Patient Safety Indicators at an Academic Veterans Affairs Hospital: Addressing Dual Goals of Clinical Care and Validity.

Background: Hospital-acquired complications add to patient morbidity and mortality, costs, length of stay, and negative patient experience. Patient Safety Indicators (PSIs) are a validated and widely used metric to evaluate hospital administrative data on preventing these events. Although many studies have addressed PSI validity, few have aimed to reduce PSI through clinical care.

Bronchoalveolar fluid and plasma inflammatory biomarkers in contemporary ARDS patients.

Bronchoalveolar fluid (BALF) and plasma biomarkers are often endpoints in early phase randomized trials (RCTs) in acute respiratory distress syndrome (ARDS). With ARDS mortality decreasing, we analyzed baseline biomarkers in samples from contemporary ARDS patients participating in a prior RCT and compared these to historical controls. Ninety ARDS adult patients enrolled in the parent trial.

Risk-benefit of consuming Lake Erie fish.

Background: Consumption of fish is promoted as a healthy way to obtain essential fatty acids (EFA) in the diet, yet the risk of ingesting harmful contaminants remains a concern. A recent study concluded that the risk-benefit of consuming fish from the North American Laurentian Great Lakes, which sustain important commercial and recreational fisheries, is currently unclear. We report the fatty acid (FA) content in skin-off fillets of fifteen fish species from Lake Erie and assess whether recommended dietary requirements for two EFA (EPA and DHA) can be met by safely consuming Lake Erie fishes, as an example of a risk-benefit analysis.

Effects of different cooking methods on fatty acid profiles in four freshwater fishes from the Laurentian Great Lakes region.

Fish is often promoted as a healthy part of the human diet due its high content of long chain n-3 polyunsaturated fatty acids (LC-PUFA). Previous studies have shown that cooked fish can have different fatty acid profiles than raw fillets, depending on the cooking method and fish species. In this study, the fatty acid content of broiled, baked or fried skinless, boneless fillets of four fish species from the tributaries of the Great Lakes, or connecting rivers, was compared to fatty acid profiles in raw sections from the same fillet.

Long-term changes in fish mercury levels in the historically impacted English-Wabigoon River system (Canada).

The English-Wabigoon River system in Northwestern Ontario, Canada, was one of the most heavily mercury-contaminated waterways in the world due to historical discharges in the 1960s from a chlor-alkali plant. This study examines long-term (1970-2010) monitoring data to assess temporal trends in mercury contamination in Walleye, Northern Pike and Lake Whitefish, three species important for sport and subsistence fishing in this region, using dynamic linear modeling and piecewise regression. For all lakes and species, there is a significant decline (36-94%) in mercury concentrations through time; however, there is evidence that this decline is either slowing down or levelling off.

Clinical outcomes of linezolid vs vancomycin in methicillin-resistant Staphylococcus aureus ventilator-associated pneumonia: retrospective analysis.

Background: Vancomycin has been the treatment standard for methicillin-resistant Staphylococcus aureus (MRSA) infections, but clinical efficacy is limited. We report outcomes of a cohort with MRSA ventilator-associated pneumonia (VAP) treated with vancomycin vs linezolid.

Methods: Retrospective analysis of 113 participants with MRSA VAP confirmed by bronchoscopy who have been initiated on therapy with either vancomycin or linezolid within 24 hours after bronchoscopy and completed ≥7 days of therapy during their hospitalization from July 2003 to June 2007.

A phase II randomized placebo-controlled trial of omega-3 fatty acids for the treatment of acute lung injury.

Objectives: Administration of eicosapentaenoic acid and docosahexanoic acid, omega-3 fatty acids in fish oil, has been associated with improved patient outcomes in acute lung injury when studied in a commercial enteral formula. However, fish oil has not been tested independently in acute lung injury. We therefore sought to determine whether enteral fish oil alone would reduce pulmonary and systemic inflammation in patients with acute lung injury.

Intraoperative adherence to a low tidal volume ventilation strategy in critically ill patients with preexisting acute lung injury.

Purpose: Low tidal volume (LTV) ventilation reduces mortality in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). This study investigates adherence of intraoperative LTV and whether patient outcomes were different with or without continued intraoperative LTV ventilation in patients with previously established ALI or ARDS.

Materials And Methods: A retrospective analysis was performed of adults with ALI/ARDS over a 2-year period who underwent surgery between 24 hours and 14 days after the diagnosis of ALI/ARDS.

Genetic variation in the FAS gene and associations with acute lung injury.

Rationale: Fas (CD95) modulates apoptosis and inflammation and is believed to play an important role in lung injury.

Objectives: To determine if common genetic variation in FAS is associated with acute lung injury (ALI) susceptibility, risk of death, and FAS gene expression.

