The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines

INTRODUCTION

The SCARE Guidelines were first published in 2016 and were last updated in 2018. They provide a structure for reporting surgical case reports and are used and endorsed by authors, journal editors and reviewers, in order to increase robustness and transparency in reporting surgical cases. They must be kept up to date in order to drive forwards reporting quality. As such, we have updated these guidelines via a DELPHI consensus exercise.

METHODS

The updated guidelines were produced via a DELPHI consensus exercise. Members were invited from the previous DELPHI group, as well as editorial board members and peer reviewers of the International Journal of Surgery Case Reports. The expert group completed an online survey to indicate their agreement with proposed changes to the checklist items.

RESULTS

A total of 54 surgical experts agreed to participate and 53 (98%) completed the survey. The responses and suggested modifications were incorporated into the new 2020 guideline. There was a high degree of agreement amongst the SCARE Group, with all modified SCARE items receiving over 70% scores 7-9.

CONCLUSION

A DELPHI consensus exercise was completed and an updated and improved SCARE Checklist is now presented.

The SCARE 2018 statement: Updating consensus Surgical CAse REport (SCARE) guidelines

INTRODUCTION

The SCARE Guidelines were published in 2016 to provide a structure for reporting surgical case reports. Since their publication, SCARE guidelines have been widely endorsed by authors, journal editors, and reviewers, and have helped to improve reporting transparency of case reports across a range of surgical specialties. In order to encourage further progress in reporting quality, the SCARE guidelines must themselves be kept up to date. We completed a Delphi consensus exercise to update the SCARE guidelines.

METHODS

A Delphi consensus exercise was undertaken. All members of the previous Delphi group were invited to participate, in addition to researchers who have previously studied case reports, and editors from the International Journal of Surgery Case Reports. The expert group was sent an online questionnaire where they were asked to rate their agreement with proposed changes to each of the 24 items.

RESULTS

56 people agreed to participate and 45 (80%) invitees completed the survey which put forward modifications to the original guideline. The collated responses resulted in modifications. There was high agreement amongst the expert group.

CONCLUSION

A modified and improved SCARE checklist is presented, after a Delphi consensus exercise was completed. The SCARE 2018 Statement: Updating Consensus Surgical CAse REport (SCARE) Guidelines.

The PROCESS 2020 Guideline: Updating Consensus Preferred Reporting Of CasESeries in Surgery (PROCESS) Guidelines

INTRODUCTION

The PROCESS Guidelines were first published in 2016 and were last updated in 2018. They provide a structure for reporting surgical case series in order to increase reporting robustness and transparency, and are used and endorsed by authors, journal editors and reviewers alike. In order to drive forwards reporting quality, they must be kept up to date. As such, we have updated these guidelines via a DELPHI consensus exercise.

METHODS

The updated guidelines were produced via a DELPHI consensus exercise. Members from the previous DELPHI group were again invited, alongside editorial board members and peer reviewers of the International Journal of Surgery and the International Journal of Surgery Case Reports. An online survey was completed by this expert group to indicate their agreement with proposed changes to the checklist items.

RESULTS

A total of 53 surgical experts agreed to participate and 49 (92%) completed the survey. The responses and suggested modifications were incorporated into the previous 2018 guidelines. There was a high degree of agreement amongst the PROCESS Group, with all but one of the PROCESS items receiving over 70% of scores ranging 7-9.

CONCLUSION

A DELPHI consensus exercise was completed and an updated and improved PROCESS Checklist is now presented.

