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Background and Aims: Controversy exists over whether emergent liver transplantation (LT) should be performed for patients with acute-on-chronic liver failure (ACLF), especially for patients with multiple organ failure., Methods: A total of 110 ACLF patients, defined by the European Association for the Study of the Liver (EASL) Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) criteria were analyzed. The primary outcome was overall survival after ACLF diagnosis., Results: During follow-up, 76 patients received LT (59 received deceased-donor LT and 17 patients received living-donor LT). The overall survival was better for patients who received LT than patients who did not (82.9% vs. 17.6%, P < 0.001). Among the 76 patients who received LT, the overall survival was not different according to ACLF grade at diagnosis (70.0%, 85.3%, and 84.4% at one-year for ACLF grades 1, 2, and 3, respectively, P = 0.45). The baseline model for end-stage liver disease (MELD) score and progression of the ACLF grade during the pre-transplant period were independent factors for survival after LT. The one-year survival rate was 92.3% for patients with baseline MELD scores of ≤ 32 without ACLF grade progression, whereas it was 33.3% for those with baseline MELD scores of > 32 and ACLF grade progression., Conclusions: Emergent LT provided a significant survival benefit to ACLF patients, regardless of the baseline ACLF grade. Post-LT outcomes were associated with baseline MELD scores and ACLF progression during the pre-transplant period, which might be used in the emergent LT plan for patients presenting with ACLF., Competing Interests: Declaration of Competing Interest All authors declare that they have no conflicts of interest regarding the content of this manuscript., (Copyright © 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Objectives: The Pancreatitis Activity Scoring System (PASS) is an objective tool validated in acute pancreatitis but not in infected pancreatic necrosis (IPN). Our aim was to evaluate the role of PASS in IPN., Methods: We performed a retrospective cohort study of IPN patients admitted to the University of California, San Francisco from January 2011 to March 2019. Daily PASS scores were calculated for each patient. Receiver operator characteristic analysis was used to define the optimal cutoff PASS score to predict outcomes. The primary and secondary outcomes were 72 hours postintervention multiorgan failure (MOF) and early readmission (within 30 days), respectively., Results: One hundred and four patients underwent intervention (median age, 55 years). Thirty-five patients (33.6%) developed MOF postintervention. A 72-hour postintervention PASS greater than 250 was strongly associated with postintervention MOF (area under curve, 0.87; adjusted odds ratio, 26.83; 95% confidence interval, 6.37-112.86; P < 0.001). Discharge PASS greater than 150 was associated with 30-day readmission (area under curve, 0.82; adjusted odds ratio, 26.44; 95% confidence interval, 8.48-82.43; P < 0.001)., Conclusions: The PASS score was associated with postintervention clinical outcomes and early readmission, suggesting it is a valid measure of disease activity in patients with IPN. Further prospective validation of PASS in IPN is needed., Competing Interests: M.A.A. is a consultant for Boston Scientific, Olympus America, and Medtronic. The remaining authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The purpose of our study was to assess organ function in 102 patients with severe COVID-19 infections, using retrospective clinical analysis., Material and Methods: A retrospective analysis was conducted on 102 patients with severe COVID-19 infections. The patients were divided into a survival group (n=73) and a non-survival group (n=29) according to their prognosis. The age, sex, underlying diseases, clinical laboratory data within 48h (routine blood tests, ALT, AST, TBIL, ALB, BUN, CR, D-Dimer, PT, APTT, FIB, F VIII:C, CK-MB, CK, and LDH), and ventilation status were collected. The organ functions of these severe COVID-19 patients were assessed by comparing the differences between the two groups., Results: AST, BUN, CR, CK-MB, LDH, and CK in the non-survival group were higher than those in the survival group, and the differences were statistically significant (P<0.05). D-Dimer, PT, FIB, and F VIII:C in the non-survival group were higher than the values observed in the survival group, and the differences were statistically significant (P<0.05). PLT, AST, BUN, CR, D-Dimer, PT, FIB, F VIII:C, CK-MB, CK, and LDH predicted the area under the ROC curve (AUC) of the COVID19 endpoint events and were 0.721, 0.854, 0.867, 0.757, 0.699, 0.679, 0.715, 0.811, 0.935, and 0.802, respectively., Conclusion: The results showed that there were different degrees of damage to the liver, kidneys, blood coagulation, and heart function in the non-survival group. In addition, PLT, AST, BUN, CR, D-Dimer, PT, FIB, F VIII:C, CK-MB, CK, and LDH had value in evaluating disease prognosis., (Copyright © 2020 Elsevier España, S.L.U. All rights reserved.)

Current sepsis biomarkers may be helpful in determining organ failure and evaluating patient clinical course; however, direct molecular biomarkers to predict subsequent organ failure have not yet been discovered. Exosomes, a small population of extracellular vesicles, play an important role in the inflammatory response, coagulation process and cardiac dysfunction in sepsis. Nonetheless, the association of plasma exosome with severity and mortality of sepsis is not well known. Therefore, the overall levels of plasma exosome in sepsis patients were assessed and whether exosome levels were associated with organ failure and mortality was evaluated in the present study. Plasma level of exosomes was measured by ELISA. Among 220 patients with sepsis, 145 (66%) patients were diagnosed with septic shock. A trend of increased exosome levels in control, sepsis and septic shock groups was observed (204 µg/mL vs 525 µg/mL vs 802 µg/mL, P < 0.001). A positive linear relationship was observed between overall exosome levels and Sequential Organ Failure Assessment (SOFA) score in the study cohorts (r value = 0.47). When patients were divided into two groups according to best cut-off level, a statistical difference in 28- and 90-day mortality between patients with high and low plasma exosomes was observed. Elevated levels of plasma exosomes were associated with severity of organ failure and predictive of mortality in critically ill patients with sepsis., (© 2020 The Authors. Journal of Cellular and Molecular Medicine published by Foundation for Cellular and Molecular Medicine and John Wiley & Sons Ltd.)