Methods: We genotyped 14 single nucleotide polymorphisms (tagSNPS) in FAS in samples from healthy white volunteers (control subjects, n = 294) and patients with ALI (cases, n = 324) from the ARDSnet Fluid and Catheter Treatment Trial (FACTT).

Institutional review board consideration of chart reviews, case reports, and observational studies.

Though the need for human-subjects review is readily apparent to investigators when conducting a randomized clinical trial, that same requirement is often less obvious when considering activities such as chart reviews, observational studies, or even case reports. In some cases all that is needed is notification of the institutional review board, which might then exempt the research. In other cases, waiver of consent and Health Insurance Portability and Accountability Act authorization may be granted, whereas in some situations risk to privacy may be considered too great and approval denied.

Informed consent: what is it? Who can give it? How do we improve it?

The freedom to choose is integral to our daily lives, directs our interactions with patients, and is a key component of our conduct of human-subjects research. Most of the historical errors and atrocities in human experimentation had at their core a failure of consent. In response to those events, national and international law developed to direct researchers to a process of informed consent to participate in research.

Cytomegalovirus reactivation in critically ill immunocompetent patients.

Context: Cytomegalovirus (CMV) infection is associated with adverse clinical outcomes in immunosuppressed persons, but the incidence and association of CMV reactivation with adverse outcomes in critically ill persons lacking evidence of immunosuppression have not been well defined.

Objective: To determine the association of CMV reactivation with intensive care unit (ICU) and hospital length of stay in critically ill immunocompetent persons.

Design, Setting, And Participants: We prospectively assessed CMV plasma DNAemia by thrice-weekly real-time polymerase chain reaction (PCR) and clinical outcomes in a cohort of 120 CMV-seropositive, immunocompetent adults admitted to 1 of 6 ICUs at 2 separate hospitals at a large US tertiary care academic medical center between 2004 and 2006.

Hypertonic resuscitation of hypovolemic shock after blunt trauma: a randomized controlled trial.

Background: The leading cause of late mortality after trauma is multiple organ failure syndrome, due to a dysfunctional inflammatory response early after injury. Preclinical studies demonstrate that hypertonicity alters the activation of inflammatory cells, leading to reduction in organ injury. The purpose of this study was to evaluate the effect of hypertonicity on organ injury after blunt trauma.

The clinical pulmonary infection score poorly predicts pneumonia in patients with burns.

The Clinical Pulmonary Infection Score (CPIS) has been reported to be a useful tool in the diagnosis of ventilator-associated pneumonia (VAP) in the critical care setting. However, the systemic inflammation associated with injury may limit the utility of CPIS in patients with burns. The purpose of this study was to determine the potential utility of CPIS in the management of burn patients.

Incidence and outcomes of acute lung injury.

Background: Acute lung injury is a critical illness syndrome consisting of acute hypoxemic respiratory failure with bilateral pulmonary infiltrates that are not attributed to left atrial hypertension. Despite recent advances in our understanding of the mechanism and treatment of acute lung injury, its incidence and outcomes in the United States have been unclear.

Methods: We conducted a prospective, population-based, cohort study in 21 hospitals in and around King County, Washington, from April 1999 through July 2000, using a validated screening protocol to identify patients who met the consensus criteria for acute lung injury.

Low tidal volume ventilation does not increase sedation use in patients with acute lung injury.

Objective: Low tidal volume ventilation is associated with reduced mortality in patients with acute lung injury, yet concerns exist about patient comfort and the levels of sedation and analgesia required during its use. We compared the doses and duration of sedatives and opioid analgesics in patients receiving low vs. traditional tidal volumes at our institution.

The epidemiology and definition of the acute respiratory distress syndrome.

Acute lung injury and ARDS have been clinically recognized syndromes for nearly 30 years. During that time, the understanding of the risks, pathophysiology, and outcomes has changed and improved. The definition for this disease has evolved in an attempt to identify more accurately and reliably a more homogeneous patient population that could be expected to have similar responses to the disease and therapies.

Mitogen-activated protein kinases in the intensive care unit: prognostic potential.

Objective: To evaluate the prognostic significance of the activational status of p38, specifically progression to multiple organ dysfunction syndrome (MODS), in a group of severely injured trauma patients.

Summary Background Data: To date, therapeutic manipulation of the host immunoinflammatory response has not affected the outcome of patients with MODS. A major concern is the inability to identify the patient most at risk so as to enable early intervention.

Randomized, prospective trial of antioxidant supplementation in critically ill surgical patients.

Objective: To determine the effectiveness of early, routine antioxidant supplementation using alpha-tocopherol and ascorbic acid in reducing the rate of pulmonary morbidity and organ dysfunction in critically ill surgical patients.

Summary Background Data: Oxidative stress has been associated with the development of the acute respiratory distress syndrome (ARDS) and organ failure through direct tissue injury and activation of genes integral to the inflammatory response. In addition, depletion of endogenous antioxidants has been associated with an increased risk of nosocomial infections.