OBJECTIVES: Compare ICU outcomes and respiratory system mechanics in patients with and without acute kidney injury during invasive mechanical ventilation. DESIGNS: Retrospective cohort study. SETTINGS: ICUs of the University of California, San Diego, from January 1, 2014, to November 30, 2016. PATIENTS: Five groups of patients were compared based on the need for invasive mechanical ventilation, presence or absence of acute kidney injury per the Kidney Disease: Improving Global Outcomes criteria, and the temporal relationship between the development of acute kidney injury and initiation of invasive mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 9,704 patients were included and 4,484 (46%) required invasive mechanical ventilation; 2,009 patients (45%) had acute kidney injury while being treated with invasive mechanical ventilation, and the mortality rate for these patients was 22.4% compared with 5% in those treated with invasive mechanical ventilation without acute kidney injury (p < 0.01). Adjusted hazard of mortality accounting for baseline disease severity was 1.58 (95% CI, 1.22–2.03; p < 0.001]. Patients with acute kidney injury during invasive mechanical ventilation had a significant increase in total ventilator days and length of ICU stay with the same comparison (both p < 0.01). Acute kidney injury during mechanical ventilation was also associated with significantly higher plateau pressures, lower respiratory system compliance, and higher driving pressures (all p < 0.01). These differences remained significant in patients with net negative cumulative fluid balance. CONCLUSIONS: Acute kidney injury during invasive mechanical ventilation is associated with increased ICU mortality, increased ventilator days, increased length of ICU stay, and impaired respiratory system mechanics. These results emphasize the need for investigations of ventilatory strategies in the setting of acute kidney injury, as well as mechanistic studies of crosstalk between the lung and kidney in the critically ill.

BACKGROUND Patients with end-stage heart failure are at high risk for sudden cardiac death. However, implantable cardioverterdefibrillator (ICD) is not routinely implanted given the high competing risk of pump failure. A unique population worth separate consideration are patients with end-stage heart failure awaiting heart transplantation, as prolonged survival improves the chances of receiving transplant.OBJECTIVE To compare clinical outcomes of heart failure patients with and without an ICD awaiting heart transplant. METHODSWe performed an extensive literature search and systematic review of studies that compared end-stage heart failure patients with and without an ICD awaiting heart transplantation. We separately assessed the rates of total mortality, sudden cardiac death, nonsudden cardiac death, and heart transplantation. Risk ratio (RR) and 95% confidence intervals were measured using the Mantel-Haenszel method. The random effects model was used owing to heterogeneity across study cohorts. RESULTSTen studies with a total of 36,112 patients were included. A total of 62.5% of patients had an ICD implanted. Patients with an ICD had decreased total mortality (RR 0.60, 95% CI 0.51-0.71, P , .00001) and sudden cardiac death (RR 0.27, 95% CI 0.11-0.66, P 5 .004) and increased rates of heart transplantation (RR 1.09, 95% CI 1.05-1.14, P , .0001). There was no difference in prevalence of nonsudden cardiac death (RR 0.68, 95% CI 0.44-1.04, P 5 .07).CONCLUSION ICD implantation is associated with improved outcomes in patients awaiting heart transplant, characterized by decreased total mortality and sudden cardiac death as well as higher rates of heart transplantation.

Background Cardiovascular disease (CVD) remains the number one cause of death in women. Current screening tools in this population do not identify all women who are at risk. Screening for breast artery calcification (BAC) via routine mammography is emerging as a risk enhancing tool; however, how risk prediction varies by age is unknown. Methods This single-center, retrospective study included 14,544 women who had a digital mammogram from 2008-2016. BAC was quantified with the Bradley score derived from an automated algorithm developed by CureMetrix; presence of BAC was defined as a Bradley score ≥10. Mortality data were collected after index mammogram by review of medical records. Adjusted hazard rations (aHR) were calculated using Cox regression models with interaction terms to evaluate the influence of age on the association between presence of BAC and mortality, after adjusting for age, diabetes, medications, race, current smoking, systolic blood pressure, total and HDL cholesterol, plus prior CVD. Results In the overall study population 8% had diabetes, 30% hypertension, 30% hyperlipidemia and 5% were current smokers. BAC was detectable in 522 of 9,027 (6%) of women age 40-59 years, 657 of 2,865 (23%) 60-69 years, and 702 of 1,358 (52%) 70+. Over mean follow-up of 4.2 years, there were 328 deaths (15.1%) among women with BAC. When subjects were separated by age, presence of BAC was associated with mortality among younger women (40-59 years: aHR 1.50 [95% CI 1.06-2.12]; 60-69 years: aHR 1.59 [95% CI 1.19-2.12], Figure ). Among women ages 70+, BAC was not a significant predictor of mortality (aHR 1.11 [95% CI 0.86-1.43]). There was a significant negative interaction effect of age with BAC for prediction of mortality (p < 0.001). Conclusions: BAC is predictive of mortality, especially in younger women. BAC may be a useful screening adjunct to traditional CVD risk factors, to help identify women at an early age who may benefit from more targeted preventive measures. Figure

Introduction: Breast arterial calcification (BAC), seen on mammography, has emerged as a risk stratification tool and surrogate marker of cardiovascular disease (CVD). Studies evaluating the association of BAC with clinical outcomes are limited. Methods: This single-center, retrospective study included 14,544 women who had a digital mammogram from 2008-2016. BAC was quantified with the Bradley score using an automated algorithm based on a trained, deep neural network (CureMetrix). The presence of BAC was defined as Bradley score >10. Clinical outcomes were collected via medical records using ICD-10 diagnoses. Cox regression models were used to evaluate the association between BAC (continuous and binary) and clinical outcomes including mortality and composite outcome (mortality, stroke, and myocardial infarction). Models were adjusted for age, diabetes, medications, race, current smoking, systolic blood pressure, total & HDL cholesterol, and prior CVD diagnosis. Results: The mean age was 54.7 ±11.0 years with 8% diabetes, 30% hypertension, 30% hyperlipidemia and 5% smokers. BAC was present in 13%. Over a mean follow-up of 4.2 years, there were 1,687 deaths (6.8%) and 2,113 composite outcomes (8.5%). On multivariable analysis, each 10-point increase in BAC score was significantly associated with clinical outcomes: mortality (aHR 1.05 [95% CI 1.02-1.08], p < 0.001) and composite outcome (aHR 1.07 [95% CI 1.04-1.09], p < 0.001). With BAC as a binary variable, women with BAC had a 1.52 (95% CI 1.22-1.89) higher risk of mortality and a 1.72 (95% CI 1.40-2.11) higher risk of composite outcome compared to those without BAC. Conclusion: BAC is significantly associated with clinical outcomes, including mortality and CVD. Further study is needed to confirm these findings.

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