Introduction: Coronavirus disease 2019 (COVID‑19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) infection spread worldwide., Objectives: The aim of the study was to identify the clinical characteristics and risk factors associated with severe incidence of SARS ‑CoV‑2 infection., Patients and Methods: All adult patients (median [IQR] age, 52 [37-58] years) consecutively admitted to the Dabieshan Medical Center from January 30, 2020 to February 11, 2020 were collected and reviewed. Only patients diagnosed with COVID‑19  according to the World Health Organization interim guidance were included in this retrospective cohort study., Results: A total of 108 patients with COVID‑19 were retrospectively analyzed. Twenty‑five patients (23.1%) developed severe disease, and of those 12 patients (48%) died. Advanced age, comorbidities (most commonly hypertension), higher blood leukocyte count, neutrophil count, higher C‑reactive protein level, D‑dimer level, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Sequential Organ Failure Assessment (SOFA) score were associated with greater risk of COVID‑19, and so were lower lymphocyte count and albumin level. Multivariable regress ion showed increasing odds of severe COVID‑19 associated with higher SOFA score (odds ratio [OR], 2.45; 95% CI, 1.302-4.608; P = 0.005), and lymphocyte count less than 0.8 × 109/l (OR, 9.017; 95% CI, 2.808-28.857; P <0.001) on admission. Higher SOFA score (OR, 2.402; 95% CI, 1.313-4.395; P = 0.004) on admission was identified as risk factor for in‑hospital death., Conclusions: Lymphocytopenia and a higher SOFA score on admission could help clinicians to identify patients at high risk for developing severe COVID‑19. More related studies are needed in the future.

Objective: This study was aimed to determine the relationship between static and dynamic intra-abdominal pressure (IAP) with the mortality and outcome of acute pancreatitis., Methods: From July 2017 to December 2018, 150 patients admitted at the Institute of Gastrosciences and Liver and diagnosed as acute pancreatitis were included in the study. Intra-abdominal pressure was measured for the first few days, and mean value of day 1 (static IAP) and highest value on day 2 and day 3 (dynamic IAP) were calculated and categorized into intra-abdominal hypertension and abdominal compartment syndrome., Results: A statistical relationship was observed between static and dynamic IAP with the severity and mortality of acute pancreatitis. Both static and dynamic IAPs tended to be higher in nonsurvivors (83.33% and 88.88%, respectively) compared with survivors (51.51% and 63.63%, respectively). Higher IAP had more severe disease. However, IAP did not correlate with the evidence of sepsis or serum procalcitonin levels., Conclusion: Determination of static IAP is an easy, useful, and inexpensive method to determine and predict the mortality of acute pancreatitis. Prevention and/or early detection of intra-abdominal hypertension helps in reducing the mortality in acute pancreatitis.

Objective: A comparison is made of the accuracy between severity models, based on different sepsis definitions (systemic inflammatory response syndrome (SIRS), predisposition, insult, response, organ dysfunction (PIRO), and sequential organ failure assessment (SOFA) concepts), in predicting outcomes among sepsis patients., Design: A retrospective study was carried out., Setting: The study was conducted in the Intensive Care Unit (ICU) of a university teaching hospital., Patients: Septic patients admitted to the ICU during 2007-2016., Main Variables of Interest: The primary outcome was in-hospital mortality, with ICU mortality being the secondary outcome., Results: A total of 2152 septic patient were identified, with ICU and in-hospital mortality rates of 33.3% and 45.9%, respectively. The Moreno PIRO (AUC, 95%CI) (0.835; 0.818-0.852) showed the highest discriminating capacity, followed by SOFA (0.828; 0.811-0.846), qSOFA (0.792; 0.775-0.809), Rubulotta PIRO (0.708; 0.687-0.730), Howell PIRO (0.706; 0.685-0.728) and SIRS (0.578; 0.556-0.600). The AUC of the SOFA score was comparable to that of the Moreno PIRO (p=0.43), though the AUCs of both of these scores were significantly higher than those of the other scores (p<0.001 for all other comparisons). However, the SOFA score showed the best discriminating capacity in predicting ICU mortality (0.838; 0.820-0.855), followed by Moreno PIRO (0.804; 0.785-0.823) and qSOFA (0.787; 0.770-0.805). The accuracy of the qSOFA in predicting ICU mortality was comparable to that of the Moreno PIRO score (p=0.15)., Conclusion: The SOFA score and Moreno PIRO score showed the best accuracy in predicting in-hospital mortality among septic patients admitted to the ICU., (Copyright © 2018 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.)

Background: Multiple organ failure (MOF) is a serious complication of moderately severe (MASP) and severe acute pancreatitis (SAP). This study aimed to develop and assess three machine-learning models to predict MOF., Methods: Patients with MSAP and SAP who were admitted from July 2014 to June 2017 were included. Firstly, parameters with significant differences between patients with MOF and without MOF were screened out by univariate analysis. Then, support vector machine (SVM), logistic regression analysis (LRA) and artificial neural networks (ANN) models were constructed based on these factors, and five-fold cross-validation was used to train each model., Results: A total of 263 patients were enrolled. Univariate analysis screened out sixteen parameters referring to blood volume, inflammatory, coagulation and renal function to construct machine-learning models. The predictive efficiency of the optimal combinations of features by SVM, LRA, and ANN was almost equal (AUC = 0.840, 0.832, and 0.834, respectively), as well as the Acute Physiology and Chronic Health Evaluation II score (AUC = 0.814, P > 0.05). The common important predictive factors were HCT, K-time, IL-6 and creatinine in three models., Conclusions: Three machine-learning models can be efficient prognostic tools for predicting MOF in MSAP and SAP. ANN is recommended, which only needs four common parameters.