A comprehensive review of Vibrio vulnificus: an important cause of severe sepsis and skin and soft-tissue infection

Vibrio vulnificus is a halophilic Gram-negative bacillus found worldwide in warm coastal waters. The pathogen has the ability to cause primary sepsis in certain high-risk populations, including patients with chronic liver disease, immunodeficiency, iron storage disorders, end-stage renal disease, and diabetes mellitus. Most reported cases of primary sepsis in the USA are associated with the ingestion of raw or undercooked oysters harvested from the Gulf Coast. The mortality rate for patients with severe sepsis is high, exceeding 50% in most reported series. Other clinical presentations include wound infection and gastroenteritis. Mild to moderate wound infection and gastroenteritis may occur in patients without obvious risk factors. Severe wound infection is often characterized by necrotizing skin and soft-tissue infection, including fasciitis and gangrene. V. vulnificus possesses several virulence factors, including the ability to evade destruction by stomach acid, capsular polysaccharide, lipopolysaccharide, cytotoxins, pili, and flagellum. The preferred antimicrobial therapy is doxycycline in combination with ceftazidime and surgery for necrotizing soft-tissue infection.

Social media usage among health care providers

OBJECTIVE

The objective of this study was to evaluate the use of social media among healthcare workers in an attempt to identify how it affects the quality of patient care.

RESULTS

An anonymous survey of 35 questions was conducted in South Texas, on 366 healthcare workers. Of the 97% of people who reported owning electronic devices, 87.9% indicated that they used social media. These healthcare workers indicated that they spent approximately 1 h on social media every day. The healthcare workers below the age of 40 were more involved in social media compared to those above 40 (p < 0.05). The use of social media among physicians and nurses was noted to be identical (88% for each group), and both groups encouraged their patients to research their clinical conditions on social media (p < 0.05). A higher number of physicians reported awareness of a social media policy in their hospital compared to nurses (p < 0.05). However, a large proportion of healthcare workers (40%) were unaware of their workplace policy, which could potentially cause a privacy breach of confidential medical information. Further studies are required to evaluate specific effects of these findings on the quality of patient care.

Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature

Extended work hours, interrupted sleep, and shift work are integral parts of medical training among all specialties. The need for 24-hour patient care coverage and economic factors have resulted in prolonged work hours for resident physicians. This has traditionally been thought to enhance medical educational experience. These long and erratic work hours lead to acute and chronic sleep deprivation and poor sleep quality, resulting in numerous adverse consequences. Impairments may occur in several domains, including attention, cognition, motor skills, and mood. Resident performance, professionalism, safety, and well-being are affected by sleep deprivation, causing potentially adverse implications for patient care. Studies have shown adverse health consequences, motor vehicle accidents, increased alcohol and medication use, and serious medical errors to occur in association with both sleep deprivation and shift work. Resident work hour limitations have been mandated by the Accreditation Council for Graduate Medical Education in response to patient safety concerns. Studies evaluating the impact of these regulations on resident physicians have generated conflicting reports on patient outcomes, demonstrating only a modest increase in sleep duration for resident physicians, along with negative perceptions regarding their education. This literature review summarizes research on the effects of sleep deprivation and shift work, and examines current literature on the impact of recent work hour limitations on resident physicians and patient-related outcomes.

Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review

In this systematic review, we compared the incidences of psychological issues during the COVID-19 pandemic, such as anxiety, depression, occupational stress, PTSD and insomnia, in healthcare workers (HCW) and non-healthcare workers (NHCW). PubMed, Ovid, Google Scholar and PsycInfo were systematically searched for related published articles. In all electronic databases, the following search strategy was implemented, and these key words were used: "COVID 19″ OR "SARS-CoV-2″ AND "psychological" OR "stress" OR "depression" AND "healthcare$". We identified 6 studies, out of the final 15 selected, which reported numerical estimates for incidences of psychological effects. Meta-analysis was conducted, comparing both combined and individual effect sizes of all psychological manifestations. Qualitative evidence was reported from the remaining 9 cross- sectional studies. The summary effects of the combined quantitative meta-analysis conducted on 6 studies did indicate near significant differences between HCW and NHCW. Summary effects of individual manifestations indicated significantly higher incidence of insomnia among HCW, when compared to NHCW. Qualitative evidence from remaining cross-sectional studies provided additional information into the nature of the psychological issues. We conclude that even though reasons for psychological distress among HCW and NHCW may be different, both suffered in equal measures excepting for insomnia.

