University-affiliated Teaching Hospital Research Articles

Evaluation of the Response of Odontogenic Keratocysts to Tube Decompression: A Clinical and Radiographic Study

Background and Objectives: Keratocyst is the most aggressive entity of odontogenic cysts with a high tendency to recure after enucleation. This study was conducted to assess the effect of decompression in inducing cyst shrinkage before enucleation. Materials and Methods: A prospective non-randomized study was conducted on 11 patients with odontogenic keratocyst the department of maxillofacial surgery, university-affiliated teaching hospital, between February 2016 to March 2021. There were 8 males and 3 females, with a mean age of 57 years. Tube decompression was conducted as a preliminary treatment, before enucleation. The size of the cyst was measured on orthopantomograph, before, during, and after decompression. The percentage of reduction was calculated, as well as, the correlation of cyst regression with the initial size of the lesion and age of the patient. Results: The mean duration time of decompression was 208 days (152-316). The pre- and post-decompression size of the cysts was 14.51 cm2 (5.63 cm2 -32.37 cm2) and 6.69 cm2 (1.76 cm2-14.81 cm2), respectively. The total and monthly percentage of reduction in the size of the cysts was 54.39% (37.29%-76.37%) and 7.84% (4.45%-11.27%), respectively. The initial size of the lesion has no significant correlation with the percentage of reduction, whereas the age of the patients showed a significant negative correlation with the percentage of reduction. Conclusion: Decompression is a well-tolerated conservative treatment, which leads to marked reduction in cyst dimensions. It induces shrinkage of the cyst away from anatomical structures, to reduce the morbidity associated with subsequent surgical treatment.

Background frequency can enhance the prognostication power of EEG patterns categories in comatose cardiac arrest survivors: a prospective, multicenter, observational cohort study

BackgroundWe assessed the prognostic accuracy of the standardized electroencephalography (EEG) patterns (“highly malignant,” “malignant,” and “benign”) according to the EEG timing (early vs. late) and investigated the EEG features to enhance the predictive power for poor neurologic outcome at 1 month after cardiac arrest.MethodsThis prospective, multicenter, observational, cohort study using data from Korean Hypothermia Network prospective registry included adult patients with out-of-hospital cardiac arrest (OHCA) treated with targeted temperature management (TTM) and underwent standard EEG within 7 days after cardiac arrest from 14 university-affiliated teaching hospitals in South Korea between October 2015 and December 2018. Early EEG was defined as EEG performed within 72 h after cardiac arrest. The primary outcome was poor neurological outcome (Cerebral Performance Category score 3–5) at 1 month.ResultsAmong 489 comatose OHCA survivors with a median EEG time of 46.6 h, the “highly malignant” pattern (40.7%) was most prevalent, followed by the “benign” (33.9%) and “malignant” (25.4%) patterns. All patients with the highly malignant EEG pattern had poor neurologic outcomes, with 100% specificity in both groups but 59.3% and 56.1% sensitivity in the early and late EEG groups, respectively. However, for patients with “malignant” patterns, 84.8% sensitivity, 77.0% specificity, and 89.5% positive predictive value for poor neurologic outcome were observed. Only 3.5% (9/256) of patients with background EEG frequency of predominant delta waves or undetermined had good neurologic survival. The combination of “highly malignant” or “malignant” EEG pattern with background frequency of delta waves or undetermined increased specificity and positive predictive value, respectively, to up to 98.0% and 98.7%.ConclusionsThe “highly malignant” patterns predicted poor neurologic outcome with a high specificity regardless of EEG measurement time. The assessment of predominant background frequency in addition to EEG patterns can increase the prognostic value of OHCA survivors.Trial registration KORHN-PRO, NCT02827422. Registered 11 September 2016—Retrospectively registered.

Sentinel Lymph Node Sampling in Robot-Assisted Staging of Endometrial Cancer.