Objective: The objective of the study is to determine the usefulness of the SOFA (Sequential Organ Failure Assessment), quick SOFA (qSOFA), LODS (Logistic Organ Dysfunction System) and EWS (Early Warning Score) scores to predict in-hospital mortality among septic patients attended in the emergency department; to evaluate what factors are associated with mortality; and develop a predictive model of in-hospital mortality., Methods: Retrospective study including patients over 14 years of age included in the sepsis code of an Emergency Department of a University Hospital between November 2013 and September 2015. Demographic variables, hemodynamic and analytical variables, and in-hospital mortality were collected to obtain qSOFA, SOFA, LODS, EWS scores. Receiver operating characteristic curves were constructed for each score. Logistic regression was used to evaluate the probability of in-hospital mortality., Results: A total of 349 patients were analyzed, median age 72.7 (range 86), males: 54.4%. The in-hospital mortality was 21.8%. AUC obtained: LODS: 0.73 (IC 95% 0.67-0.80; p<0.001), EWS: 0.73 (IC 95% 0.65-0.81; p<0.001), SOFA: 0.72 (IC 95% 0.65- 0.78; p<0.001), qSOFA: 0.67 (IC 95% 0.58-0.76; p<0.001). After the multivariate analysis, these were the independent factors associated with in-hospital mortality: Oxygen saturation ≤92%, Glasgow coma score <14, lactate ≥2mmol/L (p<0.05). Two prognostic models were generated: MPRO1: age, oxygen saturation ≤92% and Glasgow coma score <14, AUC: 0.78 (IC 95% 0.72-0.84; p<0.001) and MPRO2 formed by the previous ones and lactate ≥2mmol/L, AUC: 0.82 (IC 95% 0.76-0.87; p<0.001)., Conclusions: SOFA score and the new developed scores could be useful in asses the risk of in-hospital mortality in patients included in the sepsis code., (©The Author 2018. Published by Sociedad Española de Quimioterapia. This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).)

The study aimed to compare two scores: the pediatric logistic organ dysfunction (PELOD) with its updated version (PELOD-2) in describing the severity of organ dysfunction in pediatric intensive care unit (PICU) and assess the performance of PELOD-2 in the Egyptian population. A prospective cohort study of 200 patients consecutively admitted to PICU between July 2015 and A 2016 was included. The median age was 6 months, and the male to female ratio was 1.04. The median length of PICU stay was 4 days. The overall predicted number of deaths using PELOD was 76 patients whereas, by PELOD-2, it was 50 patients. The observed mortality was 50 patients. The area under the receiving operating characteristic curve was excellent for both PELOD and PELOD-2 (0.93 and 0.91, respectively). The Hosmer and Lemeshow goodness-of-fit test showed good calibration of PELOD-2 (χ 2  = 9.9, p = 0.27), while PELOD showed poor calibration (χ 2  = 42, p = 0.000) in the same studied group., Conclusion: Both scores had excellent discrimination. PELOD-2 is reproducible and easier to perform and had better calibration compared to PELOD score. What is Known: • Pediatric logistic organ dysfunction (PELOD) score was developed 1999 and validated in 2003 to describe the organ dysfunction severity in pediatric intensive care units. • A new and easier version of (PELOD-2) was developed 2013 in France and Belgium to replace the old score. It is important to assess the performance of the new score in other population else than the original. What is New: In an Egyptian pediatric intensive care, the performance of the score revealed: • PELOD-2 was an excellent discriminatory score comparable to the original score. • PELOD-2 calibrated well in the Egyptian population while the old score had poor calibration.

Introduction: Acute pancreatitis (AP) is an emerging problem in pediatrics, with most cases resolving spontaneously. Approximately 10% to 30%, however, are believed to develop "severe acute pancreatitis" (SAP)., Methods: This consensus statement on the classification of AP in pediatrics was developed through a working group that performed an evidence-based search for classification of AP in adult pancreatitis, definitions and criteria of systemic inflammatory response syndrome, and organ failure in pediatrics., Results and Discussion: Severity in pediatric AP is classified as mild, moderately severe, or severe. Mild AP is defined by AP without organ failure, local or systemic complications, and usually resolves in the first week. Moderately SAP is defined by the presence of transient organ failure that resolves in no >48 hours, or local complications or exacerbation of co-morbid disease. SAP is defined by persistent organ failure that lasts <48 hours. The presence of systemic inflammatory response syndrome is associated with increased risk for persistent organ dysfunction. Criteria to define organ failure must be pediatric- and age-based., Conclusions: Classifying AP in pediatrics in a uniform fashion will help define outcomes and encourage the development of future studies in the field of pediatric pancreatitis.

Objective: To describe new technologies (biomarkers and tests) used to assess and monitor the severity and progression of multiple organ dysfunction syndrome in children as discussed as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development MODS Workshop (March 26-27, 2015)., Data Sources: Literature review, research data, and expert opinion., Study Selection: Not applicable., Data Extraction: Moderated by an experienced expert from the field, investigators developing and assessing new technologies to improve the care and understanding of critical illness presented their research and the relevant literature., Data Synthesis: Summary of presentations and discussion supported and supplemented by relevant literature., Conclusions: There are many innovative tools and techniques with the potential application for the assessment and monitoring of severity of multiple organ dysfunction syndrome. If the reliability and added value of these candidate technologies can be established, they hold promise to enhance the understanding, monitoring, and perhaps, treatment of multiple organ dysfunction syndrome in children.

Objectives: The objectives are to 1) determine whether there is a positive correlation between the severity of hypoxic-ischemic encephalopathy and multiple organ dysfunction and 2) evaluate the organ dysfunction pattern in infants with hypoxic-ischemic encephalopathy in the hypothermia era., Design: Retrospective observational study of prospective data collected between April 2009 and December 2012., Setting: The study took place in the neonatal ICU of Hospital Sant Joan de Déu-Hospital Clínic of Barcelona., Patients: Prospective consecutive newborns with greater than or equal to 36 weeks of gestation, greater than or equal to 1,800 g of weight at birth, and a diagnosis of hypoxic-ischemic encephalopathy was included., Interventions: Severity of hypoxic-ischemic encephalopathy was established before starting controlled hypothermia. Six organ systems and 23 clinical and laboratory variables were studied by means of an asymmetrical grading scale. Data were recorded daily during the first 72 hours of life., Measurements and Main Results: Seventy-nine patients were studied. All presented with multiple organ dysfunction on day 1. There were differences in the number of affected organs on day 1 according to hypoxic-ischemic encephalopathy stage (p < 0.001). Scale scores correlated positively with the severity of hypoxic-ischemic encephalopathy (area under the curve ranged from 0.77 to 0.87 on every day studied). There were significant differences in the severity of dysfunction of each organ system among the three hypoxic-ischemic encephalopathy stages (p < 0.05). Although the most frequently involved were hepatic and pH and electrolyte imbalance, the most severely affected were the respiratory and cardiovascular systems., Conclusions: In the hypothermia era, multiple organ dysfunction continues to be almost universal in newborns with hypoxic-ischemic encephalopathy. There is a high correlation between the severity of hypoxic-ischemic encephalopathy and multiple organ dysfunction during the first 3 days of life. A high index of suspicion of relevant multiple organ dysfunction is required in infants admitted with a diagnosis of severe hypoxic-ischemic encephalopathy. Patients with moderate hypoxic-ischemic encephalopathy present wide variability in the severity of multiple organ dysfunction. In the absence of multiple organ dysfunction, a perinatal hypoxic-ischemic origin of acute severe neonatal encephalopathy should be carefully reconsidered.

