressure and heart rate). Statistical analysis was performed using Student’s paired t test, Mann-Whitney, Fisher's exact test and Spearman's correlation. Results 53 patients were included (glaucoma group: 25; control group: 28). The magnitude in blood pressure decrease after GA induction was similar between the two groups (p value 0.61-0.70). However, the decrease in OA blood velocities was significantly larger in the glaucoma groups than in the control group (p < 0.03 in all comparisons). Unlike the control subjects, in the glaucoma group there was a significant association between the magnitude of blood pressure decrease and the lowering of the OA mean blood velocity ( r = 0.69, 95% IC: 0.36-0.87, p < 0.001). Conclusions These results suggest that glaucoma patients are unable to keep a stable blood velocity in the OA when subjected to acute significant decreases in blood pressure (such as the ones seen after GA induction). [ABSTRACT FROM AUTHOR]

Purpose To evaluate the difference in assessment between fundoscopic and confocal scanning vertical cup-disc-ratio (VCDR) in open angle glaucoma patients. Methods Data from a single eye of normal tension (NTG) and primary open angle glaucoma (POAG) patients from the Leuven Eye Study were included: age, gender, visual field mean deviation (MD), fundoscopic and HRT III VCDR assessment as well as mean retinal nerve fiber layer thickness (mRNFL). Differences within groups were assessed by paired sample t-tests. Receiver operator curves (ROC) were constructed to assess and compute the likelihood ratio and positive predictive value. Results 303 eyes (161 POAG and 142 NTG) were included. The average VCDR clinically assessed was significantly larger than the value derived from the HRT III software (0.81 ± 0.14 versus 0.61 ± 0.16, p < 0.001) and this difference remained statistically significant in both groups. In advanced glaucoma (MD > −12 dB), the area under the curve for HRT III and fundoscopic VCDR was respectively 0.80 ± 0.05 versus 0.84 ± 0.04 for NTG and 0.66 ± 0.044 versus 0.82 ± 0.033 for POAG. To predict a MD of maximum -12 dB with 80% certainty in NTG patients the VCDR needs to be at least 0.79 and 0.88 for HRT III and fundoscopic VCDR values, whereas in POAG patients these numbers are 0.88 and 0.93, respectively. Conclusions Clinical assessment of VCDR renders significantly higher values than HRT III derived values. Fundoscopic assessment of the optic nerve can predict better the visual field damage compared to the HRT III assessment. [ABSTRACT FROM AUTHOR]

Purpose To present a comparison of the thickness variation of the different retinal layers in diabetic patients without diabetic retinopathy. Methods A prospective observational study was performed. 175 eyes of 175 patients: 125 diabetic patients without diabetic retinopathy and 50 subjects without diabetes (age and gender matched) from the ophthalmology outpatient clinic were included. Optical Coherence Tomography (OCT SPECTRALIS®) was performed with high-resolution macular scans. Automated retinal layer segmentation was performed using validated software and layers thicknesses were determined. The coefficient of variation of the different layers was calculated. A p value < 0.05 was considered statistically significant. Results Diabetic patients were in average 66.9 ± 9.3 years old. There weren't significant differences in the coefficients of variation between diabetic and non-diabetic patients: total retinal thickness (9.3% vs. 9.3%; p = 0.39), RNFL (41.09% vs. 42.25%; p = 0.33), GCL (30.39% vs. 31.13%; p = 0.20), IPL (23.62% vs. 24.13; p = 0.40), ILN (21.26% vs. 19.86; p = 0.44). Conclusions Previous studies have demonstrated that choroidal thickness coefficient of variation is lower in diabetic patients. Nevertheless, in retinal layers no difference was found in diabetic patients without macular edema. There is a combination of choroid with diminished thickness coefficient of variation and retinal layers with normal thickness coefficient of variation. This suggests that vascular choroidal pathology precedes retinal layers dysfunction. Exudation and lipid accumulation associated with microvascular retinal dysfunction and changes in axonal homeostasis only appear at a second step. This study emphasizes the importance of the retinal layer thickness measurement with OCT in the evaluation of diabetic patients. [ABSTRACT FROM AUTHOR]

Purpose To evaluate retinal layers thickness in diabetic patients without diabetic retinopathy (DR) using spectral-domain optical coherence tomography (SD- OCT). To correlate retinal layers thickness in diabetic patients with disease duration, systemic blood pressure ( BP), glycemia, glycosylate haemoglobin (HbA1c), intraocular pressure (IOP) and ocular pulse amplitude (OPA). Methods Prospective, observational case-control study. A total of 175 eyes from 175 patients (125 diabetic patients without DR; 50 healthy controls) were recruited from the outpatient clinic in a tertiary center. A complete ophthalmological examination was performed (visual acuity, refraction, Goldmann applanation and dynamic contour tonometries, fundoscopy, axial length and SD- OCT-Spectralis®). After automated retinal segmentation the thickness of each layer was calculated in the 9 ETDRS areas. Results A significant increase of retinal nerve fiber layer (RNFL) thickness in inner and outer rings was found in diabetic eyes vs. controls (p between <0.0001 and 0.02). Thickness was also increased in specific sites of ganglion cell layer (GCL), inner nuclear layer (INL) and retinal pigment epithelium (RPE) in diabetic eyes (p between 0.001 and 0.03). A significant decrease of outer plexiform layer (OPL) was detected in diabetic eyes at two sites of the inner ring (p = 0.04 and p < 0.0001). The different retinal layers weren't correlated with systemic BP, glycemia, HbA1c, IOP and OPA, but the photoreceptor layer was negatively correlated with disease duration at 3 sites (r between −0.18 and −0.21, p < 0.05). Conclusions In diabetic patients without DR thickness of the inner retina seems to be increased. This suggests that metabolic and morphological changes of the cells of these inner retinal layers occur early and before the apoptosis and neural degeneration. [ABSTRACT FROM AUTHOR]

CONTEXT: Renal dysfunction is associated with poor outcomes in critically ill children. OBJECTIVE: To evaluate the current evidence for criteria defining renal dysfunction in critically ill children and association with adverse outcomes. To develop contemporary consensus criteria for renal dysfunction in critically ill children. DATA SOURCES: PubMed and Embase were searched from January 1992 to January 2020. STUDY SELECTION: Included studies evaluated critically ill childrenwith renal dysfunction, performance characteristics of assessment tools for renal dysfunction, and outcomes related to mortality, functional status, or organ-specific or other patient-centered outcomes. Studieswith adults or premature infants (≤36 weeks' gestational age), animal studies, reviews, case series, and studies not published in Englishwith inability to determine eligibility criteriawere excluded. DATA EXTRACTION: Data were extracted from included studies into a standard data extraction form by task force members. RESULTS: The systematic reviewsupported the following criteria for renal dysfunction: (1) urine output < 0.5mL/kg per hour for ≥ 6 hours and serumcreatinine increase of 1.5 to 1.9 times baseline or ≥0.3mg/dL, or (2) urine output < 0.5mL/kg per hour for ≥12 hours, or (3) serum creatinine increase ≥2 times baseline, or (4) estimated glomerular filtration rate <35 mL/minute/1.73m², or (5) initiation of renal replacement therapy, or (6) fluid overload ≥20%. Data also support criteria for persistent renal dysfunction and for high risk of renal dysfunction. LIMITATIONS: All included studies were observational and many were retrospective. CONCLUSIONS: We present consensus criteria for renal dysfunction in critically ill children. [ABSTRACT FROM AUTHOR]