Fiona K Gibbons

Massachusetts General Hospital, Boston, Massachusetts, United States

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Publications (46)303.12 Total impact

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    ABSTRACT: Background and Purpose In patients with intracerebral hemorrhage (ICH), it is not clear if hypernatremia is merely a marker of disease severity or if elevated sodium levels are harmful. We hypothesized that hypernatremia at hospital discharge in primary ICH patients would be associated with increased mortality following discharge. Methods We performed a two-center observational study of critically ill ICH patients in Boston. We studied 5100 patients, age ≥18 years, who were diagnosed with ICH (ICD-9 code 431), received medical or surgical critical care between 1997 and 2011 and survived hospitalization. The exposure of interest was serum sodium within 24 h of hospital discharge, categorized as Na ≤ 145 mmol/L and Na > 145 mmol/L. The primary outcome was 30-day post-discharge mortality. Odds ratios were estimated by logistic regression models adjusted for age, race, gender, Deyo–Charlson Index, patient type (medical versus surgical) and sepsis. Results In ICH patients who received critical care and survived hospitalization, the serum sodium at discharge was a predictor of post-discharge mortality. Patients with a discharge Na > 145 mmol/L have an OR for mortality in the 30 days following hospital discharge of 1.82 (95 %CI 1.38–2.38; P < 0.001) and an adjusted OR of 1.87 (95 %CI 1.40–2.48; P < 0.001) both relative to patients with a discharge Na ≤ 145 mmol/L. The adjusted model showed good discrimination AUC 0.77 (95 %CI 0.74–0.79) and calibration (Hosmer–Lemeshow χ 2P = 0.68). Conclusions In critically ill ICH patients who survive hospitalization, hypernatremia at the time of discharge is a robust predictor of post-discharge mortality.
    No preview · Article · Feb 2016 · Neurocritical Care
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    ABSTRACT: Background: Acute kidney injury (AKI) is a serious postoperative complication. Objective: To determine whether AKI in patients after craniotomy is associated with heightened 30-day mortality. Methods: We performed a 2-center, retrospective cohort study of 1656 craniotomy patients who received critical care between 1998 and 2011. The exposure of interest was AKI defined as meeting RIFLE (Risk, Injury, Failure, Loss of Kidney Function, and End-stage Kidney Disease) class risk, injury, and failure criteria, and the primary outcome was 30-day mortality. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both AKI and mortality. Additionally, mortality in craniotomy patients with AKI was analyzed with a risk-adjusted Cox proportional hazards regression model and propensity score matching as a sensitivity analysis. Results: The incidences of RIFLE class risk, injury, and failure were 5.7%, 2.9%, and 1.3%, respectively. The odds of 30-day mortality in patients with RIFLE class risk, injury, or failure fully adjusted were 2.79 (95% confidence interval [CI], 1.76-4.42), 7.65 (95% CI, 4.16-14.07), and 14.41 (95% CI, 5.51-37.64), respectively. Patients with AKI experienced a significantly higher risk of death during follow-up; hazard ratio, 1.82 (95% CI, 1.34-2.46), 3.37 (95% CI, 2.36-4.81), and 5.06 (95% CI, 2.99-8.58), respectively, fully adjusted. In a cohort of propensity score-matched patients, RIFLE class remained a significant predictor of 30-day mortality. Conclusion: Craniotomy patients who suffer postoperative AKI are among a high-risk group for mortality. The severity of AKI after craniotomy is predictive of 30-day mortality. Abbreviations: KI, acute kidney injuryAPACHE II, Acute Physiology and Chronic Health Evaluation IICI, confidence intervalCPT, Current Procedural TerminologyICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical ModificationRIFLE, risk, injury, failure, loss of kidney function, and end-stage kidney diseaseRPDR, Research Patient Data Registry.