Objective: To describe the diagnostic criteria of new and progressive multiple organ dysfunction syndrome and scoring systems that might be used to assess and monitor the severity and progression of multiple organ dysfunction syndrome in children presented as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development MODS Workshop (March 26-27, 2015)., Data Sources: Literature review, research data, and expert opinion., Study Selection: Not applicable., Data Extraction: Moderated by an experienced expert from the field, issues relevant to the monitoring of the severity of multiple organ dysfunction syndrome including new and progressive multiple organ dysfunction syndrome and scoring systems were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities., Data Synthesis: Summary of presentations and discussion supported and supplemented by relevant literature., Conclusions: Many sets of diagnostic criteria of multiple organ dysfunction syndrome are presently available. All are useful, but their diagnostic and predictive value can be improved. Several types of diagnostic criteria are candidates to describe the severity and to monitor the progression of cases of multiple organ dysfunction syndrome, which include existing scores of organ dysfunction: Pediatric Logistic Organ Dysfunction, version 2, daily Pediatric Logistic Organ Dysfunction, version 2, organ failure-free days, etc. If a new set of diagnostic criteria of multiple organ dysfunction syndrome is created, its value must be validated. Furthermore, the epidemiology of multiple organ dysfunction syndrome based on these new diagnostic criteria must be compared with the epidemiology found with the preexisting sets of diagnostic criteria. The reliability as well as the added values of additional or new candidate markers of organ dysfunction and multiple organ dysfunction syndrome severity must be studied and compared.

No early serum marker of disease severity contributes to the treatment decision-making process of acute superior mesenteric venous thrombosis (ASMVT). This study aims to assess the value of serum D-dimer level in the first 3 days after admission as a severity marker of ASMVT patients. From May 2010 to June 2014, 50 consecutive patients of ASMVT were enrolled in this observational study. The serum D-dimer level was measured on a daily basis during the first 3 days after admission as well as other laboratory-testing parameters, clinical score, and outcome variables recorded during the same period. The maximum and mean D-dimer values were analyzed and compared with other potential markers for prediction of multiple-organ dysfunction syndrome (MODS) and short-bowel syndrome (SBS). The correlation of D-dimer level with other potential severity markers and inflammation parameters were also studied. Both maximum and mean D-dimer level during the first 3 days of admission were significantly higher in patients with several clinical variables such as death within 30 days, bowel resection, sepsis, abdominal compartment syndrome, MODS, and SBS. In addition, serum D-dimer level showed precise prediction for MODS and SBS, greater than L-lactate and intestinal-type fatty acid-binding protein (I-FABP). The D-dimer level was correlated well with L-lactate, I-FABP, and APACHE II score on the first 3 days of admission. Poor correlation of D-dimer level and inflammation parameters, white blood cell count, and C-reactive protein level, was detected. D-dimer level could be an effective, early, and specific serum marker indicating the clinical evolution and outcome of ASMVT.

Background: Acute pancreatitis is a severe condition that requires early identification of patients at risk of developing potentially lethal complications. Current clinical scoring systems and biochemical parameters are insufficient. In this study, we aimed to assess whether early plasma Angiopoietin-2 (Ang-2) is associated with adverse outcomes in patients with predicted severe acute pancreatitis (SAP)., Study Design: This analysis is a substudy of the PROPATRIA trial (probiotics vs placebo in patients with predicted SAP). The Ang-2 levels were measured prospectively in plasma in the first 5 days after admission in 115 patients., Results: Early Ang-2 levels were higher in patients who developed SAP: 6.4 vs 3.1 μg/L (p < 0.001) and also were higher in patients who developed multiorgan failure in the first week (p = 0.001) and after the first week (p = 0.049). Furthermore, high Ang-2 levels were associated with infectious complications in the first week (p < 0.001) and after the first week (p < 0.001). Finally, plasma Ang-2 was significantly higher in patients who died (p < 0.001) and in patients who developed bowel ischemia (p < 0.001). As a predictor of adverse outcomes, plasma Ang-2 was superior to a number of current scores, such as the APACHE II score, the Imrie score, C-reactive protein, lipopolysaccharide binding protein, and procalcitonin., Conclusions: In the setting of this randomized controlled trial, early plasma Ang-2 was found to be an accurate predictor of SAP, multiorgan failure, and infectious complications. As a biomarker, it did outperform all of the investigated conventional predictors that are currently used in clinical practice., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the usefulness of 2-[18F]-fluoro-2-deoxy-d-glucose-positron emission tomography/computed tomography (FDG-PET/CT) in IgG4-related disease (IgG4-RD) for the staging of the disease and the followup under treatment., Methods: All patients included in the French IgG4-RD registry who underwent ≥1 FDG-PET/CT scan were included in the study. Clinical, biologic, pathologic, radiologic, and FDG-PET/CT qualitative and quantitative findings were retrospectively collected and analyzed., Results: Twenty-one patients were included in the study and 46 FDG-PET/CT examinations were evaluated. At either diagnosis or relapse, all evaluated patients presented abnormal 18F-FDG uptake in typical IgG4-RD localizations. In most cases, FDG-PET/CT was more sensitive than conventional imaging to detect organ involvement, especially in arteries, salivary glands, and lymph nodes. In few cases (small-sized lesions and brain or kidney contiguous lesions), false-negative results were noted. Evaluation before and after treatment showed in most cases a good correlation of FDG-PET/CT results with treatment response and disease activity., Conclusion: This large retrospective study shows that FDG-PET/CT imaging is useful for the staging of IgG4-RD. Moreover, FDG-PET/CT is useful to assess the response to treatment during followup., (Copyright © 2014 by the American College of Rheumatology.)