Sentinel lymph node (SLN) sampling in endometrial cancer staging has become an acceptable standard. Indocyanine green dye injected into the cervix and detected by near-infrared light is technically simple and sensitive. We aimed to evaluate SLN sampling in robot-assisted surgical staging of endometrial cancer at a university-affiliated teaching hospital. A retrospective chart review, from January 2016 to December 2017, of patients who underwent robot-assisted surgical staging with cervical injection of indocyanine green dye detected by near-infrared light. The map rate, sensitivity, false negatives, and negative predictive value were calculated. A total of 105 charts were reviewed; 79 patients met inclusion criteria. The mean age was 65 (range 38-93) and the mean body mass index was 33.3 (range 16-49). Most patients (72.2%) had stage I disease and grade 1 or 2 histology (77.1%). Eight (10.1%) patients had lymph node metastasis. Seventy-two (91.1%) patients had positive mapping to at least 1 SLN. Sixty-two (78.5%) patients had bilateral mapping. Forty-four patients had concurrent pelvic ± para-aortic lymph node dissection and were included in the sensitivity analysis. Five of 44 cases had LN metastasis. The sensitivity was 80%, and the negative predictive value of SLN sampling was 97.5%. SLN mapping and sampling at a university-affiliated teaching hospital have comparable map rate, sensitivity, and negative predictive value as demonstrated in multiple trials. The technique has the potential to standardize endometrial cancer staging across different practice settings.

Robot Debulking of Right Pelvic Lymph Nodes 360-Degree Approach

<h3>Study Objective</h3> To demonstrate a 360-degree approach to debulking of an enlarged malignant right pelvic lymphadenopathy <h3>Design</h3> A surgical video case presentation. <h3>Setting</h3> A University affiliated teaching hospital. <h3>Patients or Participants</h3> A 78-year-old patient with uterine serous cancer. <h3>Interventions</h3> Robot assisted laparoscopic debulking surgery. <h3>Measurements and Main Results</h3> Complete debulking is accomplished to no residual disease. Video demonstrates approach to debulking the enlarged right pelvic lymph node. <h3>Conclusion</h3> Robot assisted laparoscopic debulking of enlarged pelvic masses allows enhanced identification of anatomy and adequate safe dissection.

Asherman's Syndrome (AS) after Long Term Use of a Levenorgestrel Containing IUD, Cause or Coincidence?

<h3>Study Objective</h3> Identifying risk factors for developing Asherman's Syndrome after a first trimester procedure. Could the influence of long-term use of a levenorgestrel IUD (LNG-IUD) be a risk factor? <h3>Design</h3> Cohort study 2017-2020. <h3>Setting</h3> University affiliated teaching hospital and secondary referral center for Asherman's Syndrome in The Netherlands. <h3>Patients or Participants</h3> A cohort of 55 women with a first trimester curettage preceding Asherman's Syndrome who became pregnant after long term use of a LNG-IUD. <h3>Interventions</h3> Adhesiolysis was performed with an Olympus 5.5 mm rigid hysteroscope with conventional instruments using fluoroscopy as a guidance method. After successful adhesiolysis an IUD without Cu or hormones was placed inside the uterine cavity to prevent recurrence of adhesions. Women were treated with two consecutive cycles of hormones (estrogen and progesterone). A second look hysteroscopy was performed 8-10 weeks post-surgery. <h3>Measurements and Main Results</h3> 364 cases of women with AS who underwent hysteroscopic adhesiolysis. We identified 55 women using a LNG-IUD for a longer period of time (more than 3 years). All of them hadhypomenorrhoe or had a amenorrhea during the LNG-IUD use. They almost all conceived within 3 months after removal of the IUD. All of them had a miscarriage for which eventually a curettage was performed. The grade of Intrauterine adhesions varied from grade 2-4 ESGE classification. Adhesiolysis was performed and the uterine cavity was restored in all cases. <h3>Conclusion</h3> The exact predisposing factors for women to develop AS are unknown. One of the reasons might be a vulnerable endometrium due to a hypo estrogenic uterine environment which might women more prone to developing AS. If so, long term use of a LNG-IUD could be an independent factor for the commencement of AS.