    No preview · Article · Dec 2015 · Neurosurgery

  • No preview · Article · Nov 2015 · Critical care medicine
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    Full-text · Article · Oct 2015
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    LE Homer · C Edmark · KM Mogensen · FK Gibbons · KB Christopher

    Full-text · Article · Oct 2015
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    SL Gans · FK Gibbons · MA Boermeester · KB Christopher

    Preview · Article · Oct 2015
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    Full-text · Article · Oct 2015
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    ABSTRACT: Importance The Model for End-Stage Liver Disease (MELD) score is predictive of trauma outcomes.Objective To determine whether a decrease in MELD score is associated with improved mortality in critically ill trauma patients.Design, Setting, and Participants We performed a retrospective registry study of critically ill trauma patients 18 years or older with chronic liver disease treated between August 3, 1998, and January 5, 2012, at 2 level I trauma centers in Boston, Massachusetts. The consecutive sample included 525 patients (male, 373 [71.0%]; white, 399 [76.0%]; mean [SD] age, 55.0 [12.4] years).Exposures Change in MELD score from intensive care unit (ICU) admission to 48 to 72 hours later.Main Outcomes and Measures Thirty-day all-cause mortality.Results The mean (SD) MELD score at ICU admission was 19.3 (9.7). The 30-day mortality was 21.9%. The odds of 30-day mortality with a change in MELD score of less than −2, −2 to −1, +1 to +4, and greater than +4 were 0.23 (95% CI, 0.10-0.51), 0.30 (95% CI, 0.10-0.85), 0.57 (95% CI, 0.27-1.20), and 1.31 (95% CI, 0.58-2.96), respectively, relative to a change in MELD score of 0 and adjusted for age, sex, race, Charlson/Deyo Index, sepsis, number of acute organ failures, International Classification of Diseases, Ninth Revision–based injury severity score, and ICU admission MELD score.Conclusions and Relevance A decrease in MELD score within 72 hours of ICU admission is associated with improved mortality.
    No preview · Article · Sep 2015 · JAMA SURGERY
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    ABSTRACT: Objective: In animal models of renal, intestinal, liver, cardiac, and cerebral ischemia, alcohol exposure is shown to reduce ischemia-reperfusion injury. Inpatient mortality of trauma patients is shown to be decreased in a dose-dependent fashion relative to blood alcohol concentration (BAC) at hospital admission. In this study, we examined the association between BAC at hospital admission and risk of 30-day mortality in critically ill patients. Design: We performed a 2-center observational study of patients treated in medical and surgical intensive care units in Boston, Massachusetts. Setting: Medical and surgical intensive care units in 2 teaching hospitals in Boston, Massachusetts. Patients: We studied 11850 patients, 18 years or older, who received critical care between 1997 and 2007. The exposure of interest was the BAC determined in the first 24 hours of hospital admission and categorized a priori as BAC less than 10 mg/dL (below level of detection), 10 to 80 mg/dL, 80 to 160 mg/dL, and greater than 160 mg/dL. The primary outcome was all-cause mortality in the 30 days after critical care initiation. Secondary outcomes included 90- and 365-day mortality after critical care initiation. Mortality was determined using the US Social Security Administration Death Master File, and 365-day follow-up was present in all cohort patients. Adjusted odds ratios (ORs) were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both BAC and mortality. Adjustment included age, sex, race (white or nonwhite), type (surgical vs medical), Deyo-Charlson index, sepsis, acute organ failure, trauma, and chronic liver disease. Results: Thirty-day mortality of the cohort was 13.7%. Compared to patients with BAC levels less than 10 mg/dL, patients with levels greater than or equal to 10 mg/dL had lower odds of 30-day mortality; for BAC levels 10 to 79.9 mg/dL, the OR was 0.53 (95% confidence interval [CI], 0.40-0.70); for BAC levels 80 to 159.9 mg/dL, it was 0.36 (95% CI, 0.26-0.49); and for BAC levels greater than or equal to 160 mg/dL, it was 0.35 (95% CI, 0.27-0.44). After multivariable adjustment, the OR of 30-day mortality was 0.97 (0.72-1.31), 0.79 (0.57-1.10), and 0.69 (0.54-0.90), respectively. When the cohort was analyzed with sepsis as the outcome of interest, the multivariable adjusted odds of sepsis in patients with BAC 80 to 160 mg/dL or greater than 160 mg/dL were 0.72 (0.50-1.04) or 0.68 (0.51-0.90), respectively, compared to those with BAC less than 10 mg/dL. In a subset of patients with blood cultures drawn (n = 4065), the multivariable adjusted odds of bloodstream infection in patients with BAC 80 to 160 mg/dL or greater than 160 mg/dL were 0.53 (0.27-1.01) or 0.49 (0.29-0.83), respectively, compared to those with BAC less than 10 mg/dL. Conclusions: Analysis of 11850 adult patients showed that having a detectable BAC at hospitalization was associated with significantly decreased odds of 30-day mortality after critical care. Furthermore, BAC greater than 160 mg/dL is associated with significantly decreased odds of developing sepsis and bloodstream infection.
