Levocarnitine supplementation for management of hypertriglyceridemia in patients receiving parenteral nutrition.

Background: Levocarnitine deficiency has been observed in patients receiving parenteral nutrition (PN) and can cause or worsen hypertriglyceridemia. The objective was to characterize use of levocarnitine supplementation in PN and evaluate its effect on triglyceride levels in hospitalized adults.

Methods: This retrospective, single-center study included patients with triglyceride levels ≥175 mg/dl while receiving PN who had a subsequent reduction in lipid injectable emulsion dose.

Impact of Postoperative Glycemic Control on Postoperative Morbidity in Patients Undergoing Open Pancreaticoduodenectomy.

Objective: To evaluate the impact of postoperative glycemic control on postoperative morbidity in patients undergoing a pancreaticoduodenectomy.

Methods: A retrospective study was performed on patients at The Johns Hopkins Hospital between April 2015 and April 2016. Data were collected on postoperative insulin regimens, blood glucose, rates of hyperglycemia and hypoglycemia, and postoperative complications and were evaluated.

Perioperative methadone prescribing and association with respiratory depression.

Objective: Over 80 percent of surgery patients experience acute post-operative pain and less than half feel their pain is adequately controlled. Patients receiving chronic opioids, including methadone, are at the highest risk of inadequate pain control. Guidelines do not provide specific recommendations for analgesia management in this population.

Implementation of a Protocol Using the 5-Item Brief Alcohol Withdrawal Scale for Treatment of Severe Alcohol Withdrawal in Intensive Care Units.

Background: There is variation in the treatment of patients with severe alcohol withdrawal and a need for effective protocols. The purpose of this study was to evaluate the implementation of a symptom-triggered benzodiazepine protocol using the 5-item Brief Alcohol Withdrawal Scale (BAWS) for treatment of alcohol withdrawal in intensive care units (ICUs).

Methods: This retrospective study included admissions to ICUs of 2 hospitals over 6 months who had an alcohol withdrawal protocol ordered and experienced severe withdrawal.

Valganciclovir Dosing for Cytomegalovirus Prophylaxis in Solid-organ Transplant Recipients on Continuous Veno-venous Hemodialysis.

Background: Optimal valganciclovir dosing for cytomegalovirus (CMV) prophylaxis in solid-organ transplant (SOT) patients on continuous veno-venous hemodialysis (CVVHD) is not known. Ganciclovir trough concentrations ≥0.60 μg/mL have been suggested for CMV prophylaxis.

Where is my infusion pump? Harnessing network dynamics for improved hospital equipment fleet management.

Objective: Timely availability of intravenous infusion pumps is critical for high-quality care delivery. Pumps are shared among hospital units, often without central management of their distribution. This study seeks to characterize unit-to-unit pump sharing and its impact on shortages, and to evaluate a system-control tool that balances inventory across all care areas, enabling increased availability of pumps.

Aminoglycoside Dosing and Volume of Distribution in Critically Ill Surgery Patients.

At a tertiary referral and Level I trauma center, current institutional guidelines suggest initial aminoglycoside doses of gentamicin or tobramycin 4 mg/kg and amikacin 16 mg/kg for patients admitted to surgical intensive care units (SICUs) with suspected gram-negative infection. The objective of this study was to evaluate initial aminoglycoside dosing and peak serum drug concentrations in critically ill surgery patients to characterize the aminoglycoside volume of distribution (V) and determine an optimal standardized dosing strategy. This retrospective, observational, single-center study included adult SICU patients who received an aminoglycoside for additional gram-negative coverage.

Microbial Contamination, Infection, and Antimicrobial Use During Total Pancreatectomy With Islet Autotransplantation.

Objectives: Total pancreatectomy with islet autotransplantation can relieve pain associated with chronic pancreatitis while preserving islet function. Islet preparations are often contaminated by enteric flora. We assessed the impact of contaminated islet preparations on the prevalence of postoperative infection.

Anti-Xa activity by weight in critically ill patients receiving unfractionated heparin for venous thromboembolism prophylaxis.

Purpose: This study compared anti-Xa activity in critically ill patients receiving UFH for VTE prophylaxis between two weight groups (<100 kg vs ≥100 kg).

Methods: This prospective, observational study included critically ill patients on UFH 5000 or 7500 units every 8 h. A peak and trough anti-Xa activity assay was ordered for each patient at steady state.

Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location.

Objectives: To determine the point prevalence of medication errors at the time of transition of care from an ICU to non-ICU location and assess error types and risk factors for medication errors during transition of care.

Design: This was a multicenter, retrospective, 7-day point prevalence study.

Setting: Fifty-eight ICUs within 34 institutions in the United States and two in the Netherlands.

Evaluation of the Brief Alcohol Withdrawal Scale Protocol at an Academic Medical Center.

Objectives: The standard of care for treatment of alcohol withdrawal is symptom-triggered dosing of benzodiazepines using a withdrawal scale. Abbreviated scales are desired for clinician efficiency. The objective of this study was to evaluate the use of the 5-item Brief Alcohol Withdrawal Scale (BAWS) protocol.

Higher versus Lower Dose of Cefotetan or Cefoxitin for Surgical Prophylaxis in Patients Weighing One Hundred Twenty Kilograms or More.

Background: Clinical practice guidelines recommend a 2-g dose of cefotetan and cefoxitin for surgical prophylaxis. Pharmacokinetic data suggest benefit from higher cefotetan and cefoxitin dosing in obese patients. However, clinical studies examining higher dosing strategies in this at-risk population are lacking.