Objective: To summarize our case load in managing severe and multiple injuries (SMI) in the Intensive Care Unit (ICU)., Patients and Methods: The clinical data of 80 SMI patients treated in our ICU from January 2009 to June 2013 were analyzed., Results: Results of these 80 SMI patients, 60 (75%) were salvaged and 15 (18.75%) died. The causes of death included severe head injury (n=7), severe chest injury (n=3), destruction of injured abdominal organs (n=2), and multiple organ dysfunction syndrome (n=3). Five patients (7.50%) gave up treatment and were discharged upon their own requests. Early application of continuous renal replacement therapy (CRRT) and enteral nutrition (EN) improved outcomes., Conclusions: The key interventions during the ICU treatment of SMI include: adequate analgesia and appropriate sedation; timely management of hypoxemia; reasonable fluid resuscitation and CRRT.

The article deals with a study of 243 patients (from 18 to 65 years old) with acute hepatic failure. Purpose of the study was to evaluate the predictive capability of severity scales APACHE III, SOFA, MODS, Child-Pugh and to identify mortality predictors in patients with acute hepatic failure. Results; The best predictive ability in patients with acute hepatic failure and multiple organ failure had APACHE III and SOFA scales. The strongest mortality predictors were: serum creatinine > 132 mmol/L, fibrinogen < 1.4 g/L, Na < 129 mmol/L.

Objective: To determine the number of emergency department (ED) patients with severe sepsis who are admitted to the ICU and to assess whether the predisposition, infection, response and organ failure (PIRO) score can be used as a clinical decision-making tool for guiding the disposition of ED sepsis patients to wards or the ICU., Methods: This is a prospective study including ED patients with severe sepsis and septic shock. The PIRO score and in-hospital mortality were assessed in patients admitted to wards and ICUs. The sensitivity and specificity of the PIRO score and clinical judgement of the ED physician for guiding adequate disposition to wards or the ICU were assessed., Results: A total of 47 of 153 patients were admitted to the ICU. Thirty-nine of 106 ward admissions had a 'do not resuscitate' status (not included in analysis). Mortality was 1.5 and 21% in patients initially admitted to a ward and the ICU, respectively. Unanticipated transfer from the ward to the ICU occurred in eight of 67 patients, resulting in higher mortality (38%, P=0.002, false negatives). Nine surviving patients admitted to the ICU for mere observation for less than 1 day were defined as false positives. Sensitivity of clinical judgement and of PIRO score (cut-off 9.5) alone or combined with clinical judgement were 0.92, 0.75 and 0.98, respectively (P<0.001). For specificity, these were 0.71, 0.56 and 0.40, respectively (P<0.001)., Conclusion: Two-thirds of ED patients with severe sepsis were admitted to the ward, of whom ∼13% clinically deteriorated, resulting in ICU admission and higher mortality. The PIRO score adds little value over clinical judgement in guiding adequate disposition to wards or the ICU.

Background: The Neonatal Multiple Organ Dysfunction (NEO-MOD) scoring system is used to predict mortality in infants with multiple organ dysfunction syndrome (MODS). The NEOMOD scoring system was extended to include involvement of the microvascular system. This modified scoring system was developed to enable more accurate and earlier diagnosis of MODS in premature infants., Objective: To evaluate the modified NEOMOD scoring system in preterm infants with MODS and compare its effectiveness with the NEOMOD scoring system., Methods: This prospective study was performed in a tertiary neonatal intensive care unit. A total of 198 premature infants were enrolled. Infants were evaluated for development of MODS by using the modified NEOMOD scoring system until discharge or death according to clinical and laboratory findings. Infants who had organ dysfunction in 2 or more organ systems had MODS diagnosed., Results: In the 160 infants (80.8%) with MODS, the gastrointestinal system, respiratory system, and hematologic system were involved most often. The gastrointestinal system, respiratory system, and acid-base metabolism were involved initially in 99.4%, 86.3%, and 26.3% of infants, respectively. The mean modified NEOMOD score for the infants who died in the first 28 days after birth was significantly higher than the mean score for infants who survived. The number of systems involved was also higher in infants who died., Conclusions: The modified NEOMOD scoring system is a safe and accurate tool for determining both mortality rate and dysfunction of multiple organ systems affecting mortality in pre-term infants.