    No preview · Article · Sep 2015 · Journal of critical care
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    ABSTRACT: Objective: We hypothesise that low 25-hydroxyvitamin D (25(OH)D) levels before hospitalisation are associated with increased risk of acute respiratory failure. Design: Retrospective cohort study. Setting: Medical and Surgical Intensive care units of two Boston teaching hospitals. Patients: 1985 critically ill adults admitted between 1998 and 2011. Interventions: None. Measurements and main results: The exposure of interest was prehospital serum 25(OH)D categorised as ≤10 ng/mL, 11–19.9 ng/mL, 20–29.9 ng/mL and ≥30 ng/mL. The primary outcome was acute respiratory failure excluding congestive heart failure determined by International Classification of Diseases Ninth Edition (ICD-9) coding and validated against the Berlin Definition of acute respiratory sistress syndrome. Association between 25(OH)D and acute respiratory failure was assessed using logistic regression, while adjusting for age, race, sex, Deyo-Charlson Index and patient type (medical vs surgical). In the cohort, the mean age was 63 years, 45% were male and 80% were white; 25(OH)D was ≤10 ng/mL in 8% of patients, 11–19.9 ng/mL in 24%, 20–29.9 ng/mL in 24% and ≥30 ng/mL in 44% of patients. Eighteen per cent (n=351) were diagnosed with acute respiratory failure. Compared to patients with 25(OH)D ≥30 ng/mL, patients with lower 25(OH)D levels had significantly higher adjusted odds of acute respiratory failure (≤10 ng/mL, OR=1.84 (95% CI 1.22 to 2.77); 11–19.9 ng/mL, OR=1.60 (95% CI 1.19 to 2.15); 20–29.9 ng/mL, OR=1.37 (95% CI 1.01 to 1.86)). Conclusions: Prehospital 25(OH)D was associated with the risk of acute respiratory failure in our critically ill patient cohort.
    Full-text · Article · Jun 2015
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    ABSTRACT: The goal of the present study was to determine whether pre-hospital 25-hydroxyvitamin D (25(OH)D) levels are associated with the risk of hospital-acquired new-onset delirium (HANOD). We performed a retrospective cohort study of 4508 adult inpatients at two teaching hospitals in Boston from 1993 to 2006. All patients had 25(OH)D levels measured before hospital admission. The main outcome measure was HANOD, defined as the onset of delirium during an acute care hospitalisation. Patients with a history of delirium or dementia, or those with a diagnosis of delirium or dementia upon acute care hospitalisation were excluded from the analysis. To test the association of pre-hospital 25(OH)D levels with HANOD, we constructed a multivariable logistic regression model to adjust for clinically relevant covariates. Among our patient cohort, the mean 25(OH)D level was 22 ( sd 13) ng/ml and approximately 4 % of patients met the criteria for HANOD. Following adjustment for age, sex, race (non-white v. white), patient type (medical v. surgical) and Deyo–Charlson Index, patients with 25(OH)D levels < 10, 10–19·9 and 20–29·9 ng/ml had higher odds of HANOD than patients with 25(OH)D levels ≥ 30 ng/ml: OR 2·15 (95 % CI 1·32, 3·50), OR 1·54 (95 % CI 0·98, 2·43) and OR 1·23 (95 % CI, 0·76, 1·99), respectively. These data support the rationale for randomised, controlled trials to test the role of vitamin D supplementation in the prevention of HANOD.