The Genesis and Development of Research Ethics Committees in Canada, 1960–1978

Abstract Following World War ii, many medical investigators continued their ambitious experimental interventions as rationalized, rather than justified, trials. In Canada, there were hardly any legally proscriptive or prescriptive instruments to regulate clinical experimentation until the 1960s. What was ethical could rightly be established only in the course of devising clinical research protocols and undertaking the procedures thereof. This paper examines an historical trajectory shaping human-subject research and its regulation in Canada. I argue that public disclosures of human experimentation, court litigation resulting from clinical research, international standardization of regulations on biomedical investigation, and the proliferation of clinical trials induced the evolution of human research ethics and the elaboration of guidelines to regulate it. In this process, Canadian physician-investigators adopted British and American guidelines on the conduct of ethically acceptable clinical research and modified them according to local circumstances. The first research ethics committees emerged at the Canadian university-affiliated teaching hospitals, where the investigative practices revealed and clarified the changing meanings of human research ethics.

Features and perceptions of a critical care outreach physician role

Objective: To describe the tasks completed by the critical care outreach physician (CCOP) and staff perceptions of the CCOP role.Design: Prospective observational study and survey of intensive care unit (ICU) staff.Setting: University-affiliated teaching hospital in Australia.Participants: ICU consultants, registrars and nurses.Interventions: Implementing a dedicated ICU consultant to review deteriorating patients outside the ICU.Main outcome measures: Prospective collection of CCOP tasks and survey of ICU staff.Results: During 101 clinical shifts, the CCOP had 1524 encounters (mean, 15.1 [standard deviation, 6.1]; median, 14 [interquartile range, 10–19] per day). The three commonest interventions were emergency department visits, direct consultant communication, and coordinating ICU admissions. Involvement in Medical Emergency Team (MET) calls, expediting patient care, and goals of care discussions were also relatively common. Survey responses were obtained from 55/84 (66%) eligible participants. Most respondents thought the CCOP would improve the predefined processes of care and patient-centred outcomes. The areas of greatest perceived benefit included supporting the MET registrar and coordinating simultaneous emergencies outside the ICU. Areas where the role was perceived to be less beneficial included improving handover, identifying patients at clinical risk outside the ICU, and reducing repeat MET calls.Conclusions: The tasks of a CCOP involved high level communication, coordination of care, and supervision of ICU staff. The effect of this role on patient-centred outcomes requires further research.

Modifying phrases in surgical pathology reports: introduction of Standardized Scheme of Reporting Certainty in Pathology Reports (SSRC-Path).

Pathologists often incorporate modifying phrases in their diagnosis to imply varying levels of diagnostic certainty; however, what is implied by the pathologists is not equivalent with what is perceived by the referring physicians and patients. This discordance can have significant implications in management, safety, and cost. We intend to identify lack of consistency in interpretation of modifying phrases by comparing perceived level of certainty by pathologists and non-pathologists, and introduce a standard scheme for reporting uncertainty in pathology reports using the experience with imaging reporting and data systems. In this study, a list of 18 most commonly used modifying phrases in pathology reports was distributed among separate cohorts of pathologists (N = 17) and non-pathology clinicians (N = 225) as a questionnaire survey, and the participants were asked to assign a certainty level to each phrase. All the participants had practice privileges in Brown University-affiliated teaching hospitals. The survey was completed by 207 participants (17 pathologists, 190 non-pathologists). It reveals a significant discordance between the interpretations of the modifying phrases between the two cohorts, with significant variations in subgroups of non-pathology clinicians. Also there is disagreement between pathologists and other clinicians regarding the causes of miscommunication triggered by pathology reports. Pathologists and non-pathology clinicians should be mindful of the potential sources of misunderstanding of pathology reports and take necessary actions to prevent and clarify the uncertainties. Using a standard scheme for reporting uncertainty in pathology reports is recommended.