Preferred Reporting Of Case Series in Surgery (PROCESS) 2023 guidelines

INTRODUCTION

The Preferred Reporting Of CasE Series in Surgery (PROCESS) guidelines were developed in 2016 in order to improve the reporting quality of surgical case series. Since its inception, it has been updated twice, in 2018 and 2020, and has been cited over 1000 times. PROCESS guidelines have enjoyed great acceptance within the surgical research community. Our aim is to update the PROCESS guidelines in order to maintain its applicability in the field of surgical research.

METHODS

A PROCESS 2023 steering group was created. By working in collaboration, members of this group came up with proposals to update the PROCESS 2020 guidelines. These proposals were presented to an expert panel of researchers, who in turn scrutinised these proposals and decided whether they should become part of PROCESS 2023 guidelines or not, through a Delphi consensus exercise.

RESULTS

A total of 38 people participated in the development of PROCESS 2023 guidelines. The majority of items received a score between 7 and 9 from greater than 70% of the participants, indicating consensus with the proposed changes to those items. However, two items (3c and 6a) received a score between 7 and 9 from less than 70% of the participants, indicating a lack of consensus with the proposed changes to those items. Those items will remain unchanged.

DISCUSSION

The updated PROCESS 2023 guidelines are presented with an aim to continue improving the reporting quality of case series in surgery.

Abnormal liver enzymes: A review for clinicians

Liver biochemical tests are some of the most commonly ordered routine tests in the inpatient and outpatient setting, especially with the automatization of testing in this technological era. These tests include aminotransferases, alkaline phosphatase, gamma-glutamyl transferase, bilirubin, albumin, prothrombin time and international normalized ratio (INR). Abnormal liver biochemical tests can be categorized based on the pattern and the magnitude of aminotransferases elevation. Generally, abnormalities in aminotransferases can be classified into a hepatocellular pattern or cholestatic pattern and can be further sub-classified based on the magnitude of aminotransferase elevation to mild [< 5 × upper limit of normal (ULN)], moderate (> 5-< 15 × ULN) and severe (> 15 × ULN). Hepatocellular pattern causes include but are not limited to; non-alcoholic fatty liver disease/non-alcoholic steatohepatitis, alcohol use, chronic viral hepatitis, liver cirrhosis (variable), autoimmune hepatitis, hemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, celiac disease, medication-induced and ischemic hepatitis. Cholestatic pattern causes include but is not limited to; biliary pathology (obstruction, autoimmune), other conditions with hyperbilirubinemia (conjugated and unconjugated). It is crucial to interpret these commonly ordered tests accurately as appropriate further workup, treatment and referral can greatly benefit the patient due to prompt treatment which can improve the natural history of several of the diseases mentioned and possibly reduce the risk of progression to the liver cirrhosis.

Gender and ethnic differences in prevalence of self-reported insomnia among patients with obstructive sleep apnea

BACKGROUND

Insomnia and obstructive sleep apnea (OSA) are the two most common sleep disorders. Studies have shown that complaints of insomnia are prevalent among sleep clinic patients evaluated for OSA. Less is known about the gender and ethnic variations in this association.

OBJECTIVES

This paper aims to study the influence of gender and ethnicity in the prevalence of insomnia in patients with OSA and explore the association between these two disorders with an emphasis on psychophysiologic insomnia.

METHODS AND MEASUREMENTS

We reviewed case files, including self-reported questionnaires and polysomnography studies of 300 OSA patients [apnea-hypopnea index (AHI) of >10] from three ethnic groups--Caucasian, Hispanic, and African American, 50 patients each, male and female, seen at a tertiary care county hospital adult sleep center. Self-reported insomnia was classified as sleep onset insomnia, sleep maintenance insomnia, or insomnia with early morning awakening. Psychophysiologic insomnia was documented if the patient reported two of the following five symptoms: racing thoughts when trying to sleep, increased muscle tension when trying to sleep, fear of being unable to sleep, fear of being unable to fall back to sleep after waking up, and lying in bed worrying. Fischer exact tests for each contingency table were run using SPSS.