    Full-text · Article · Jun 2015 · The British journal of nutrition
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    ABSTRACT: Pre-hospital vitamin D status may be a modifiable risk factor for all-cause mortality among hospitalized patients. To examine the association between increases in serum 25-hydroxyvitamin D [25(OH)D] levels during the year before hospitalization and risk of 30-day all-cause mortality after hospital admission. Retrospective cohort study. Two Boston teaching hospitals. We studied 4344 adults hospitalized between 1993 and 2011 who had serum 25(OH)D concentrations measured at least twice within 7-365 days before the index hospitalization. None. The exposure of interest was change in pre-hospital serum 25(OH)D concentrations. The main outcome was 30-day all-cause mortality. We used mixed-effects logistic regression to describe how 30-day mortality differed with changes in pre-hospital 25(OH)D concentrations. Additionally, the odds of 30-day mortality in patients with pre-hospital 25(OH)D increases of ≥10 ng/mL was compared to that of patients with increases of <10 ng/mL. In a mixed-effect logistic regression model adjusted for age, gender, race, type (medical/surgical), Deyo-Charlson Index, creatinine and hematocrit, 30-day all-cause mortality rate was 8% (95%CI: 1-15) lower for each 10 ng/mL increase in pre-hospital 25(OH)D (P = 0.025) compared with the 30-day all-cause mortality rate in the entire cohort. In an adjusted logistic regression model, absolute changes of ≥10 ng/mL in patients with initial 25(OH)D concentrations < 20 ng/mL (n = 1944) decreased the odds of 30-day all-cause mortality by 48% (adjusted OR 0.52; 95%CI 0.30-0.93; P = 0.026) compared to patients with changes of <10 ng/mL. In patients with initial 25(OH)D < 20 ng/mL, subsequent improvements in vitamin D status before hospitalization are associated with decreased odds of 30-day all-cause mortality after hospital admission. A causal relation may not be inferred from this observational study. Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
    Full-text · Article · Apr 2015 · Clinical Nutrition
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    ABSTRACT: Prediction models for ICU mortality rely heavily on physiologic variables that may not be available in large retrospective studies. An alternative approach when physiologic variables are absent stratifies mortality risk by acute organ failure classification. Retrospective cohort study. Two large teaching hospitals in Boston, MA. Ninety-two thousand eight hundred eighty-six patients aged 18 years old or older admitted between November 3, 1997, and February 25, 2011, who received critical care. None. The derivation cohort consisted of 35,566 patients from Brigham and Women's Hospital, and the validation cohort comprised 57,320 patients from Massachusetts General Hospital. Acute organ failure was determined for each patient based on International Classification of Diseases, 9th Revision, Clinical Modification code combinations. The main outcome measure was 30-day mortality. A clinical prediction model was created based on a logistic regression model describing the risk of 30-day mortality as a function of age, medical versus surgical patient type, Deyo-Charlson index, sepsis, and type acute organ failure (respiratory, renal, hepatic, hematologic, metabolic, and neurologic) after ICU admission. We computed goodness-of fit statistics and c-statistics as measures of model calibration and 30-day mortality discrimination, respectively. Thirty-day mortality occurred in 5,228 of 35,566 patients (14.7%) assigned to the derivation cohort. The clinical prediction model was predictive for 30-day mortality. The c-statistic for the clinical prediction model was 0.7447 (95% CI, 0.74-0.75) in the derivation cohort and 0.7356 (95% CI, 0.73-0.74) in the validation cohort. For both the derivation and validation cohorts, the Hosmer-Lemeshow chi-square p values indicated good model fit. In a smaller cohort of 444 patients with Acute Physiologic and Chronic Health Evaluation II scores determined, differences in model discrimination of 30-day mortality between the clinical prediction model and Acute Physiologic and Chronic Health Evaluation II were not significant (chi-square = 0.76; p = 0.38). An acute organ failure-based clinical prediction model shows good calibration and discrimination for 30-day mortality in the critically ill. The clinical prediction model compares favorably to Acute Physiologic and Chronic Health Evaluation II score in the prediction of 30-day mortality in the critically ill. This score may be useful for severity of illness risk adjustment in observational studies where physiologic data are unavailable.