Platelet count as an independent risk factor for acute kidney injury induced by rhabdomyolysis.

Platelet count as an independent risk factor for acute kidney injury induced by rhabdomyolysis.

Effects of a simulation-based education programme on delirium care for critical care nurses: A randomized controlled trial.

To evaluate the effects of a simulation-based education programme on critical care nurses' knowledge, confidence, competence and clinical performance in providing delirium care. Single-blinded randomized controlled trial. Registered nurses who work in intensive care units were recruited from a university-affiliated acute major metropolitan teaching hospital. The intervention group received: (i) five online-learning delirium care videos, (ii) one face-to-face delirium care education session and (iii) a simulation-based education programme with a role-play scenario-based initiative and an objective structured clinical examination. The control group received only online videos which were the same as those provided to the intervention group. Delirium care knowledge, confidence, competence, and clinical performance as outcomes were collected at: baseline, immediately after intervention, and within 6weeks post-intervention to test whether there were any changes and if they were sustained over time. Data were collected between 2 October and 29 December 2020. The repeated-measures analysis of variance was used to examine for changes in delirium care knowledge, confidence, and competence within groups. Seventy-two critical care nurses participated with 36 each allocated to the intervention group and control group. No statistically significant difference was observed between the two groups in outcome variables at 6weeks post-intervention. In the intervention group, significant within-group changes were observed in terms of delirium care knowledge, confidence, and competence over time. By contrast, no significant changes were observed in outcome measures over time in the control group. The simulation-based education programme is an effective and feasible strategy to improve delirium care by enhancing the knowledge, confidence, competence and clinical performance of critical care nurses. Our findings provide evidence regarding the development and implementation of a simulation-based education programme in hospitals for health professional education in Taiwan.

1075-P: Acute and Chronic Glucose Control in Critically Ill Patients with Diabetes: Impact of Prior Insulin Treatment

Objective: The impact of preadmission insulin treatment on the interactions of chronic glycemia, reflected by admission A1c levels, glucose control during critical illness, and mortality is unknown. Design: This is a retrospective analysis of 1,524 patients with diabetes admitted to the ICU of a university-affiliated teaching hospital, including 538 receiving (INS) and 986 without (NON-INS) insulin treatment prior to admission. Groups were stratified by A1c level: Results: Mean glucose (BG), coefficient of variation (CV) and hypoglycemia ( Conclusions: Significant differences were found among patients with diabetes based on insulin treatment status prior to admission regarding ICU glucose control and the relationship of glucose control metrics during ICU stay to mortality. These data support an individualized approach to glucose control in the critically ill. Disclosure J. S. Krinsley: None. P. R. Rule: None. J. Preiser: None. G. Roberts: None. S. Chaudry: None. C. Heluey-rodrigues: None. K. Dionne: None. G. E. Umpierrez: Research Support; Self; AstraZeneca, Dexcom, Inc., Novo Nordisk. I. B. Hirsch: Consultant; Self; Abbott Diabetes, Bigfoot Biomedical, Inc., Research Support; Self; Insulet Corporation, Leona M. and Harry B. Helmsley Charitable Trust, Medtronic.