Purpose: The aim of this study was to assess the ability of the Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system, and Trauma and Injury Severity Score (TRISS) method to predict group mortality for intensive care unit (ICU) trauma patients., Methods: The medical records of 706 consecutive major trauma patients admitted to the ICU of Samsung Changwon Hospital from May 2006 to April 2010 were retrospectively examined. The SOFA and the APACHE II scores were calculated based on data from the first 24 hours of ICU admission, and the TRISS was calculated using initial laboratory data from the emergency department and operative data. The probability of death was calculated for each patient based on the SOFA score, APACHE II score, and TRISS equations. The ability to predict group mortality for the SOFA score, APACHE II score, and TRISS method was assessed by using 2-by-2 decision matrices and receiver operating characteristic curve analysis and calibration analysis., Results: In 2-by-2 decision matrices with a decision criterion of 0.5, the sensitivities, specificities, and accuracies were 74.1%, 97.1%, and 92.4%, respectively, for the SOFA score; 58.5%, 99.6%, and 91.1%, respectively, for the APACHE II scoring system; and 52.4%, 94.8%, and 86.0%, respectively, for the TRISS method. In the receiver operating characteristic curve analysis, the areas under the curve for the SOFA score, APACHE II scoring system, and TRISS method were 0.953, 0.950, and 0.922, respectively., Conclusion: The results from the present study showed that the SOFA score was not different from APACHE II scoring system and TRISS in predicting the outcomes for ICU trauma patients. However, the method for calculating SOFA scores is easier and simpler than APACHE II and TRISS., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background & Aims: It is important to identify patients with acute pancreatitis who are at risk for developing persistent organ failure early in the course of disease. Several scoring systems have been developed to predict which patients are most likely to develop persistent organ failure. We head-to-head compared the accuracy of these systems in predicting persistent organ failure, developed rules that combined these scores to optimize predictive accuracy, and validated our findings in an independent cohort., Methods: Clinical data from 2 prospective cohorts were used for training (n = 256) and validation (n = 397). Persistent organ failure was defined as cardiovascular, pulmonary, and/or renal failure that lasted for 48 hours or more. Nine clinical scores were calculated when patients were admitted and 48 hours later. We developed 12 predictive rules that combined these scores, in order of increasing complexity., Results: Existing scoring systems showed modest accuracy (areas under the curve at admission of 0.62-0.84 in the training cohort and 0.57-0.74 in the validation cohort). The Glasgow score was the best classifier at admission in both cohorts. Serum levels of creatinine and blood urea nitrogen provided similar levels of discrimination in each set of patients. Our 12 predictive rules increased accuracy to 0.92 in the training cohort and 0.84 in the validation cohort., Conclusions: The existing scoring systems seem to have reached their maximal efficacy in predicting persistent organ failure in acute pancreatitis. Sophisticated combinations of predictive rules are more accurate but cumbersome to use, and therefore of limited clinical use. Our ability to predict the severity of acute pancreatitis cannot be expected to improve unless we develop new approaches., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: There is limited literature describing clinical predictors for critically ill patients with cancer who present to the emergency department (ED)., Purpose: The aim of this study was to investigate the usefulness of the Sequential Organ Failure Assessment (SOFA) score at the time of ED presentation for predicting short-term mortality in patients with advanced cancer., Methods: This was a prospective observational study of 108 consecutive patients with advanced cancer who presented to the ED. The outcome was defined as death within 14 days after admission., Results: The median survival time of the study subjects was 26.5 days (interquartile range, 9.0-78.0 days), and 31 patients (28.7%) died within 14 days after admission. In univariate analysis, SOFA score (≥4), previous chemotherapy, and altered mental status were predictive of 14-day mortality. Of those variables, only SOFA score was an independent predictor in multivariate analysis., Conclusions: The use of the SOFA score is an acceptable method for risk stratification and prognosis of patients with advanced cancer in the ED. This score can help clinicians to predict 14-day mortality and plan appropriate treatment for critically ill patients with cancer who present to the ED., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: While much attention is given to the fifth vital sign, the utility of the 4 classic vital signs (blood pressure, respiratory rate, body temperature, and heart rate) has been neglected. The aim of this study was to assess a possible association between vital signs and the Sequential Organ Failure Assessment (SOFA) score in patients with sepsis., Methods: We performed a prospective, observational study of 206 patients with sepsis. Blood pressure, respiratory rate, body temperature, and heart rate were measured on arrival at the hospital. The SOFA score was also determined on the day of admission., Results: Bivariate correlation analysis showed that all of the vital signs were correlated with the SOFA score. Multiple regression analysis indicated that decreased values of systolic blood pressure (multivariate regression coefficient [Coef] = -0.030, 95% confidence interval [CI] = -0.046 to -0.013) and diastolic blood pressure (Coef = -0.045, 95% CI = -0.070 to -0.019), increased respiratory rate (Coef = 0.176, 95% CI = 0.112 to 0.240), and increased shock index (Coef = 4.232, 95% CI = 2.401 to 6.062) significantly influenced the SOFA score., Conclusion: Increased respiratory rate and shock index were significantly correlated with disease severity in patients with sepsis. Evaluation of these signs may therefore improve early identification of severely ill patients at triage, allowing more aggressive and timely interventions to improve the prognosis of these patients.

The dynamics of the state severity changes and polyorgan dysfunction degree were analyzed in patients, who have died as a consequence of severe acute pancreatitis. In patients, operated on later than 14th day after the disease beginning, and not operated, lethality is caused by primary pancreatogenic polyorgan dysfunction with subsequent progressing of their state due to purulent-septic complications occurrence. The state severity and polyorgan dysfunction in patients, operated on in terms up to 6 days, is connected, possibly, with not substantiated operative-anesthesiological aggression. These data witness the possibility of the patients death prevention, while refusal from "early" operations conduction.

We analyzed all patients undergoing allogeneic stem cell transplantation (ASCT) and transferred to the intensive care unit (ICU) from January 1995 to December 2005. During this period, 661 patients underwent ASCT at our center. A total of 91 patients were admitted to the ICU. Median time from ASCT to ICU admission was 69 days (-24 to 1572) and median stay at the ICU was 4 (1-60) days. The survival after transfer to the ICU at day 100 and at 1 year was 22 and 16%, respectively. Median Sequential Organ Failure Assessment (SOFA) score was 10 (1-17). Patients with SOFA score <8 (n=18) had a 44% survival compared with 17% with SOFA score 8-11 (n=30) and no survival with SOFA score >11 (n=20) (P=0.0002). None of the 14 retransplanted patients survived compared with 31% among patients after first ASCT (P=0.006). Patients receiving TBI had a lower survival compared with patients treated with chemotherapy only (14 vs 45%, P=0.02). Patients needing vasopressor support had a worse survival, 15 vs 41%, compared with patients without vasopressor treatment (P=0.01). In multivariate analysis of death, SOFA score was the only significant factor (P<0.001). In conclusion, SOFA score predicted prognosis in ASCT patients treated at the ICU.

Objectives: To evaluate the application of the Sequential Organ Failure Assessment (SOFA) in describing the severity of organ dysfunctions and the associated mortality rates in critically ill patients at a teaching hospital., Research Methodology: Prospective longitudinal study performed in 1164 adult, critically ill patients who were admitted consecutively into intensive care units between January 2004 and December 2005. We analysed static evaluation of SOFA and dynamic changes in the SOFA scores. The discriminative power of SOFA was evaluated using ROC curves., Results: There was an increase in the mortality rate when the SOFA scores increased (chi2(trend)=272.08, p<0.001, increase rate=0.13). The SOFA score on the third day in the ICU had the highest area under the curve for hospital mortality (AUC: 0.817+/-0.0133, CI 95%: 0.792-0.840). We analysed SOFA score changes with time and observed that patients with low scores (0-5) upon admission and who increased to the medium or high SOFA groups had a significantly higher mortality rate (51.7 and 100%, respectively, p<0.001)., Conclusions: Applying SOFA to critically ill patients effectively described the severity of organ dysfunctions, and higher SOFA scores had a positive association with mortality., (Copyright 2009 Elsevier Ltd. All rights reserved.)