    Full-text · Article · Feb 2015 · Critical Care Medicine
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    ABSTRACT: Objective: Hospital readmissions contribute significantly to the cost of inpatient care and are targeted as a marker for quality of care. Little is known about risk factors associated with hospital readmission in survivors of critical illness. We hypothesized that acute kidney injury in patients who survived critical care would be associated with increased risk of 30-day postdischarge hospital readmission, postdischarge mortality, and progression to end-stage renal disease. Design: Two center observational cohort study. Setting: Medical and surgical ICUs at the Brigham and Women's Hospital and the Massachusetts General Hospital in Boston, Massachusetts. Patients: We studied 62,096 patients, 18 years old and older, who received critical care between 1997 and 2012 and survived hospitalization. Interventions: None Measurements and Main Results: All data was obtained from the Research Patient Data Registry at Partners HealthCare. The exposure of interest was acute kidney injury defined as meeting Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease Risk, Injury or Failure criteria occurring 3 days prior to 7 days after critical care initiation. The primary outcome was hospital readmission in the Conclusions: Patients who suffer acute kidney injury are among a highrisk group of ICU survivors for adverse outcomes. In patients treated with critical care who survive hospitalization, acute kidney injury is a robust predictor of subsequent unplanned hospital readmission. In critical illness survivors, acute kidney injury is also associated with the odds of 30-day postdischarge mortality and the risk of subsequent end-stage renal disease. (Crit Care Med 2015; 43:354-364). Copyright © 2015 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.
    Full-text · Article · Dec 2014 · Critical Care Medicine
  • T. G. Simon · C. K. McKane · F. K. Gibbons · K. B. Christopher

    No preview · Conference Paper · Sep 2014
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    ABSTRACT: Objective: To investigate whether preadmission 25-hydroxyvitamin D (25(OH)D) levels are associated with the risk of hospital-acquired Clostridium difficile infection (HACDI). Materials and methods: Our retrospective cohort study focused on 568 adult patients from 2 Boston teaching hospitals between August 1993 and November 2006. All patients had 25(OH)D levels measured before hospitalization and were at risk for HACDI (defined as the presence of C difficile toxin A or B in stool samples obtained >48 hours after hospitalization). We performed multivariable regression analyses to test the association of prehospital 25(OH)D levels with HACDI while adjusting for clinically relevant covariates. Results: In these 568 patients, mean (SD) 25(OH)D level was 19 (12) ng/mL, and 11% of patients met criteria for incident HACDI. Following adjustment for age, sex, race (nonwhite vs white), patient type (medical vs surgical), and Deyo-Charlson index, patients with 25(OH)D levels <10 ng/mL had higher odds of HACDI (odds ratio [OR], 2.90; 95% confidence interval [CI], 1.01-8.34) compared with patients with 25(OH)D levels ≥30 ng/mL. When patients with HACDI were analyzed relative to a larger patient cohort without HACDI (n = 5047), those with 25(OH)D levels <10 ng/mL (OR, 4.96; 95% CI, 1.84-13.38) and 10-19.9 ng/mL (OR, 3.36; 95% CI, 1.28-8.85) had higher adjusted odds of HACDI compared with patients with 25(OH)D levels ≥30 ng/mL. Conclusions: In our cohort of adult patients, vitamin D status before hospital admission was inversely associated with the risk of developing HACDI. These data support the need for randomized, controlled trials to test the role of vitamin D supplementation to prevent HACDI.