Comparison of anxiety scores between unexplained primary and secondary infertile couples

Objective To investigate the anxiety levels among infertile women and their partners also factors that may affect the anxiety status Study design A total of 403 infertile couples who applied to Infertility Outpatient Clinics of a University-affiliated Teaching and Research Hospital were included in the study. The infertile group was divided into two groups as primary and secondary infertile. One hundred and thirty-two fertile couples who applied to Gynecology Outpatient Clinics composed the control group. Hamilton Anxiety Rating Scale (HAM-A) form was filled by the infertile couples to evaluate the anxiety status before they started their treatment. Results Three hundred and twenty infertile and 84 fertile couples completed the study. The mean total scores of HAM-A of women were similar between the groups. So were the scores of their husbands. In all groups, women had significantly higher mean total HAM-A scores than their husbands. There was no association between the mean HAM-A score of women and age, BMI, AFC, duration of marriage, duration of infertility, number of previous treatment cycles. Education status, working status and family structure of women did not correlate with the mean HAM-A score. Conclusion Unexplained primary and secondary infertile couples had similar anxiety scores before the commencement of fertility treatments. However, the scores were higher in women than their male partners. Since the burden of treatment and the likelihood of treatment failure might increase the level of anxiety the women could be offered proper cognitive coping and relaxation interventions.

438 Rapid Eye Movement Rebound After Continuous Positive Airway Pressure in Co-Morbid Obstructive Sleep Apnea and Fibromyalgia

Abstract Introduction Fibromyalgia (FM) is a chronic pain condition that is associated with poor sleep quality and may present with obstructive sleep apnea (OSA). In OSA patients without FM, previous research has demonstrated a 57% relative increase in rapid eye movement (REM) sleep duration following treatment with continuous positive airway pressure (CPAP). However, there is limited data on REM rebound in patients with co-morbid FM and OSA. Patients with FM are often prescribed medication, like opioid analgesics, that decrease REM sleep. Additionally, pain perception may be altered by decreased REM duration. In the context of a national opioid crisis, it is imperative to explore how nonpharmacological options for treatment of co-morbid FM and OSA may improve REM sleep duration. Methods Following IRB approval at a university-affiliated teaching hospital, an electronic medical chart review was completed on patients diagnosed with FM and OSA who received polysomnography testing (PSG) and subsequent CPAP titration treatment. REM duration and REM total sleep time (TST) percentages were reviewed at baseline PSG and after CPAP titration. Results FM with OSA (n = 30). Mean age: 50.87, female: 28 (93%), male: 2 (7%). Baseline PSG: mean REM duration 34.47 minutes, mean REM TST 11.03%. After CPAP titration: mean REM duration 56.78 minutes, mean REM TST 18.84%. Pre- and post-CPAP titration REM TST percentage increased from 11.0% to 18.8%, indicating a mean difference of 7.8% (p &amp;lt; 0.001) and a 71% relative increase in REM TST percentage duration. Conclusion These findings suggest delivery of CPAP to patients with FM and OSA improved REM sleep duration. The role of sleep in FM and pain severity is underexplored. Given the potential of chronic opioid use in patients with FM, treatment of OSA with CPAP may be a nonpharmacological alternative to pain management. Future studies are needed to see if REM rebound is associated with wellbeing, including perceived sleep quality and decreased pain perception. Support (if any):

Internet-Specific Epistemic Beliefs in Medicine and Intention to Use Evidence-Based Online Medical Databases Among Health Care Professionals: Cross-sectional Survey.