RESULTS

Among OSA patients, women were older, had higher body mass index, and lower AHI at the time of diagnosis, compared to men. Insomnia was more prevalent among patients with OSA (84%) than the reported 30% among general adult population. Sleep onset insomnia was reported more frequently by women (62%) than men (53%) (p = 0.03). Similarly self-reported psychophysiologic insomnia also showed a female preponderance (53% vs. 45%, p = 0.03). Caucasian women had the highest rate of self-reported sleep maintenance insomnia (80%). Hispanic women are more likely to complain of symptoms suggestive of psychophysiologic insomnia (58%).

CONCLUSIONS

There is a higher prevalence of insomnia in OSA patients. Ethnicity and gender possibly exhibit a complex and significant influence on the reported subtype of insomnia. Further larger studies may help confirm, as well as clarify, mechanisms that underlie the ethnic and gender differences that we have noted.

Development of the Asthma Impairment and Risk Questionnaire (AIRQ): A Composite Control Measure

BACKGROUND

Asthma exacerbation risk increases with worsening asthma control. Prevailing numerical control tools evaluate only current symptom impairment despite the importance of also assessing risk based on exacerbation history. An easy-to-use questionnaire addressing impairment and risk domains of control is needed.

OBJECTIVE

To validate a composite asthma control tool that includes impairment and risk assessments (Asthma Impairment and Risk Questionnaire [AIRQ]).

METHODS

Four-hundred forty-two patients aged ≥12 years with physician-diagnosed asthma who were followed in specialty practices completed 15 impairment and risk questions with dichotomized yes/no responses. Patients spanned all Global Initiative for Asthma severities and were classified as well-controlled, not well-controlled, or very poorly controlled according to a standard of Asthma Control Test (ACT) score plus prior-year exacerbations. Logistic regression analyses identified questions with the greatest predictive validity to discriminate among patients and determine cut points for these 3 classifications.

RESULTS

The final AIRQ comprises 10 equally weighted yes/no impairment and risk questions. The final 10-item models yielded receiver operating characteristic curves of 0.94 to identify well-controlled versus not well-/very poorly controlled and 0.93 to identify well-/not well-controlled versus very poorly controlled asthma, as reflected by the ACT plus prior-year exacerbations standard. Cut points of 0-1, 2-4, and 5-10 best represented well-, not well-, and very poorly controlled asthma.

CONCLUSIONS

AIRQ is a rigorously validated composite measure designed to identify adults and adolescents with varying degrees of asthma control. Ongoing investigations will determine test-retest reliability, responsiveness to change, and predictive ability for future exacerbations.

Sleep Quality and Vigilance Differ Among Inpatient Nurses Based on the Unit Setting and Shift Worked

OBJECTIVES

Sleepiness in nurses has been shown to impact patient care and safety. The objectives of this study are to measure sleep quality, sleepiness, fatigue, and vigilance in inpatient nurses and to assess how setting (intensive care unit versus the general floor) and shift worked (day versus night) affect these measures.

METHODS

Nurses from both the ICU and floor were included in the study. Participants completed questionnaires assessing self-reported sleep quality (Pittsburgh Sleep Quality Index, PSQI), sleepiness (Stanford Sleepiness Scale and Epworth Sleepiness Scale, ESS), and fatigue (Fatigue Severity Scale, FSS). Vigilance was measured by means of the psychomotor vigilance test (PVT), before and after a 12-hour duty shift.

RESULTS

The ESS was abnormal in 22% of all nurses, the FSS was abnormal in 33%, and the global PSQI was abnormal in 63%. More ICU nurses than floor nurses reported abnormal sleep quality (component 5) on the PSQI. Sleep medication use (PSQI component 6) was higher in night shift nurses. The FSS was greater in night shift nurses. On preshift PVT testing, day-shift nurses overall provided faster mean reaction time (RT) than night-shift nurses. ICU nurses working the day shift made more than twice as many total errors and false starts than day shift floor nurses. Floor nurses demonstrated a significant decrease from preshift to postshift in the mean of the fastest 10% RT.