    Full-text · Article · Feb 2014 · Journal of Parenteral and Enteral Nutrition
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    ABSTRACT: Red cell distribution width is associated with mortality and bloodstream infection risk in the critically ill. In hospitalized patients with critical illness, it is not known if red cell distribution width can predict subsequent risk of all-cause mortality following hospital discharge. We hypothesized that an increase in red cell distribution width at hospital discharge in patients who survived to discharge following critical care would be associated with increased postdischarge mortality. Two-center observational cohort study SETTING:: All medical and surgical ICUs at the Brigham and Women's Hospital and Massachusetts General Hospital. We studied 43,212 patients, who were 18 years old or older and received critical care between 1997 and 2007 and survived hospitalization. None. The exposure of interest was red cell distribution width within 24 hours of hospital discharge and categorized a priori in quintiles as less than or equal to 13.3%, 13.3-14.0%, 14.0-14.7%, 14.7-15.8%, and more than 15.8%. The primary outcome was all-cause mortality in the 30 days following hospital discharge. Secondary outcomes included 90-day and 365-day mortality following hospital discharge. Mortality was determined using the U.S. Social Security Administration Death Master File, and 365-day follow-up was present in all cohort patients. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both red cell distribution width and mortality. Adjustment included age, race, gender, Deyo-Charlson Index, patient type (medical vs surgical), sepsis, and number of organs with acute failure. In patients who received critical care and survived hospitalization, the discharge red cell distribution width was a robust predictor of all-cause mortality and remained so following multivariable adjustment. Patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 2.86 (95% CI, 2.25-3.62), 4.57 (95% CI, 3.66-5.72), and 8.80 (95% CI, 7.15-10.83), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Following multivariable adjustment, patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 1.63 (95% CI, 1.27-2.07), 2.36 (95% CI, 1.87-2.97), and 4.18 (95% CI, 3.36-5.20), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Similar significant robust associations post multivariable adjustments are seen with death by days 90 and 365 postdischarge. Estimating the receiver-operating characteristic area under the curve shows that discharge red cell distribution width has moderate discriminative power for mortality 30 days following hospital discharge (area under the curve = 0.70; SE 0.006; 95% CI, 0.69-0.71; p < 0.0001). In patients treated with critical care who survive hospitalization, an elevated red cell distribution width at the time of discharge is a robust predictor of subsequent all-cause patient mortality. Increased discharge red cell distribution width likely reflects the presence of proinflammatory state, oxidative stress, arterial underfilling, or a combination, thereof which may explain the observed impact on patient survival following discharge. Elevated red cell distribution width at hospital discharge may identify ICU survivors who are at risk for adverse outcomes following hospital discharge.
    Full-text · Article · Jan 2014 · Critical care medicine
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    ABSTRACT: Objective: To examine the association between pre-hospital serum 25-hydroxyvitamin D and risk of mortality following hospital admission. Design: We performed a retrospective cohort study of adults hospitalized for acute care between 1993 and 2011. Setting: Two Boston teaching hospitals. Patients: 24,094 adult inpatients. Intervention: None. Measurements: All patients had serum 25(OH)D measured before hospitalization. The exposure of interest was 25(OH)D categorized as <10 ng/mL, 10-19.9 ng/mL, 20-29.9 ng/mL, 30-49.9 ng/mL, 50-59.9 ng/mL, 60-69.9 ng/mL, and ≥70 ng/mL. The main outcome measure was 90-day mortality. Adjusted odds ratios (OR) were estimated by multivariable logistic regression with inclusion of potential confounders. Results: After adjustment for age, gender, race (white vs. non-white), patient type (surgical vs. medical), season of 25(OH)D draw and Deyo-Charlson index, patients with 25(OH)D levels <30 ng/mL or ≥60 ng/mL had higher odds of 90-day mortality compared to patients with levels 30-49.9 ng/mL [adjusted OR(95% confidence interval) for 25(OH)D <10 ng/mL, 10-19.9 ng/mL, 20-29.9 ng/mL, 50-59.9 ng/mL, 60-69.9 ng/mL and ≥70 ng/mL was 2.01(1.68-2.40), 1.89(1.64-2.18), 1.34(1.16-1.56), 0.94(0.69-1.26), 1.52(1.03-2.25) and 1.69(1.09-2.61), respectively, compared to patients with 25(OH)D levels 30-49.9 ng/mL]. Limitations: A causal relationship between either low or high 25(OH)D levels and increased mortality can not necessarily be inferred from this observational study. Conclusions: Analysis of 24,094 adult patients showed that 25(OH)D levels <20 ng/mL and ≥60 ng/mL before hospitalization were associated with an increased odds of 90-day mortality. Though previous reports have suggested an association between low vitamin D status and mortality, these data raise the issue of potential harm from high serum 25(OH)D levels, provide a rationale for an upper limit to supplementation, and emphasize the need for caution in the use of extremely high doses of vitamin D among patients.