BackgroundEvidence-based medicine has been regarded as a prerequisite for ensuring health care quality. The increase in health care professionals’ adoption of web-based medical information and the lack of awareness of alternative access to evidence-based online resources suggest the need for an investigation of their information-searching behaviors of using evidence-based online medical databases.ObjectiveThe main purposes of this study were to (1) modify and validate the internet-specific epistemic beliefs in medicine (ISEBM) questionnaire and (2) explore the associations between health care professionals’ demographics, ISEBM, and intention to use evidence-based online medical databases for clinical practice.MethodsHealth care professionals in a university-affiliated teaching hospital were surveyed using the ISEBM questionnaire. The partial least squares-structural equation modeling was conducted to analyze the reliability and validity of ISEBM. Furthermore, the structural model was analyzed to examine the possible linkages between health professionals’ demographics, ISEBM, and intention to utilize the evidence-based online medical databases for clinical practice.ResultsA total of 273 health care professionals with clinical working experience were surveyed. The results of the measurement model analysis indicated that all items had significant loadings ranging from 0.71 to 0.92 with satisfactory composite reliability values ranging from 0.87 to 0.94 and average variance explained values ranging from 0.70 to 0.84. The results of the structural relationship analysis revealed that the source of internet-based medical knowledge (path coefficient –0.26, P=.01) and justification of internet-based knowing in medicine (path coefficient 0.21, P=.001) were correlated with the intention to use evidence-based online medical databases. However, certainty and simplicity of internet-based medical knowledge were not. In addition, gender (path coefficient 0.12, P=.04) and academic degree (path coefficient 0.15, P=.004) were associated with intention to use evidence-based online medical databases for clinical practice.ConclusionsAdvancing health care professionals’ ISEBM regarding source and justification may encourage them to retrieve valid medical information through evidence-based medical databases. Moreover, providing support for specific health care professionals (ie, females, without a master’s degree) may promote their intention to use certain databases for clinical practice.

Preoperative Cardiac Diagnostics in Bariatric Patients with Diabetes and Perioperative Morbidity: Results of a Cohort of 258 Patients

PurposeThe combination of obesity and diabetes mellitus are well-known risk factors for cardiovascular complications and perioperative morbidity in metabolic surgery. The aim of this study was to evaluate effectivity and reliability of the cardiac assessment in patients with diabetes prior to bariatric surgery.SettingPrivate, university-affiliated teaching hospital, SwitzerlandMaterial and MethodsRetrospective analysis of prospectively collected data on results and consequences of cardiac assessments in 258 patients with obesity and diabetes scheduled for primary bariatric surgery at our institution between January 2010 and December 2018.ResultsOut of 258 patients, 246 (95.3%) received cardiac diagnostics: 173 (67.1%) underwent stress-rest myocardial perfusion scintigraphy (MPS), 15 (5.8%) patients had other cardiac imaging including cardiac catheterization, 58 (22.5%) patients had echocardiography and/or stress electrocardiography, and 12 (4.7%) patients received no cardiac evaluation. Subsequently, cardiac catheterization was performed in 28 patients (10.9%), and coronary heart disease was detected and treated in 15 subjects (5.8%). Of these 15 individuals, 5 (33.3%) patients had diffuse vascular sclerosis, 8 (53.3%) patients underwent coronary angioplasty and stenting, and 2 (13.3%) patients coronary artery bypass surgery. Bariatric surgery was performed without perioperative cardiovascular events in all 258 patients.ConclusionOur data suggest that a detailed cardiac assessment is mandatory in bariatric patients with diabetes to identify those with yet unknown cardiovascular disease before performing bariatric surgery. We recommend carrying out myocardial perfusion scintigraphy as a reliable diagnostic tool in this vulnerable population. If not viable, stress echocardiography should be performed as a minimum.

Prenatal care experiences among pregnant women with obesity in Wisconsin, United States: a qualitative quality improvement assessment

BackgroundStigma and bias experienced during prenatal care can affect quality of care and, ultimately, the health of pregnant women with obesity and their infants. We sought to 1) better understand the bias and stigma that women with BMIs ≥40 kg/m2 experience while receiving prenatal care, 2) gauge women’s interest in group prenatal education for women with obesity, and 3) gather feedback about their preferred weight-related terminology.MethodsWe conducted and thematically content-analyzed 30 semi-structured interviews of women with BMIs ≥40 kg/m2 who received prenatal care at a university-affiliated teaching hospital in the Midwest region of the United States.ResultsAll women recalled positive experiences during their perinatal care during which they felt listened to and respected by providers. However, many also described a fear of weight-related bias or recalled weight-based discrimination. Women reacted favorably to a proposed group prenatal care option for pregnant women with obesity that focused on nutrition, physical activity, and weight management. Women rated “weight” and “BMI” as the most desirable terms for describing weight, while “large size” and “obesity” were rated least desirable.ConclusionsMany pregnant women with BMIs ≥40 kg/m2 experience bias in the prenatal care setting. Potential steps to mitigate bias towards weight include improving provider awareness of the experiences and perspectives of this population, expanding prenatal care options targeted towards women with high BMIs, including group care, and using patient-preferred weight-related terminology. Through the remainder of this manuscript, wherever possible, the term “high BMI” will be used in place of the term “obesity” to describe women with BMI ≥ 30 kg/m2 in order to respect the preferred terminology of the women we interviewed.

