Seminars in respiratory and critical care medicine
-
Sepsis is a common illness of intensive care unit patients that carries a high morbidity, mortality, and increases hospital cost. Although mortality from sepsis remains high when compared with other critical illnesses, it has declined over the last few decades due to several adjunctive therapies and focused care programs or guidelines. ⋯ However, other therapies still have an unclear benefit and remain controversial. This article discusses the controversial roles of intensive insulin therapy, corticosteroids, and activated protein C in the treatment of sepsis.
-
Outcomes research is a life sciences field that focuses on patient-oriented outcomes, which are important to a wide range of stakeholders, including patients, physicians, health care systems and payers, and society. An important emphasis of outcomes research is assessment of medical processes and interventions in "real world" settings rather than under experimental conditions. A condition of this approach is that many studies are observational in design. ⋯ Controversial topics in respiratory diseases such as intensive care unit (ICU) organization and relationships of hospital volume to patient mortality are discussed to illustrate how different study designs and analytic techniques can lead to discrepant study results. Outcomes research will increase in importance and application as health care systems and payers become more interested in maximizing patient outcomes relative to resources used. Resources should be made available to enhance the training of new investigators and provide sufficient expertise for the design and analysis of influential studies.
-
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.
-
Invasive fungal infections, especially candidemia and systemic candidiasis, have become a major cause of morbidity and mortality in the last few decades. This comes in parallel with the major advances made in intensive care. Patients who are critically ill, in medical or surgical ICUs are especially at risk for CANDIDA infections. ⋯ Despite these advancements, the mortality rates associated with candidiasis remain excessively high, with an overall mortality in the range of 30 to 50% and an attributable mortality of ~30%. In addition to this high case-fatality rate, candidemia is also associated with a substantial economic burden, primarily due to an extended length of stay. Strategies to evaluate either the prevention, early diagnosis, or initiation of appropriate therapy should yield both clinical and socioeconomic benefits.