    Full-text · Article · Jan 2014 · The Journal of Clinical Endocrinology and Metabolism
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    ABSTRACT: Introduction: The relationship between iron and infection has been investigated in Dialysis patients who are at a high risk for infection. Little is known about the relationship between serum iron status and adverse outcomes in critically ill patients. Methods: We performed a two center observational study of patients treated in medical and surgical intensive care units in Boston, Massachusetts. All data was obtained from the Research Patient Data Registry at Partners HealthCare. We studied 4,703 patients, age >= 18 years, who received critical care between 1997 and 2011 who had serum iron levels measured within a year prior to hospital admission. Patients with end stage renal disease prior to critical care initiation were identified by submitting the administrative data to the United States Renal Data System and excluded due to high prevalence of both intravenous iron supplementation and bloodstream infection in this population The exposure of interest was serum iron categorized a priori as 0-59.9 [mu]g/dL, 60-169.9 [mu]g/dL (referent) and > 170 [mu]g/dL. The primary outcome was bloodstream infection determined by positive blood culture in the 48 hours prior to ICU admission to 48 hours after ICU admission. Secondary outcomes included sepsis and 30-day mortality. Sepsis was defined by ICD-9-CM and validated by the 2001 SCCM/ESICM, ACCP, ATS, SIS international sepsis definitions conference guidelines. Information on vital status for the study cohort was obtained from the Social Security Administration Death Master File which has high sensitivity and specificity for mortality. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both serum iron and bloodstream infection. Adjustment included age, race, gender, comorbidities (Deyo-Charlson Index) and patient type (medical versus surgical). Results: The majority of patients were men (55%), white (78%) and had medical related DRGs (71%). The mean (SD) age at ICU admission was 63.9 (16.1) years. 243 (5%) patients had pre-hospital iron levels > 170 [mu]g/dL. The cohort bloodstream infection rate was 18.4%, with 35.2% of patients diagnosed with sepsis, and an all cause 30-day mortality rate of 23.5%. Pre-hospital serum iron was a robust predictor of bloodstream infection and remained so following multivariable adjustment. Patients with pre-hospital serum iron > 170 [mu]g/dL have an OR for bloodstream infection of 1.38 (95%CI, 1.00, 1.92, p=0.050) and an adjusted OR of 1.41 (95%CI, 1.01, 1.97, p=0.041) relative to patients with serum iron 60-169.9 [mu]g/dL. Pre-hospital serum iron 0-59.9 [mu]g/dL was not associated with increased odds of bloodstream infection relative to patients with serum iron 60-169.9 [mu]g/dL. Further, patients with pre-hospital serum iron > 170 [mu]g/dL have an OR for sepsis of 1.39 (95%CI, 1.05, 1.84, p=0.022) following adjustment for age, gender, race, patient type and Deyo-Charson index, relative to patients with serum iron 60-169.9 [mu]g/dL. Patients with pre-hospital serum iron > 170 [mu]g/dL have an OR for 30-day mortality of OR of 1.42 (95%CI, 1.02, 1.96, p=0.035) following adjustment for age, gender, race, patient type, Deyo-Charson index and acute organ failure, relative to patients with serum iron 60-169.9 [mu]g/dL. Conclusions: In critically ill patients, an elevated serum iron >170 [mu]g/dL prior to hospitalization is a robust predictor of the development of bloodstream infection, sepsis and 30-day mortality following ICU admission. If our findings are corroborated, information regarding iron metabolism and its relationship to infection in the critically ill may potentially help guide infection management efforts in the ICU.