CONCLUSIONS

Our data indicate that a significant number of inpatient nurses have impaired sleep quality, excessive sleepiness, and abnormal fatigue, which may place them at a greater risk of making medical errors and harming patients; these problems are especially pronounced in night shift workers. PVT results were inconsistent, but floor and day shift nurses performed better on some tasks than ICU and night shift nurses.

Influence of gender and anthropometric measures on severity of obstructive sleep apnea

PURPOSE

Gender differences influence upper airway anatomy and physiology. The purpose of our study was to evaluate the influence of gender as well as anthropometric measures on severity of obstructive sleep apnea (OSA).

METHODS

A retrospective review of patients referred to our sleep laboratory for evaluation of OSA was done. Patients with a diagnosis of OSA (Respiratory Disturbance Index (RDI) > 5) were included in the study. Anthropometric measurements were available for all the patients included in the study. Measurements of subjects' height, weight, neck size, and waist and hip sizes were used in the study; waist-hip ratio and neck-to-height ratio were calculated.

RESULTS

Three hundred eighty-six females and 661 males were included. Women were older than men and had a higher body mass index (BMI) and waist-to-hip ratio; men had a thicker neck circumference and a higher neck-to-height ratio. The severity of OSA was significantly higher in males (RDI 41.2 ± 27.9 in men vs. 30.0 ± 26.7 in women, p < 0.0001) despite a lower BMI and age in the men. Severity of OSA, as measured by RDI, varied significantly with changes in anthropometric measures such as neck circumference, and waist and hip sizes in both genders. Waist-to-hip ratio was associated with severity of OSA in men but not in women (p = 0.19 and 0.0001 in women and men, respectively). However, no single anthropometric value was found to be strongly predictive of OSA severity.

CONCLUSION

Despite having a higher mean BMI and age, women have lower RDI compared with men. Waist-to-hip ratio is more predictive of severity of OSA in men than in women. However, the correlation of anthropometric measures with severity of OSA was weak in our subjects.

Endotoxin, Toll-like Receptor-4, and Atherosclerotic Heart Disease

BACKGROUND

Endotoxin is a lipopolysaccharide (LPS) constituent of the outer membrane of most gram negative bacteria. Ubiquitous in the environment, it has been implicated as a cause or contributing factor in several disparate disorders from sepsis to heatstroke and Type II diabetes mellitus. Starting at birth, the innate immune system develops cellular defense mechanisms against environmental microbes that are in part modulated through a series of receptors known as toll-like receptors. Endotoxin, often referred to as LPS, binds to toll-like receptor 4 (TLR4)/ myeloid differentiation protein 2 (MD2) complexes on various tissues including cells of the innate immune system, smooth muscle and endothelial cells of blood vessels including coronary arteries, and adipose tissue. Entry of LPS into the systemic circulation ultimately leads to intracellular transcription of several inflammatory mediators. The subsequent inflammation has been implicated in the development and progression atherosclerosis and subsequent coronary artery disease and heart failure.

OBJECTIVE

The potential roles of endotoxin and TLR4 are reviewed regarding their role in the pathogenesis of atherosclerotic heart disease.

CONCLUSION

Atherosclerosis is initiated by inflammation in arterial endothelial and subendothelial cells, and inflammatory processes are implicated in its progression to clinical heart disease. Endotoxin and TLR4 play a central role in the inflammatory process, and represent potential targets for therapeutic intervention. Therapy with HMG-CoA inhibitors may reduce the expression of TLR4 on monocytes. Other therapeutic interventions targeting TLR4 expression or function may prove beneficial in atherosclerotic disease prevention and treatment.