Potentially Inappropriate Prescriptions to Older Patients in Emergency Departments in South Korea: A Retrospective Study

PurposeThe purpose of this study was to evaluate the incidence of the administration of potentially inappropriate medications (PIMs) and the potential drug–drug interactions (pDDIs) in older patients in emergency departments (EDs) over a 12-month period and to identify the factors associated with the administration of PIMs.Patients and MethodsThis retrospective study was conducted using the electronic medical records from two university-affiliated teaching hospitals in South Korea. ED visit cases of patients aged 65 and older from January 1, 2013, to December 31, 2013, were included in the analysis. Among the medications administered in ED, PIMs or pDDIs were identified using a drug utilization review program available in Korea.ResultsDuring the study period, a total of 13,002 ED visit cases were reported from 10,686 patients. The proportion of ED visit cases with any PIM was 79.2% and the average number of PIMs was 2.7 (range, 1–17). The most commonly administered PIMs that were contraindicated or should have been used with caution were ketorolac (41.3%) and metoclopramide (10.3%), respectively. Multivariate regression analysis indicated that female patients (p = 0.012), patients with more than six drugs in the ED (p < 0.001), and visits longer than 300 minutes (p = 0.026) were significantly associated with PIM administration in the ED. Potential DDIs between the medications administered in EDs were observed in 20.5% of total visit cases, with ketorolac being the most frequently reported drug in contraindicated drug combinations.ConclusionThis study demonstrated a high incidence of the administration of PIMs and medications with pDDIs in older patients in EDs and revealed the characteristics that are significantly associated with an increased risk of PIM administration. Healthcare providers in EDs should consider the risk of administering PIMs or medications with pDDIs, especially when treating older patients.

A Post Hoc Analysis of Osmotherapy Use in the Erythropoietin in Traumatic Brain Injury Study-Associations With Acute Kidney Injury and Mortality.

Mannitol and hypertonic saline are used to treat raised intracerebral pressure in patients with traumatic brain injury, but their possible effects on kidney function and mortality are unknown. A post hoc analysis of the erythropoietin trial in traumatic brain injury (ClinicalTrials.gov NCT00987454) including daily data on mannitol and hypertonic saline use. Twenty-nine university-affiliated teaching hospitals in seven countries. A total of 568 patients treated in the ICU for 48 hours without acute kidney injury of whom 43 (7%) received mannitol and 170 (29%) hypertonic saline. None. We categorized acute kidney injury stage according to the Kidney Disease Improving Global Outcome classification and defined acute kidney injury as any Kidney Disease Improving Global Outcome stage-based changes from the admission creatinine. We tested associations between early (first 2 d) mannitol and hypertonic saline and time to acute kidney injury up to ICU discharge and death up to 180 days with Cox regression analysis. Subsequently, acute kidney injury developed more often in patients receiving mannitol (35% vs 10%; p < 0.001) and hypertonic saline (23% vs 10%; p < 0.001). On competing risk analysis including factors associated with acute kidney injury, mannitol (hazard ratio, 2.3; 95% CI, 1.2-4.3; p = 0.01), but not hypertonic saline (hazard ratio, 1.6; 95% CI, 0.9-2.8; p = 0.08), was independently associated with time to acute kidney injury. In a Cox model for predicting time to death, both the use of mannitol (hazard ratio, 2.1; 95% CI, 1.1-4.1; p = 0.03) and hypertonic saline (hazard ratio, 1.8; 95% CI, 1.02-3.2; p = 0.04) were associated with time to death. In this post hoc analysis of a randomized controlled trial, the early use of mannitol, but not hypertonic saline, was independently associated with an increase in acute kidney injury. Our findings suggest the need to further evaluate the use and choice of osmotherapy in traumatic brain injury.

