Underlying Disease State Research Articles

The Changing Face of Osmotic Demyelination Syndrome: A Retrospective, Observational Cohort Study.

To describe the long-term outcomes of osmotic demyelination syndrome (ODS) in an updated cohort. We performed a retrospective medical records review of cases of ODS at the Massachusetts General and Brigham and Women's Hospitals using International Classification of Diseases-9th edition codes and a text-based search for central pontine myelinolysis, extrapontine myelinolysis, and osmotic demyelination syndrome (1999-2018). Cases were individually selected based on patients having neuroimaging and symptoms consistent with ODS and no other potentially explanatory etiology. Modified Rankin scale (mRS) scores were extracted at prehospitalization, hospital discharge, 6 months post discharge, and the most recently available clinical visit. We identified 45 cases of ODS (mean age 48.4 years, range 0.07-75 years; 58% female patients). Common comorbidities included liver disease (27%, n = 12), alcoholism (44%, n = 20), and kidney failure (20%, n = 9). Twenty-nine percent of patients had a rapid correction of hyponatremia. Twenty-nine percent had other electrolyte abnormalities. Only 59% (24/41) of patients with complete electrolyte data had abnormalities that could explain their ODS. At the 6-month follow-up, 16% of the patients were dead and 60% of patients had minimal-to-no disability (mRS 0-2). ODS has a diverse range of clinical presentations. Not all patients have electrolyte abnormalities. The prognosis is generally favorable, although 1 in 6 patients had died at 6 months, likely because of underlying disease states.

Obesity and Hunger Threaten the Foundations of Child Health

Obesity and Hunger Threaten the Foundations of Child Health

The effects of elevated temperature on coronary artery dimensions

The interpretation of deaths occurring in fires is often complicated by numerous tissue artefacts. The aim of this experimental study was to see whether coronary arteries exposured to heat may have altered morphology. Two specimens of coronary arteries were taken from each of 10 previously healthy men, who died due to trauma, who had no macroscopic evidence of coronary atherosclerosis – one specimen was immediately fixed in formalin (control group), while the other was exposed to high temperature (70°C for five minutes), and then fixed (experimental group). Morphometric analysis of arterial walls showed significant thickening of about 45 % in tissue samples from the experimental group (control vs. experimental: 604.8μm vs. 879.2μm, p<0.002), with much more prominent thickening of the tunica intima and externa (70 % and>50 %), compared to the tunica media (4%). Another feature was either partial or complete loss of the internal elastic lamina in all of the heated arteries. The results of the current study suggest that the morphology of coronary arteries in cases of fire-related deaths should be carefully interpreted, since the thickness of their wall could be increased not due to underlying disease states, but simply due to heat exposure, which may lead to inaccurate pathological interpretations. This may have considerable medicolegal significance if a deceased driver or pilot is being assessed for liability in an accident.

Hemodynamic Effects of Dexmedetomidine in Adults With Reduced Ejection Fraction Heart Failure.

Dexmedetomidine (DEX) can cause hypotension complicating its use in critically ill patients with labile hemodynamics secondary to an underlying disease state such as heart failure. The aim of this study was to determine the effect of DEX on mean arterial pressure (MAP) in nonsurgical patients with heart failure and reduced ejection fraction (HFrEF). This retrospective single-center cohort study evaluated patients who received DEX in the cardiac care and medical intensive care units at a large academic hospital. The primary end point was the change in MAP within 6 hours following DEX initiation. Sixty-five patients with HFrEF diagnosis were compared 1:1 to a control group without HFrEF. Both groups experienced a decrease in MAP over the study period. Patients with HFrEF had a greater absolute percentage reduction in MAP 1 hour following DEX initiation compared to the control group (-9.6% vs -5.2%; P < .01). When accounting for the combined effect of DEX initiation and HFrEF diagnosis on the primary end point, patients with HFrEF did not have a significant difference in MAP compared to the control group over the study period. Within 6 hours following DEX initiation, both groups experienced a decrease in MAP. The effect of DEX on MAP over the composite time period was not found to be significantly different in the HFrEF group compared to the non-HFrEF group. However, patients with HFrEF experienced a greater reduction in MAP in the first hour following DEX initiation compared to the non-HFrEF group. Prospective studies are needed to evaluate the effect of DEX on patients with acute decompensated HFrEF compared to patients with compensated HFrEF.