The aim was to demonstrate the performance of a modified version of the Sequential Organ Failure Assessment (SOFA) score to predict mortality in medical and surgical patients with cancer. We performed an electronic retrospective review of databases. We included adult patients with cancer admitted into a 53-bed ICU over 28 months. We electronically calculated a modified SOFA (mSOFA) score at admission. A majority of the patients were admitted into the surgical ICU. Of 328 nonsurvivors, 85.1 per cent were medical patients and only 14.9 per cent surgical patients. The mean admission mSOFA scores for medical and surgical patients were 4.7 +/- 3.2 and 1.7 +/- 1.9, respectively. The overall area under the curve (AUC) of the mSOFA score was 0.84. The AUCs for medical and surgical patients were 0.72 and 0.78, respectively. Our results demonstrate that electronic assessment of mSOFA score has potential in resource allocation decisions as well as in critical care outreach programs.

Severity of illness scores are increasingly used in the intensive care environment to help predict outcome, to characterize disease severity and degree of organ dysfunction, to stratify patients for clinical trial enrollment, to assess resource use, and to compare intensive care unit (ICU) performance. This article reviews the most commonly used severity of illness scoring systems and discusses some of their uses and limitations., (Copyright Thieme Medical Publishers.)

Sequential Organ Failure Assessment (SOFA) score based triage of influenza A H1N1 critically ill patients has been proposed for surge capacity management as a guide for clinical decision making. We conducted a retrospective records review and SOFA scoring of critically ill patients with influenza A H1N1 in a mixed medical-surgical intensive care unit in an urban hospital. Eight critically ill patients with influenza A H1N1 were admitted to the intensive care unit. Their mean (range) age was 39 (26-52) years with a length of stay of 11 (3-17) days. All patients met SOFA score based triage admission criteria with a modal SOFA score of five. Five patients required invasive ventilation for a mean (range) of 5 (4-11) days. Five patients would have been considered for withdrawal of treatment using SOFA scoring guidelines at 48 h. All patients survived. We conclude that SOFA score based triage could lead to withdrawal of life support in critically ill patients who could survive with an acceptably low length of stay in the intensive care unit.

The aim of the current study was to describe the utility of the Sequential Organ Failure Assessment score in assessing the severity of organ dysfunction in patients with cancer before admission to the intensive care unit. This was a prospective cohort study performed from January to October 2007. The Sequential Organ Failure Assessment score was recorded before admission to intensive care unit. Two hundred patients were included. The Sequential Organ Failure Assessment score of patients having survived the intensive care unit stay was 3.44 +/- 3.56 and of the patients no survivor's was 9.35 +/- 3.45. There were 89.5% of the patients who had 2 or more organ dysfunctions. The area under the receiver operating characteristic curve for score Sequential Organ Failure Assessment was 0.87. The mortality in the intensive care unit was 27.5%. The Sequential Organ Failure Assessment score was predictive for survival in intensive care unit when applied before admission.

Background: Patients in the intensive care unit (ICU) require huge resources because of the dysfunction of several of their vital organs. The heterogeneity and complexity of the ICU patient have generated interest in systems able to measure severity of illness as a method of predicting outcome, comparing quality-of-care and stratification for clinical trials., Methods: By searching Medline and EMBASE for publications describing scoring systems in the ICU, the most frequently used systems, defined as resulting in more than 50 references, are included in this review. Scoring systems belong to one of four classes prognostic, single-organ failure, trauma scores and organ dysfunction (OD). The different systems are described and discussed., Results: Three different prognostic scoring systems, including several versions, four single OD scores and three OD scores, were included in this review., Conclusion: Different forms of scoring systems are frequently used in the ICU. They have become a necessary tool to describe ICU populations and to explain differences in mortality. As there are several pitfalls related to the interpretation of the numbers supplied by the systems, they should not be used without knowledge on the science of severity scoring.

The present paper outlines the basic idea on multiple organ dysfunctions in the newborn. The major clinical manifestations of multiple organ dysfunctions (MOD) have been studied and are described. The basic systems most susceptible to MOD are determined, and the critical stages of neonality when the development of MOD is extremely high are identified.

The ability to accurately adjust for the severity of illness in outcome studies of critically ill patients is essential. Previous studies have showed that Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation (APACHE) II score can predict hospital mortality of critically ill patients. The effects of combining these two scores to predict hospital mortality of critically ill patients has not been evaluated. This cohort study evaluated the performance of combining the APACHE II score with SOFA score in predicting hospital mortality of critically ill patients. A total of 1311 consecutive adult patients admitted to a tertiary 22-bed multidisciplinary intensive care unit (ICU) in Western Australia were considered. The APACHE II, Admission SOFA, Delta SOFA and maximum SOFA score were all related to hospital survival in the univariate analyses. Combining Max SOFA (area under receiver operating characteristic curve 0.875 vs. 0.858, P = 0.014; Nagelkerke R2: 0.411 vs. 0.371; Brier Score: 0.086 vs. 0.090) or Delta SOFA score (area under receiver operating characteristic curve 0.874 vs. 0.858, P = 0.003; Nagelkerke R2: 0.412 vs. 0.371; Brier Score: 0.086 vs. 0.090) with the APACHE II score improved the discrimination and overall performance of the predictions when compared with using the APACHE II score alone, especially in the emergency ICU admissions. Combining Max SOFA or Delta SOFA score with the APACHE II score may improve the accuracy of risk adjustment in outcome studies of critically ill patients.

The critical care community has been using severity and organ failure assessment tools for over 2 decades. The major adult severity assessment models are Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score, and Mortality Probability Model. All three recent versions of these models perform well in predicting hospital mortality. Sequential Organ Failure Assessment score is the most used tool for assessment of multiple organ failure. These tools have been used extensively in clinical research involving critically ill patients and for benchmarking and the measurement of performance improvement. Their roles as clinical decision support tools at the bedside await future studies because of their unknown or poor performance at the individual patient level.