Novel drug delivery systems for inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic illness characterized by relapsing inflammation of the intestines. The disorder is stratified according to the severity and is marked by its two main phenotypical representations: Ulcerative colitis and Crohn's disease. Pathogenesis of the disease is ambiguous and is expected to have interactivity between genetic disposition, environmental factors such as bacterial agents, and dysregulated immune response. Treatment for IBD aims to reduce symptom extent and severity and halt disease progression. The mainstay drugs have been 5-aminosalicylates (5-ASAs), corticosteroids, and immunosuppressive agents. Parenteral, oral and rectal routes are the conventional methods of drug delivery, and among all, oral administration is most widely adopted. However, problems of systematic drug reactions and low specificity in delivering drugs to the inflamed sites have emerged with these regular routes of delivery. Novel drug delivery systems have been introduced to overcome several therapeutic obstacles and for localized drug delivery to target tissues. Enteric-coated microneedle pills, various nano-drug delivery techniques, prodrug systems, lipid-based vesicular systems, hybrid drug delivery systems, and biologic drug delivery systems constitute some of these novel methods. Microneedles are painless, they dislodge their content at the affected site, and their release can be prolonged. Recombinant bacteria such as genetically engineered Lactococcus Lactis and eukaryotic cells, including GM immune cells and red blood cells as nanoparticle carriers, can be plausible delivery methods when evaluating biologic systems. Nano-particle drug delivery systems consisting of various techniques are also employed as nanoparticles can penetrate through inflamed regions and adhere to the thick mucus of the diseased site. Prodrug systems such as 5-ASAs formulations or their derivatives are effective in reducing colonic damage. Liposomes can be modified with both hydrophilic and lipophilic particles and act as lipid-based vesicular systems, while hybrid drug delivery systems containing an internal nanoparticle section for loading drugs are potential routes too. Leukosomes are also considered as possible carrier systems, and results from mouse models have revealed that they control anti- and pro-inflammatory molecules.

Hepatic hemangioma: What internists need to know

Hepatic hemangioma (HH) is the most common benign liver tumor and it is usually found incidentally during radiological studies. This tumor arises from a vascular malformation; however, the pathophysiology has not been clearly elucidated. Symptoms usually correlate with the size and location of the tumor. Less commonly the presence of a large HH may cause life-threatening conditions. The diagnosis can be established by the identification of HH hallmarks in several imaging studies. In patients that present with abdominal symptoms other etiologies should be excluded first before attributing HH as the cause. In asymptomatic patient's treatment is not required and follow up is usually reserved for HH of more than 5 cm. Symptomatic patients can be managed surgically or with other non-surgical modalities such as transcatheter arterial embolization or radiofrequency ablation. Enucleation surgery has shown to have fewer complications as compared to hepatectomy or other surgical techniques. Progression of the tumor is seen in less than 40%. Hormone stimulation may play a role in HH growth; however, there are no contraindications for hormonal therapy in patients with HH due to the lack of concrete evidence. When clinicians encounter this condition, they should discern between observation and surgical or non-surgical management based on the clinical presentation.

Guidelines for Perioperative Management of the Diabetic Patient

Management of glycemic levels in the perioperative setting is critical, especially in diabetic patients. The effects of surgical stress and anesthesia have unique effects on blood glucose levels, which should be taken into consideration to maintain optimum glycemic control. Each stage of surgery presents unique challenges in keeping glucose levels within target range. Additionally, there are special operative conditions that require distinctive glucose management protocols. Interestingly, the literature still does not report a consensus perioperative glucose management strategy for diabetic patients. We hope to outline the most important factors required in formulating a perioperative diabetic regimen, while still allowing for specific adjustments using prudent clinical judgment. Overall, through careful glycemic management in perioperative patients, we may reduce morbidity and mortality and improve surgical outcomes.