    No preview · Article · Dec 2013 · Critical Care Medicine
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    ABSTRACT: Introduction: Hospital readmissions contribute significantly to the cost of inpatient care and are targeted as a marker for quality of care. Little is known about risk factors associated with hospital readmission in survivors of critical illness. Methods: We studied 62,587 patients, age >= 18 years, who received critical care between 1997 and 2012 and survived hospitalization. The exposure of interest was acute kidney injury (AKI) defined as meeting RIFLE Risk, Injury or Failure criteria occurring 3 days prior to 7 days after critical care initiation. Patients with end stage renal disease prior to critical care initiation were identified by submitting the administrative data to the United States Renal Data System and excluded. In patients whom developed end stage renal disease following an AKI episode, the date chronic dialysis began was recorded. The primary outcome was unplanned hospital readmission in the 30 days following hospital discharge. The first hospitalization associated with critical care is identified as the index critical care exposure, and a 30-day unplanned readmission was defined as a subsequent unplanned admission to the hospitals under study within 30 days of discharge following the hospitalization associated with the index critical care exposure. Readmissions with DRG codes commonly associated with planned readmissions were excluded. The secondary outcome was mortality in the 30 days following hospital discharge. Information on vital status for the study cohort was obtained from the Social Security Administration Death Master File. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both AKI and readmission status. Adjustment included age, race (white versus non-white), gender, Deyo-Charlson Index, patient type (medical versus surgical) and sepsis. Additionally, long-term progression to End Stage Renal Disease in patients with AKI was analyzed with a risk-adjusted Cox proportional hazards regression model. Results: Most cohort patients were men (60%) and white (78%). 48% had medically related DRGs. The mean age at hospital admission was 57 (SD 18) years. 30-day post-discharge hospital readmission rate was 13% and the 30-day post-discharge mortality rate was 3%. In patients who received critical care and survived hospitalization, AKI was a robust predictor of unplanned hospital readmission and post-discharge mortality and remained so following multivariable adjustment. The odds of 30-day post-discharge hospital readmission in patients with RIFLE class Risk, Injury or Failure fully adjusted were 1.44 (95%CI, 1.25, 1.66), 1.98 (95%CI, 1.66, 2.36), and 1.55 (95%CI, 1.26, 1.91) respectively, relative to patients without AKI. Further, the odds of 30-day post-discharge mortality in patients with RIFLE class Risk, Injury or Failure fully adjusted per our primary analysis were 1.39 (95%CI, 1.28, 1.51), 1.46 (95%CI, 1.30, 1.64), and 1.42 (95%CI, 1.26, 1.61) respectively, relative to patients without AKI. Finally, taking into account age, gender, race, Deyo-Charlson Index, and patient type (medical versus surgical), we observed a relationship between AKI and development of End Stage Renal Disease. Patients with RIFLE class Risk, Injury, Failure experienced a significantly higher risk of End Stage Renal Disease during follow-up than patients without acute kidney injury (HR 2.03, 95% CI, 1.56, 2.65; HR 3.99, 95%CI, 3.04, 5.23; HR 10.40, 95%CI, 8.54, 12.69 respectively). Conclusions: Patients who suffer acute kidney injury during critical illness are among a high-risk group of ICU survivors for adverse outcomes. In patients treated with critical care who survive hospitalization, acute kidney injury is a robust predictor of subsequent unplanned hospital readmission. In critical illness survivors, acute kidney injury is also associated with the odds of 30-day post-discharge mortality and the risk of subsequent End Stage Renal Disease.
    No preview · Conference Paper · Dec 2013

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742 Citations
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Institutions

  • 2008-2015
    • Massachusetts General Hospital
      • • Department of Medicine
      • • Division of Pulmonary and Critical Care Medicine
      Boston, Massachusetts, United States
  • 2006-2015
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2006-2013
    • Brigham and Women's Hospital
      • Division of Pulmonary and Critical Care Medicine
      Boston, Massachusetts, United States
  • 2002-2011
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States