Objective: To compare the validity of the Multiple Organ Dysfunction Score (MODS), Sequential Organ Failure Assessment (SOFA), and Logistic Organ Dysfunction Score (LOD) for predicting ICU mortality of Thai critically ill patients., Material and Method: A retrospective study was made of prospective data collected between the 1st July 2004 and 31st March 2006 at Songklanagarind Hospital., Results: One thousand seven hundred and eighty two patients were enrolled in the present study. Two hundred and ninety three (16.4%) deaths were recorded in the ICU. The areas under the Receiver Operating Curves (A UC) for the prediction of ICU mortality the results were 0.861 for MODS, 0.879 for SOFA and 0.880 for LOD. The AUC of SOFA and LOD showed a statistical significance higher than the MODS score (p = 0.014 and p = 0.042, respectively). Of all the models, the neurological failure score showed the best correlation with ICU mortality., Conclusion: All three organ dysfunction scores satisfactorily predicted ICU mortality. The LOD and neurological failure had the best correlation with ICU outcome.

This study compared the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II score with two organ failure scores in predicting hospital mortality of critically ill patients. A total of 1311 consecutive adult patients in a tertiary 22-bed multidisciplinary intensive care unit (ICU) in Western Australia were considered. The APACHE II score had a better calibration and discrimination than the Max Sequential Organ Failure Score (Max SOFA) (area under receiver operating characteristic (ROC) curve 0.858 vs 0.829), Admission SOFA (area under ROC 0.858 vs 0.791), and the first day or cumulative 5-day Royal Perth Hospital Intensive Care Unit (RPHICU) organ failure score (area under ROC 0.858 vs 0.822 and 0.819, respectively) in predicting hospital mortality. The APACHE II score predicted hospital mortality of critically ill patients better than the SOFA and RPHICU organ failure scores in our ICU.

As the extension of nursing into roles previously within the domain of medicine and the demand for evidence based practice continue to increase, the quality of decision making becomes imperative. Making accurate decisions is essential, both for the practitioner and for the patient, especially in the provision of critical care outreach (CCOR), to improve outcomes of care. With changes in health care delivery and increased accountability for practitioners' decisions, it is important to understand more about how clinical decisions are made and what factors influence them in order to inform practice. The previous paper outlined the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In this paper, the authors, a Nurse Consultant in CCOR and a research fellow, examine the process of a practitioner's decision making in the practice of CCOR, through a collaborative reflective account of a case study. From this, recommendations are made about the future development of CCOR practitioners and services.

A relationship was studied between the outcomes of severe acute pancreatitis and the pattern and multiple organ dysfunctions in 72 patients. Organ dysfunction was observed in 39 (54.2%) patients: multiple organ dysfunction (MOD) in 20 (27.8%) patients and dysfunction of an organ or a system in 19 (26.4%). The deceased patients had a statistically significantly higher incidence of MOS than the survivors (88.2% versus 9.1%; p < 0.01). Logistic regression showed that only respiratory and neurological dysfunctions were the factors that predispose to death.

The authors studied bioelectrical millivolt-range potentials (omega potential), followed up the health status by the SAPS II and APACHE III scales and organ dysfunction by the MODS scale in patients with sepsis verified by the classification described by R. C. Bone. It was established that in patients with sepsis from the systemic inflammatory response syndrome (SIRS) to the multiple organ dysfunction syndrome (MODS), three main functional groups could be identified with their characteristic clinical course, the level of a lesion, and estimated mortality. In septic patients, the severest condition was noted in a decompensated state when septic shock developed, which was equal to 83 (79.3/ 83) scores by the SAPS II scale. In the patients whose condition was defined as sepsis and severe sepsis in the presence of a subcompensated state, the severity was equal to 55 (51/56.3) scores by the SAPS II scale. The mildest severity (51 (46.8/53.4) scores characterized the development of SIRS or sepsis in the presence of a compensated state.

Objective: To determine whether severity and organ failure scores over the first 3 days in an ICU predict in-hospital mortality in onco-hematological malignancy patients., Design and Setting: Retrospective study in a 22-bed medical ICU., Patients: 92 consecutive patients with onco-hematological malignancies including 20 hematopoietic stem cell transplantation (HSCT) patients (11 with allogenic HSCT)., Measurements: Simplified Acute Physiology Score (SAPS) II, Organ Dysfunction and/or Infection (ODIN) score, Logistic Organ Dysfunction System (LODS), and Sequential Organ Failure Assessment (SOFA) score were recorded on admission. The change in each score (Delta score) during the first 3 days in the ICU was calculated as follows: severity or organ failure score on day 3 minus severity or organ failure score on day 1, divided by severity or organ failure score on day 1., Results: In-hospital mortality was 58%. Using multivariate analysis in-hospital mortality was predicted by all scores on day 1 and all Delta scores. Areas under the receiver operating characteristics curves were similar for SAPS II (0.78), ODIN (0.78), LODS (0.83), and SOFA (0.78) scores at day 1. They were also similar for DeltaSAPS II, DeltaODIN, DeltaLODS, and DeltaSOFA. Similar results were observed when excluding patients with allogenic HSCT., Conclusion: Severity and three organ failure scores on day 1 and Delta scores perform similarly in predicting in-hospital mortality in ICU onco-hematological malignancy patients but do not predict individual outcome. Decision to admit such patients to the ICU or to forgo life-sustaining therapies should not be based on these scores.

The database of a multicentre cohort study was analysed to determine the impact of intensive care unit (ICU) organ failures and their association with ICU mortality using sequential organ failure assessment (SOFA). A consecutive sample of 873 adult patients with a non-neurological diagnosis was identified. SOFA scores were measured every 24 h of ICU stay. The odds of ICU death within 7 days doubled (95% CI 1.3-2.9) for a 5-unit increase in total SOFA score at admission, p < 0.001. However ICU death after 7 days was not associated with total SOFA score at admission, p = 0.36. Compared to patients with a day 6 total SOFA score = 5, there was a 1-unit (95% CI 0.8-3.1) increase in the odds ratio of ICU death after 7 days with every 5-unit increase in SOFA score on day 6, p = 0.009. Continuous assessments of organ failures during an ICU admission are more useful than scores measured at admission to determine outcome and to compare ICUs.