Advancements in Oncology with Artificial Intelligence-A Review Article

Well-trained machine learning (ML) and artificial intelligence (AI) systems can provide clinicians with therapeutic assistance, potentially increasing efficiency and improving efficacy. ML has demonstrated high accuracy in oncology-related diagnostic imaging, including screening mammography interpretation, colon polyp detection, glioma classification, and grading. By utilizing ML techniques, the manual steps of detecting and segmenting lesions are greatly reduced. ML-based tumor imaging analysis is independent of the experience level of evaluating physicians, and the results are expected to be more standardized and accurate. One of the biggest challenges is its generalizability worldwide. The current detection and screening methods for colon polyps and breast cancer have a vast amount of data, so they are ideal areas for studying the global standardization of artificial intelligence. Central nervous system cancers are rare and have poor prognoses based on current management standards. ML offers the prospect of unraveling undiscovered features from routinely acquired neuroimaging for improving treatment planning, prognostication, monitoring, and response assessment of CNS tumors such as gliomas. By studying AI in such rare cancer types, standard management methods may be improved by augmenting personalized/precision medicine. This review aims to provide clinicians and medical researchers with a basic understanding of how ML works and its role in oncology, especially in breast cancer, colorectal cancer, and primary and metastatic brain cancer. Understanding AI basics, current achievements, and future challenges are crucial in advancing the use of AI in oncology.

Self-reported sleep bruxism and nocturnal gastroesophageal reflux disease in patients with obstructive sleep apnea: relationship to gender and ethnicity

STUDY OBJECTIVES

Nocturnal bruxism is associated with gastroesophageal reflux disease (GERD), and GERD is strongly associated with obstructive sleep apnea (OSA). Gender and ethnic differences in the prevalence and clinical presentation of these often overlapping sleep disorders have not been well documented. Our aim was to examine the associations between, and the symptoms associated with, nocturnal GERD and sleep bruxism in patients with OSA, and to examine the influence of gender and ethnicity.

METHODS

A retrospective chart review was performed of patients diagnosed with OSA at an academic sleep center. The patients completed a sleep questionnaire prior to undergoing polysomnography. Patients with confirmed OSA were evaluated based on gender and ethnicity. Associations were determined between sleep bruxism and nocturnal GERD, and daytime sleepiness, insomnia, restless legs symptoms, and markers of OSA severity in each group.

RESULTS

In these patients with OSA, the prevalence of nocturnal GERD (35%) and sleep bruxism (26%) were higher than the general population. Sleep bruxism was more common in Caucasians than in African Americans or Hispanics; there was no gender difference. Nocturnal GERD was similar among all gender and ethnic groups. Bruxism was associated with nocturnal GERD in females, restless legs symptoms in all subjects and in males, sleepiness in African Americans, and insomnia in Hispanics. Nocturnal GERD was associated with sleepiness in males and African Americans, insomnia in females, and restless legs symptoms in females and in Caucasians.

CONCLUSION

Patients with OSA commonly have comorbid sleep bruxism and nocturnal GERD, which may require separate treatment. Providers should be aware of differences in clinical presentation among different ethnic and gender groups.

Burnout in the intensive care unit professionals

BACKGROUND

Professional burnout has been widely explored in health care. We conducted this study in our hospital intensive care unit (ICU) in United States to explore the burnout among nurses and respiratory therapists (RT).

MATERIALS AND METHODS

A survey consisting of two parts was used to assess burnout. Part 1 addressed the demographic information and work hours. Part 2 addressed the Maslach Burnout Inventory-Human Service Survey.

RESULTS

The analysis included 213 total subjects; Nurses 151 (71%) and RT 62 (29%). On the emotional exhaustion (EE) scale, 54% scored "Moderate" to "High" and 40% scored "Moderate" to "High" on the depersonalization (DP) scale. Notably 40.6% scored "Low" on personal accomplishment (PA) scale.

CONCLUSION

High level of EE, DP and lower PAs were seen among two groups of health care providers in the ICUs.