Posterior Reversible Encephalopathy Syndrome (PRES): Pathophysiology and Neuro-Imaging.

Posterior reversible encephalopathy syndrome (PRES) represents a unique clinical entity with non-specific clinical symptoms and unique neuroradiological findings. This syndrome may present with a broad range of clinical symptoms from headache and visual disturbances to seizure and altered mentation. Typical imaging findings include posterior-circulation predominant vasogenic edema. Although there are many well-documented diseases associated with PRES, the exact pathophysiologic mechanism has yet to be fully elucidated. Generally accepted theories revolve around disruption of the blood-brain barrier secondary to elevated intracranial pressures or endothelial injury. In this article, we will review the clinical, typical, and atypical radiological features of PRES, as well as the most common theories behind the pathophysiology of PRES. Additionally, we will discuss some of the treatment strategies for PRES related to the underlying disease state.

Monitoring During Mechanical Ventilation.

Mechanical ventilation is an indispensable form of life support for patients undergoing general anesthesia or experiencing respiratory failure in the setting of critical illness. These patients are at risk for a number of complications related to both their underlying disease states and the mechanical ventilation itself. Intensive monitoring is required to identify early signs of clinical worsening and to minimize the risk of iatrogenic harm. Pulse oximetry and capnography are used to ensure that appropriate oxygenation and ventilation are achieved and maintained. Assessments of driving pressure, transpulmonary pressure, and the pressure-volume loop are performed to ensure that adequate PEEP is applied and excess distending pressure is minimized. Finally, monitoring and frequent adjustment of airway cuff pressures is performed to minimize the risk of airway injury and ventilator-associated pneumonia. We will discuss monitoring during mechanical ventilation with a focus on the accuracy, ease of use, and effectiveness in preventing harm for each of these monitoring modalities.

COVID-19 and your rheumatology patients.

The COVID-19 pandemic has caused a sense of unease in the rheumatology community about the risk to patients with immune-mediated diseases, given their predisposition to infection due to underlying disease states and immunosuppressive therapies. Thus far, there have been few cases of COVID-19 reported in patients with immune-mediated diseases and there have been no formal guidelines released on the management of patients with immune-mediated diseases in the setting of COVID-19. Results of clinical trials and data from the Global Rheumatology Alliance registry are eagerly awaited to gain further insight into the impact of this novel infection on our vulnerable patient population.

PMU76 VARIATIONS IN MEDICATION ADHERENCE BARRIERS IN SELECT CHRONIC CONDITIONS: AN APPLICATION OF THE WORLD HEALTH ORGANIZATION (WHO) CRITERIA

To characterize, classify and prioritize the barriers to medication adherence across multiple disease states to enhance researchers’ and providers’ understanding and decision-making using real world evidence. A targeted literature review was initially conducted for 5 disease areas: oncology, diabetes, asthma, rheumatoid arthritis (RA), and multiple sclerosis (MS). Search terms included adherence, barriers, facilitators, and interventions; time-frame was 6 years (2014-2019). The focus was on selection of primary research publications and systematic literature reviews. Data was extracted by 2 independent researchers into an Excel spreadsheet. Barriers were categorized using the World Health Organization (WHO) 2003 classification scheme and ranked based on reported prevalence in identified studies. The 5 dimensions of adherence specified by the WHO are 1) social & economic, 2) healthcare system, 3) condition-related, 4) therapy-related, and 5) patient-related. A total of 194 publications were reviewed and 28 were selected for abstraction in oncology, 20 in diabetes; 42 in asthma; 14 in RA; and 24 in MS. The most prevalent barriers to adherence barriers were identified initially for oncology and MS. For oncology, key barriers to adherence were employment/poverty status & income level, insurance coverage, health & medication beliefs, psychological stress, forgetfulness, drug type, and adverse effects (actual/perceived). For MS, key barriers identified were adverse effects of the medication, forgetfulness, drug effectiveness, and depression/emotional problems. This research demonstrates the disparity in barriers studied and reported across different disease states. Potential reasons for this variation may range from the underlying disease state, to study design, to ease of reporting individual barriers. These results warrant the need for a systematic classification of medication adherence barriers to enable evaluation and prioritization across multiple disease states, and a means to ameliorate identified barriers via interventions to enhance and optimize patient outcomes.

