Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance.

If the risk of ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) is causally determined by driving pressure rather than by Vt, then the effect of ventilation with lower Vt on mortality would be predicted to vary according to respiratory system elastance (Ers). To determine whether the mortality benefit of ventilation with lower Vt varies according to Ers. In a secondary analysis of patients from five randomized trials of lower- versus higher-Vt ventilation strategies in ARDS and acute hypoxemic respiratory failure, the posterior probability of an interaction between the randomized Vt strategy and Ers on 60-day mortality was computed using Bayesian multivariable logistic regression.

Occupational Burnout among Otolaryngology-Head and Neck Surgery Trainees in Australia.

Objectives: Surgical trainee burnout has gained attention recently as a significant factor leading to poorer quality of patient care, decreased productivity, and personal dysfunction. As a result, we aimed to determine the prevalence and associated risk factors for burnout among otolaryngology-head and neck surgery (OHNS) trainees in Australia.

Study Design: Cross-sectional survey.

Multivariable fractional polynomial interaction to investigate continuous effect modifiers in a meta-analysis on higher versus lower PEEP for patients with ARDS.

Objectives: A recent individual patient data (IPD) meta-analysis suggested that patients with moderate or severe acute respiratory distress syndrome (ARDS) benefit from higher positive end-expiratory pressure (PEEP) ventilation strategies. However, thresholds for continuous variables (eg, hypoxaemia) are often arbitrary and linearity assumptions in regression approaches may not hold; the multivariable fractional polynomial interaction (MFPI) approach can address both problems. The objective of this study was to apply the MFPI approach to investigate interactions between four continuous patient baseline variables and higher versus lower PEEP on clinical outcomes.

Development of a Robotic Assembly for Analyzing the Instantaneous Axis of Rotation of the Foot Ankle Complex.

Ankle instantaneous axis of rotation (IAR) measurements represent a more complete parameter for characterizing joint motion. However, few studies have implemented this measurement to study normal, injured, or pathological foot ankle biomechanics. A novel testing protocol was developed to simulate aspects of in vivo foot ankle mechanics during mid-stance gait in a human cadaveric specimen.

Impact of an innovative inpatient patient navigator program on length of stay and 30-day readmission.

Background: The current climate of increasing patient complexity coupled with rising costs have prompted the need for adaptive innovation. There are limited data describing inpatient interventions targeting improvements in both communication and transitional care.

Objective: Evaluate the patient navigator (PN) program, an innovative inpatient intervention intended to enhance navigation through the complexity of hospital admissions for patients and providers.

Driving pressure and survival in the acute respiratory distress syndrome.

Background: Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (VT), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (CRS) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size), we hypothesized that driving pressure (ΔP=VT/CRS), in which VT is intrinsically normalized to functional lung size (instead of predicted lung size in healthy persons), would be an index more strongly associated with survival than VT or PEEP in patients who are not actively breathing.

Methods: Using a statistical tool known as multilevel mediation analysis to analyze individual data from 3562 patients with ARDS enrolled in nine previously reported randomized trials, we examined ΔP as an independent variable associated with survival.

Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial.

Background: Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care.

A ventilator strategy combining low tidal volume ventilation, recruitment maneuvers, and high positive end-expiratory pressure does not increase sedative, opioid, or neuromuscular blocker use in adults with acute respiratory distress syndrome and may improve patient comfort.

Background: The Lung Open Ventilation Study (LOV Study) compared a low tidal volume strategy with an experimental strategy combining low tidal volume, lung recruitment maneuvers, and higher plateau and positive end-expiratory pressures (PEEP) in adults with acute respiratory distress syndrome (ARDS). Herein, we compared sedative, opioid, and neuromuscular blocker (NMB) use among patients managed with the intervention and control strategies and clinicians' assessment of comfort in both groups.

Methods: This was an observational substudy of the LOV Study, a randomized trial conducted in 30 intensive care units in Canada, Australia, and Saudi Arabia.

Supraglottitis due to group B streptococcus in an adult with IgG4 and C2 deficiency: a case report and review of the literature.

Acute supraglottitis is a medical emergency as it can rapidly lead to airway compromise. With routine pediatric immunization for Hemophilus influenzae serotype b, supraglottitis is now more prevalent in adults, with a shift in the causative organisms and a change in the natural history of this disease. Here, we present a case of supraglottitis due to group B streptococcus that occurred in an adult with previously undetected immunoglobulin 4 (IgG4) and complement protein C2 deficiency.

High-frequency oscillation in early acute respiratory distress syndrome.

Background: Previous trials suggesting that high-frequency oscillatory ventilation (HFOV) reduced mortality among adults with the acute respiratory distress syndrome (ARDS) were limited by the use of outdated comparator ventilation strategies and small sample sizes.

Methods: In a multicenter, randomized, controlled trial conducted at 39 intensive care units in five countries, we randomly assigned adults with new-onset, moderate-to-severe ARDS to HFOV targeting lung recruitment or to a control ventilation strategy targeting lung recruitment with the use of low tidal volumes and high positive end-expiratory pressure. The primary outcome was the rate of in-hospital death from any cause.

Complications from recruitment maneuvers in patients with acute lung injury: secondary analysis from the lung open ventilation study.

Background: There are limited data on the safety and efficacy of recruitment maneuvers (RMs) in acute lung injury (ALI) patients.

Objective: To evaluate the frequency, timing, and risk factors for complications from RMs in adult ALI patients.

Methods: Secondary analysis of data from a randomized controlled trial of a lung open ventilation strategy that included sustained inflation RMs.

Functional disability 5 years after acute respiratory distress syndrome.