Patient participation and associated factors in the discussions on do-not-attempt-resuscitation and end-of-life disclosure: a retrospective chart review study

BackgroundPatient participation is a key foundation of advance care planning (ACP). However, a patient himself/herself may be left out from sensitive conversations such as end-of-life (EOL) care discussions. The objectives of this study were to investigate patients’ participation rate in the discussion of Cardiopulmonary Resuscitation (CPR) / Do-Not-Attempt-Resuscitation (DNAR) order, and in the discussion that the patient is at his/her EOL stage (EOL disclosure), and to explore their associated factors.MethodsThis is a retrospective chart review study. The participants were all the patients who were hospitalized and died in a university-affiliated teaching hospital (tertiary medical facility) in central Tokyo, Japan during the period from April 2018 to March 2019. The following patients were excluded: (1) cardiopulmonary arrest on arrival; (2) stillbirth; (3) under 18 years old at the time of death; and (4) refusal by their bereaved family. Presence or absence of CPR/DNAR discussion and EOL disclosure, patients’ involvement in those discussions, and their associated factors were investigated.ResultsCPR/DNAR discussions were observed in 336 out of the 358 patients (93.9%). However, 224 of these discussions were carried out without a patient (patient participation rate 33.3%). Male gender (odds ratio (OR) = 2.37 [95% confidence interval (CI) 1.32–4.25]), living alone (OR = 2.51 [1.34–4.71]), and 1 year or more from the date of diagnosis (OR = 1.78 [1.03–3.10]) were associated with higher patient’s participation in CPR/DNAR discussions. The EOL disclosure was observed in 341 out of the 358 patients (95.3%). However, 170 of the discussions were carried out without the patient (patient participation rate 50.1%). Patients who died of cancer (OR = 2.41[1.45–4.03]) and patients without mental illness (OR=2.41 [1.11–5.25]) were more likely to participate in EOL disclosure.ConclusionsIn this clinical sample, only up to half of the patients participated in CPR/DNAR discussions and EOL disclosure. Female, living with family, a shorter period from the diagnosis, non-cancer, and mental illness presence are risk factors for lack of patients’ participation in CPR/DNAR or EOL discussions. Further attempts to facilitate patients’ participation, based on their preference, are warranted.

Follow-up blood cultures in E. coli and Klebsiella spp. bacteremia-opportunities for diagnostic and antimicrobial stewardship.

Uncomplicated Enterobacteriaceae bacteremia is usually transient and may not require follow-up blood cultures (FUBC). This is a retrospective observational study conducted at a university-affiliated urban teaching hospital in Seattle, WA. All patients ≥ 18years hospitalized between July 2014 and August 2019 with ≥ 1 positive blood culture for either Escherichia coli or Klebsiella species were included. The primary outcome was to determine the number and frequency of FUBC obtained, and the detection rate for positive FUBC. There were 335 episodes of E. coli and Klebsiella spp. bacteremia with genitourinary (54%) being the most common source. FUBC were sent in 299 (89.3%) patients, with a median of 3 (interquartile range (IQR): 2, 4) sets of FUBC drawn per patient. Persistent bacteremia occurred in 37 (12.4%) patients. In uncomplicated E. coli and Klebsiella spp. bacteremia, when the pre-test probability of persistent bacteremia is relatively low, FUBC may not be necessary in the absence of predisposing factors.