Exploring eye movements of Parkinson’s disease patients performing the Judgement of line orientation test

IntroductionParkinson’s disease (PD) patients are reported to score significantly lower on the Judgement of Line Orientation (JLO) test compared with controls. The traditional method of scoring JLO ignores potentially interesting information on the mechanism of errors made. AimThe aim of the current study was to analyse the performance of PD patients on the JLO while monitoring eye movements. Employing eye tracking methods while PD participants attempt JLO items may prove valuable in further characterising error-patterns. MethodsWe recruited three groups, each comprising 16 participants: PD participants with normal cognition (PD-N), PD participants with mild cognitive impairment (PD-MCI) and matched controls. ResultsThe mean correct response rates were high: 93% (±6) for controls, 88% (±12) for PD-N and 87% (±11) for PD-MCI; the difference did not reach statistical significance (p = 0.21). Participants made more errors as they progressed from easy to harder item (r = 0.7; p = 0.02). Using the Ska classification, error types QO1 and QO3 were by far and away the most common. The mean amplitudes of saccadic eye movements were 5.9° (±0.9) for controls, 5.7° (±1.1) for PD-N, and 5.5° (±1.0) for PD-MCI. The differences among the three groups did not reach statistical significance (p = 0.64). As a whole, participant fixation patterns were similar throughout the JLO task. For the reference lines, most fixations were made on the distal ends. Fixations on the test lines, on the other hand, appeared to vary among trials, dependent on whether the response was correct or incorrect. ConclusionsThere were few differences among the study groups in test performance-eye movement associations. However, we gained important insights into oculomotor behaviour during JLO test completion in both healthy controls and PD patients which could reflect the underlying disease state as we hypothesised.

INVITED COMMENTARY

INVITED COMMENTARY

Award for Distinguished Scientific Early Career Contributions to Psychology: Marc G. Berman.

The APA Awards for Distinguished Scientific Early Career Contributions to Psychology recognize psychologists who have demonstrated excellence early in their careers and have held a doctoral degree for no more than 9 years. One of the 2019 award winners is Marc G. Bergman "for innovative research delving into environmental influences on cognition and affect. Marc G. Berman's research has engaged behavioral, neuroscientific, and computational techniques to expose how natural and artificial scenes can alter cognitive processes and induce affective reactions. In addition, his research seeks to understand the underlying visual computational mechanisms that underlie these effects. This work spans the study of healthy individuals and individuals with various cognitive dysfunctions due to underlying disease states." (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Results from the Completed Hgb-205 Trial of Lentiglobin for β-Thalassemia and Lentiglobin for Sickle Cell Disease Gene Therapy

Results from the Completed Hgb-205 Trial of Lentiglobin for β-Thalassemia and Lentiglobin for Sickle Cell Disease Gene Therapy