Background: There have been few detailed, in-person interviews and examinations to obtain follow-up data on 5-year outcomes among survivors of the acute respiratory distress syndrome (ARDS).

Methods: We evaluated 109 survivors of ARDS at 3, 6, and 12 months and at 2, 3, 4, and 5 years after discharge from the intensive care unit. At each visit, patients were interviewed and examined; underwent pulmonary-function tests, the 6-minute walk test, resting and exercise oximetry, chest imaging, and a quality-of-life evaluation; and reported their use of health care services.

Pressure and volume limited ventilation for the ventilatory management of patients with acute lung injury: a systematic review and meta-analysis.

Background: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life threatening clinical conditions seen in critically ill patients with diverse underlying illnesses. Lung injury may be perpetuated by ventilation strategies that do not limit lung volumes and airway pressures. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing pressure and volume-limited (PVL) ventilation strategies with more traditional mechanical ventilation in adults with ALI and ARDS.

The quick and the deadly: growth vs virulence in a seed bank pathogen.

*We studied the relationship between virulence (ability to kill nondormant Bromus tectorum seeds) and mycelial growth index in the necrotrophic seed pathogen Pyrenophora semeniperda. Seed pathosystems involving necrotrophs differ from those commonly treated in traditional evolution-of-virulence models in that host death increases pathogen fitness by preventing germination, thereby increasing available resources. Because fast-germinating, nondormant B.

Establishing an antimicrobial stewardship program.

Hospitals are faced with increasing challenges of antibiotic-resistant organisms and rising antimicrobial costs despite widespread attention to infection prevention and control measures. Government, professional organizations and accreditation bodies are all signalling an urgent need for the establishment of programs in hospitals to address antibiotic misuse. Although variations of such "antimicrobial stewardship programs" have been functioning in Canada for some time, a formal approach using change management and quality improvement principles has largely been lacking.

Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis.

Context: Trials comparing higher vs lower levels of positive end-expiratory pressure (PEEP) in adults with acute lung injury or acute respiratory distress syndrome (ARDS) have been underpowered to detect small but potentially important effects on mortality or to explore subgroup differences.

Objectives: To evaluate the association of higher vs lower PEEP with patient-important outcomes in adults with acute lung injury or ARDS who are receiving ventilation with low tidal volumes and to investigate whether these associations differ across prespecified subgroups.

Data Sources: Search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (1996-January 2010) plus a hand search of conference proceedings (2004-January 2010).

Preparing your intensive care unit for the second wave of H1N1 and future surges.

Faced with increased demands for critical care services as a result of the novel H1N1 pandemic, hospitals must prepare a surge response in an attempt to manage these needs. In preparing for a surge response, factors to consider are staff, stuff (supplies and equipment), space, and systems necessary to respond to the event. This article uses this general framework to discuss surge issues in the context of H1N1 challenges that we are facing currently and to provide specific advice for hospitals.

Critically Ill patients with 2009 influenza A(H1N1) in Mexico.

Context: In March 2009, novel 2009 influenza A(H1N1) was first reported in the southwestern United States and Mexico. The population and health care system in Mexico City experienced the first and greatest early burden of critical illness.

Objective: To describe baseline characteristics, treatment, and outcomes of consecutive critically ill patients in Mexico hospitals that treated the majority of such patients with confirmed, probable, or suspected 2009 influenza A(H1N1).

Exogenous natural surfactant for treatment of acute lung injury and the acute respiratory distress syndrome.

Rationale: Compositional changes in surfactant and/or decreased surfactant content of the lungs are common features in patients with acute respiratory failure. Instillation of exogenous surfactant into the lungs of neonates with respiratory distress syndrome or pediatric patients with acute respiratory distress syndrome (ARDS) has resulted in improved survival.

Objectives: We conducted this trial to determine whether the instillation of exogenous surfactant would improve the Day 28 outcome of adult patients with acute lung injury (ALI) or ARDS.

Ventilation practices and critical events during transport of ventilated patients outside of hospital: a retrospective cohort study.

Introduction: Little is known about mechanical ventilation practices during patient transport outside of hospital in the civilian setting, although these practices may have clinical impact. Objective. We set out to describe ventilation practice, the use of lung-protective ventilation strategies, administration of sedation and neuromuscular blockade, and related critical events during out-of-hospital transport of ventilated patients.

Critical care services in Ontario: a survey-based assessment of current and future resource needs.

Purpose: In response to the challenges of an aging population and decreasing workforce, the provision of critical care services has been a target for quality and efficiency improvement efforts. Reliable data on available critical care resources is a necessary first step in informing these efforts. We sought to describe the availability of critical care resources, forecast the future requirement for the highest-level critical care beds and to determine the physician management models in critical care units in Ontario, Canada.

Has mortality from acute respiratory distress syndrome decreased over time?: A systematic review.

Rationale: It is commonly stated that mortality from acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) is decreasing.

Objectives: To systematically review the literature assessing ARDS mortality over time and to determine patient- and study-level factors independently associated with mortality.

Methods: We searched multiple databases (MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL) for prospective observational studies or randomized controlled trials (RCTs) published during the period 1984 to 2006 that enrolled 50 or more patients with ALI/ARDS and reported mortality.

A study of the physiologic responses to a lung recruitment maneuver in acute lung injury and acute respiratory distress syndrome.

Objective: To determine the magnitude, duration, and consistency of the effects of lung recruitment maneuvers (RMs) on oxygenation, lung mechanics, and comfort in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS).

Methods: We conducted a prospective physiologic study at 3 tertiary-care hospitals. We enrolled 28 consecutive eligible patients with ARDS or ALI and a ratio of P(aO(2)) to fraction of inspired oxygen (P(aO(2))/F(IO(2))) or= 0.