Use and Effectiveness of Peri-Operative Cefotetan versus Cefazolin Plus Metronidazole for Prevention of Surgical Site Infection in Abdominal Surgery Patients.

Background: Current practice guidelines for antimicrobial prophylaxis in surgery recommend a cephamycin or cefazolin plus metronidazole for various abdominal surgeries. In February 2016, cephamycin drug shortages resulted in a change in The Johns Hopkins Hospital's (JHH) recommendation for peri-operative antibiotic prophylaxis in abdominal surgeries from cefotetan to cefazolin plus metronidazole. The primary objective of this study was to quantify the percentage of abdominal surgeries adherent to JHH peri-operative antibiotic prophylaxis guidelines.

Appropriateness of peripheral parenteral nutrition use in adult patients at an academic medical center.

Background & Aims: Current evidence and guidelines identify patient populations who may benefit from parenteral nutrition. Peripheral parenteral nutrition (PPN) may be indicated for a subset of patients; however, PPN therapy carries a risk of associated adverse effects. The purpose of this project was to assess appropriateness of current PPN prescribing practices at an academic medical center to determine whether additional guidance and oversight may be beneficial.

Factors associated with in-hospital mortality among critically ill surgical patients with multidrug-resistant Gram-negative infections.

Purpose: Multidrug-resistant (MDR) Gram-negative infection increases risk of mortality, other complications, and costs. The objective of this study was to determine the prevalence of and identify factors associated with in-hospital mortality among critically ill surgical patients.

Materials And Methods: This case-control study included critically ill surgical patients from 2011 to 2014 who had a carbapenem-resistant Enterobacteriaceae (CRE), MDR P.

Feasibility of a Nurse-Managed Pain, Agitation, and Delirium Protocol in the Surgical Intensive Care Unit.

Background: Society of Critical Care Medicine guidelines recommend the use of pain, agitation, and delirium protocols in the intensive care unit. The feasibility of nurse management of such protocols in the surgical intensive care unit has not been well assessed.

Objectives: To evaluate the percentage of adherent medication interventions for patients assessed by using a pain, sedation, and delirium protocol.

Defining the identity of mouse embryonic dermal fibroblasts.

Embryonic dermal fibroblasts in the skin have the exceptional ability to initiate hair follicle morphogenesis and contribute to scarless wound healing. Activation of the Wnt signaling pathway is critical for dermal fibroblast fate selection and hair follicle induction. In humans, mutations in Wnt pathway components and target genes lead to congenital focal dermal hypoplasias with diminished hair.

Short-duration treatment for catheter-associated urinary tract infections in critically ill trauma patients.

Background: The optimal treatment duration for catheter-associated urinary tract infection (CA-UTI) in critically ill patients is unclear. The Infectious Diseases Society of America recommends up to 14 days of therapy; however, short-duration therapy (SDT) for 3 days to 5 days is often used in trauma intensive care unit (ICU) patients at our center. The efficacy of SDT for CA-UTI has not been studied in this population.

Antimicrobial Pharmacokinetics and Pharmacodynamics.

Background: Antimicrobial medications are beneficial when used appropriately, but adverse effects and resistance sometimes limit therapy. These effects may be more problematic with inappropriate antimicrobial use. Consideration of the pharmacokinetic and pharmacodynamic properties of these medications can help optimize drug use.

Reducing medication errors in critical care: a multimodal approach.

The Institute of Medicine has reported that medication errors are the single most common type of error in health care, representing 19% of all adverse events, while accounting for over 7,000 deaths annually. The frequency of medication errors in adult intensive care units can be as high as 947 per 1,000 patient-days, with a median of 105.9 per 1,000 patient-days.

Dermal β-catenin activity in response to epidermal Wnt ligands is required for fibroblast proliferation and hair follicle initiation.

Dermal fibroblasts are required for structural integrity of the skin and for hair follicle development. Uniform Wnt signaling activity is present in dermal fibroblast precursors preceding hair follicle initiation, but the functional requirement of dermal Wnt signaling at early stages of skin differentiation and patterning remains largely uncharacterized. We show in mice that epidermal Wnt ligands are required for uniform dermal Wnt signaling/β-catenin activity and regulate fibroblast cell proliferation and initiation of hair follicle placodes.

Role of canonical Wnt signaling/ß-catenin via Dermo1 in cranial dermal cell development.

Cranial dermis develops from cephalic mesoderm and neural crest cells, but what signal(s) specifies the dermal lineage is unclear. Using genetic tools to fate map and manipulate a cranial mesenchymal progenitor population in the supraorbital region, we show that the dermal progenitor cells beneath the surface ectoderm process canonical Wnt signaling at the time of specification. We show that Wnt signaling/β-catenin is absolutely required and sufficient for Dermo1 expression and dermal cell identity in the cranium.

Visualizing canonical Wnt signaling during mouse craniofacial development.

Wnt signaling is critical for proper development of the head and face in the mouse embryo, playing important roles in various aspects of craniofacial development ranging from axis formation to survival of cranial neural crest cells to patterning of the brain. The signaling requirements for the development of different cell lineages in the head and face are active areas of investigation. In this study, we use a recently developed TCF/Lef-LacZ transgenic reporter mouse to characterize the expression of canonical Wnt signaling activity during craniofacial development.