1702 Acute Esophageal Necrosis: A Rare Complication of Long-Standing Alcohol Abuse With Severe Hypoperfusion

INTRODUCTION: Acute Esophageal Necrosis, the “black esophagus”, is dark pigmentation of the esophagus with histologic mucosal necrosis that presents with symptoms of bleeding from the upper GI tract. AEN itself is not a poor prognostic factor. AEN in combination with multiple comorbidities raises mortality up to 32%. Risk factors include alcohol abuse, advanced age, male gender, advanced malignancies, hypertension, coronary artery disease, renal disease, and diabetes mellitus. CASE DESCRIPTION/METHODS: A 71 yr old male with medical history of CKD4, CAD, HTN, HLD, Barrett’s esophagus, ulcerative esophagitis, and alcohol use presented with hematemesis, abdominal pain, and melena that began three days prior. Patient was hypotensive and tachycardic with a hemoglobin of 4.8g/dL. Pt was administered multiple unity's of pRBCs, IV PPI, IV Octreotide, and IV fluid resuscitation. Due to hemodynamic compromise, a left IJ CVC was placed and vasopressors started. The GI team was consulted. Emergent EGD revealed circumferential esophagitis with ulcerations, adherent clots, and large areas of black mucosal discoloration. Broad spectrum antimicrobials initiated. A gastrograffin study was obtained without extravasation noted. Patient was diagnosed with pyelonephritis and transitioned to culture sensitive antimicrobial therapy; still requiring vasopressors and blood products due to multifactorial shock. Given severity of illness and grim prognosis, the patient’s family elected for comfort care. DISCUSSION: AEN is a rare condition with an etiology thought to be multifactorial-to a low flow state from watershed distribution and corrosive injury from gastric contents due to esophagogastroparesis and gastric outlet obstruction resulting in decreased function of mucosal barrier systems and impairment of repairing mechanisms. Visualization via EGD of circumferential black mucosal necrosis with an abrupt stop at the GE junction is diagnostic. If circumferential necrosis is seen, immediate withdrawal of the scope should be performed. In patients with patchy necrosis, the clinician may be able to continue with endoscopy. Treatment is supportive with IVFR, IV PPIs, blood transfusions, carafate, and most importantly treatment of the underlying disease state. Complications include esophageal perforation, mediastinal infections with abscesses, esophageal strictures, esophageal stenosis, and death. General Surgery should be consulted for possible intervention. After the patient exhibits improvement, repeat endoscopy should be performed.

Biological variation of immunological blood biomarkers in healthy individuals and quality goals for biomarker tests

BackgroundCytokines, chemokines, adipocytokines, soluble cell receptors, and immune activation markers play an important role in immune responsiveness and can provide prognostic value since they reflect underlying conditions and disease states. This study was undertaken to investigate the components of biological variation for various laboratory tests of blood immunological biomarkers.ResultsEstimates of intra-individual coefficient of variation (CVI) and inter-individual coefficient of variation (CVG) were examined for blood immunological biomarkers. Biomarkers with CVI < 10% for both genders were CD3, CD4, and CD8 T-cells, serum levels of soluble cluster of differentiation 14 (sCD14), sCD163, and soluble glycoprotein 130 (sgp130). The CVI for serum levels of adiponectin, interleukin-1 receptor antagonist (IL-1Ra), macrophage inflammatory protein 1 beta (MIP-1β), soluble CD40 Ligand (sCD40L), soluble interleukin-2 receptor alpha (sIL-2Rα), soluble interleukin-6 receptor (sIL-6R), soluble tumor necrosis factor receptor II (sTNF-RII), and tumor necrosis factor alpha (TNF-α) were between 11 and 20%. Biomarkers with CVG < 20% were CD3 T-cell, and serum concentrations of sCD14, sCD40L, and sgp130. The biomarkers with CVG > 40% were adiponectin, IL-1ra, leptin, MIP-1β, sCD163, and sIL-2Rα.ConclusionThe biological variations of biomarkers have important monitoring value for longitudinal investigation and are essential for quality specification of tests that are performed in the laboratory. The CVI was relatively small while CVG was comparatively large and mean values of each biomarker vary between subjects. The individuality of biomarkers significantly influences reference interval values. A majority of the biomarkers in this study had strong individuality and the result of each biomarker should be cautiously interpreted if using established reference interval values. Comparison of a patient’s test result with previous ones may be more useful than the usage of conventional reference values.

Considerations for neonatal and pediatric pain management.

Current literature and clinical practice guidelines on pediatric pain management are reviewed. Acute pain is commonly present in neonatal and pediatric patients due to underlying disease states or procedures. Especially in institutions with limited pediatric pain services, it is imperative to describe the appropriate management of pain and pharmacotherapy options that are effective and safe in pediatric patients. Despite the knowledge of pain being an important aspect in the management of children, barriers exist, leading to suboptimal treatment. Addressing these barriers through education of healthcare practitioners, families, and patients will lead to optimizing the patient pain experience. Tools for pain assessment vary depending on the type of pain, the child's age and understanding of pain, and the clinical situation. Pharmacotherapy options for pain management in neonates and pediatric patients include opioid and nonopioid agents. Efficacy and safety data on the use of medications for the treatment of pain in pediatric patients is described. The delivery of medication encompasses patient-specific factors and preferences. Strategies for opioid stewardship and management of iatrogenic withdrawal pose a unique challenge in pediatric patients. The management of acute pain in neonates and pediatric patients should be a priority for all practitioners caring for these patients. Use of age-appropriate pain assessment tools and understanding of the mechanisms of action and roles in therapy of various nonopioid and opioid therapies can help optimize treatment of pain in neonatal and pediatric patients.

Effect of Gastric Acid Suppressants on Response to a Physical Activity Intervention and Major Mobility Disability in Older Adults: Results from the Lifestyle Interventions for Elders (LIFE) Study.

Proton pump inhibitors (PPIs) and histamine2 receptor antagonists (H2 RAs) are associated with pharmacologic effects that may be detrimental to mobility and response to physical activity. Mobility disability and injurious fall outcomes in PPI and H2 RA users were compared with nonusers in this secondary analysis of data from the Lifestyle Interventions for Elders (LIFE) study. Participants ages 70-89years were randomized to a physical activity (PA) or successful aging intervention and evaluated by medication use. Confounders included baseline demographic characteristics, physical function, cognitive function, sleep quality, and acid reflux symptoms that were adjusted via propensity score weighting. Outcomes were incident and persistent major mobility disability (MMD and pMMD) and injurious falls. Weighted proportional hazard models evaluated independent and interaction effects of PPIs and H2 RAs. No interaction was found between PPIs and H2 RAs and the PA intervention. Drug use associations were significant for H2 RAs (hazard ratio [HR] 1.74 [95% confidence interval [CI] 1.12-2.68]) and PPIs (HR 1.32 [95% CI 1.02-1.70]) compared with nonusers for pMMD. PPIs were associated with increased injurious falls compared with nonusers (HR 1.44 [95% CI 1.06-1.96]). Pooling of data from the H2 RA and PPI exposure groups showed a 26% increase in MMD (HR 1.26 [95% CI 1.07-1.48]), a 44% increase in pMMD (HR 1.44 [95% CI 1.16-1.77]), and a 48% increase in injurious falls (HR 1.48 [95% CI 1.15-1.91]) compared with nonusers. All direct comparisons between PPIs and H2 RAs were nonsignificant. Compared with nonusers, participants using either PPIs or H2 RAs had an increased risk of MMD, pMMD, and injurious falls. It is not known if these effects are related to the individual pharmacology of each medication, reduced acid secretion, or the underlying disease state. Further study is required to determine causality.

A Review of Cognitive Outcomes Across Movement Disorder Patients Undergoing Deep Brain Stimulation.

Introduction: Although the benefit in motor symptoms for well-selected patients with deep brain stimulation (DBS) has been established, cognitive declines associated with DBS can produce suboptimal clinical responses. Small decrements in cognition can lead to profound effects on quality of life. The growth of indications, the expansion of surgical targets, the increasing complexity of devices, and recent changes in stimulation paradigms have all collectively drawn attention to the need for re-evaluation of DBS related cognitive outcomes.Methods: To address the impact of cognitive changes following DBS, we performed a literature review using PubMed. We searched for articles focused on DBS and cognition. We extracted information about the disease, target, number of patients, assessment of time points, cognitive battery, and clinical outcomes. Diseases included were dystonia, Tourette syndrome (TS), essential tremor (ET), and Parkinson's disease (PD).Results: DBS was associated with mild cognitive issues even when rigorous patient selection was employed. Dystonia studies reported stable or improved cognitive scores, however one study using reliable change indices indicated decrements in sustained attention. Additionally, DBS outcomes were convoluted with changes in medication dose, alleviation of motor symptoms, and learning effects. In the largest, prospective TS study, an improvement in attentional skills was noted, whereas smaller studies reported variable declines across several cognitive domains. Although, most studies reported stable cognitive outcomes. ET studies largely demonstrated deficits in verbal fluency, which had variable responses depending on stimulation setting. Recently, studies have focused beyond the ventral intermediate nucleus, including the post-subthalamic area and zona incerta. For PD, the cognitive results were heterogeneous, although deficits in verbal fluency were consistent and related to the micro-lesion effect.Conclusion: Post-DBS cognitive issues can impact both motor and quality of life outcomes. The underlying pathophysiology of cognitive changes post-DBS and the identification of pathways underpinning declines will require further investigation. Future studies should employ careful methodological designs. Patient specific analyses will be helpful to differentiate the effects of medications, DBS and the underlying disease state, including disease progression. Disease progression is often an underappreciated factor that is important to post-DBS cognitive issues.

Emergent Colon Resections: Does Surgeon Specialization Influence Outcomes?

Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described. The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy. This was a retrospective cohort study. Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included. Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon. Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients. A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p < 0.001). This study was limited by its retrospective design, with potential selection bias attributed to referral patterns. After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.

Proteomics in Primary Biliary Cholangitis.

Primary biliary cholangitis is a chronic cholestatic liver disease characterized by the presence of serum antimitochondrial antibodies and immune-mediated destruction of the small and medium-sized intrahepatic bile ducts. However, the pathophysiology of primary biliary cholangitis has not yet been completely elucidated. In recent years, proteomics has been comprehensively applied in many research fields, including the pathogenesis, prognosis, and diagnosis of disease. Among multiple methods, isobaric tag for relative and absolute quantitation is a powerful analytic method to characterize complex protein mixtures in combination with liquid chromatography-tandem mass spectrometry. In this chapter, we describe a strategy for using isobaric tag for relative and absolute quantitation to discover those differentially expressed proteins in primary biliary cholangitis. The goal is to identify the differences in protein expression between patients with primary biliary cholangitis and healthy controls for defining biomarkers and elucidating molecular mechanisms underlying disease states.

Evaluation of IV to Enteral Benzodiazepine Conversion Calculations in a Pediatric Intensive Care Setting

To evaluate if institutionally established calculations for transitioning continuous IV midazolam to enteral benzodiazepines maintain Withdrawal Assessment Tool-Version 1 scores equal to or less than preconversion values. Retrospective cohort study evaluating the effectiveness and safety of benzodiazepine conversion calculations embedded within an institution-specific clinical pathway for sedation and weaning of mechanically ventilated pediatric patients. A 55-bed, mixed-medical, noncardiac surgical PICU in a tertiary care children's hospital. All patients age 6 months to 18 years who received continuous midazolam for 5 days or longer while mechanically ventilated for 5-21 days and were then converted to either enteral diazepam or lorazepam following extubation (or return to baseline ventilator settings in tracheostomy-dependent patients) between January 1, 2015, and June 30, 2016. Benzodiazepine conversion calculations were applied according to institutional clinical pathway guidance. Withdrawal Assessment Tool-Version 1 scores were compared pre and post benzodiazepine conversion. Patient demographics, benzodiazepine dose escalations, as needed benzodiazepine requirements, and severe adverse events within 48 hours of conversion were assessed. Seventy-one patient encounters were analyzed (median age, 2.5 yr; interquartile range, 1.2-5.3). The median Withdrawal Assessment Tool-Version 1 scores pre conversion and post conversion were not significantly different (1 [interquartile range, 0.75-2] and 1 [interquartile range, 0.25-2], respectively, p = 0.1). As needed benzodiazepine doses were administered in 38% of encounters post conversion, but escalation of a scheduled enteral benzodiazepine regimen was only required in 2.8% of encounters. Post conversion, one patient (1.4%) had increased seizure activity, and four patients (5.6%) required fluid boluses secondary to tachycardia or dehydration, but not hypotension. These findings suggest that standardized benzodiazepine conversions successfully achieved consistent Withdrawal Assessment Tool-Version 1 scores compared with preconversion values. Severe adverse events associated with oversedation and/or withdrawal were minimal and confounded by underlying disease states.