Abdominal compartment syndrome: Often overlooked conditions in medical intensive care units

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are well recognized entities among surgical patients. Nevertheless, a number of prospective and retrospective observational studies have shown that IAH is prevalent in about half of the critically ill patients in the medical intensive care units (ICU) and has been widely recognized as an independent risk factor for mortality. It is alarming to note that many members of the critical care team in medical ICU are not aware of the consequences of untreated IAH and the delay in making the diagnosis leads to increased morbidity and mortality. Frequently it is underdiagnosed and undertreated in this patient population. Elevated intra-abdominal pressure decreases the blood flow to the kidneys and other abdominal viscera and also results in reduced cardiac output and difficulties in ventilating the patient because of increased intrathoracic pressure. When intraabdominal hypertension is not promptly recognized and treated, it leads to abdominal compartment syndrome, multiorgan dysfunction syndrome and death. Large volume fluid resuscitation is very common in medical ICU patients presenting with sepsis, shock and other inflammatory conditions like pancreatitis and it is one of the major risk factors for the development of intra-abdominal hypertension. This article presents an overview of the epidemiology, definitions, risk factors, pathophysiology and management of IAH and abdominal compartment syndrome in critically ill medical ICU patients.

Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study

OBJECTIVE

Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation.

METHODS

A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation.

RESULTS

Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients' pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients' risk of hypotension.

CONCLUSIONS

A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients.

STUDY REGISTRATION

Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.

Diagnosis of Obstructive Sleep Apnea from ECG Signals Using Machine Learning and Deep Learning Classifiers

Obstructive sleep apnea (OSA) is a well-known sleep ailment. OSA mostly occurs due to the shortage of oxygen for the human body, which causes several symptoms (i.e., low concentration, daytime sleepiness, and irritability). Discovering the existence of OSA at an early stage can save lives and reduce the cost of treatment. The computer-aided diagnosis (CAD) system can quickly detect OSA by examining the electrocardiogram (ECG) signals. Over-serving ECG using a visual procedure is challenging for physicians, time-consuming, expensive, and subjective. In general, automated detection of the ECG signal’s arrhythmia is a complex task due to the complexity of the data quantity and clinical content. Moreover, ECG signals are usually affected by noise (i.e., patient movement and disturbances generated by electric devices or infrastructure), which reduces the quality of the collected data. Machine learning (ML) and Deep Learning (DL) gain a higher interest in health care systems due to its ability of achieving an excellent performance compared to traditional classifiers. We propose a CAD system to diagnose apnea events based on ECG in an automated way in this work. The proposed system follows the following steps: (1) remove noise from the ECG signal using a Notch filter. (2) extract nine features from the ECG signal (3) use thirteen ML and four types of DL models for the diagnosis of sleep apnea. The experimental results show that our proposed approach offers a good performance of DL classifiers to detect OSA. The proposed model achieves an accuracy of 86.25% in the validation stage.

Gender and age influence the effects of slow-wave sleep on respiration in patients with obstructive sleep apnea

INTRODUCTION

Obstructive sleep apnea (OSA) is influenced by sleep architecture with rapid eye movement (REM) sleep having the most adverse influence, especially in women. There is little data defining the influence of slow-wave sleep (SWS) on OSA. We wished to study the influence of SWS on OSA and identify differences attributable to gender and/or age, if any.

METHODS

Retrospective study of polysomnography (PSG) records of adult patients referred for diagnostic PSG. Records were excluded if they underwent split night or positive airway pressure titration studies, had <180 min of total sleep time (TST) and/or <40% sleep efficiency, or had SWS <5 min and/or <1% of TST. The apnea-hypopnea index (AHI) recorded during SWS was compared with that measured during other non-rapid eye movement (NREM) sleep and during REM sleep. The REM-SWS difference in AHI was measured, and compared between genders.

RESULTS

Records from 239 patients were included. The mean AHI in all subjects was 17.7 ± 22.6. The SWS AHI was 6.8 ± 18.9, compared to the REM AHI of 24.9 ± 25.8, and NREM AHI of 15.8 ± 22.8. Females had significantly higher SWS by percentage, and lower NREM AHI (P < 0.0001) and SWS AHI (P = 0.03). Among patients with OSA (AHI ≥5), the difference between REM AHI and SWS AHI was greater in women than in men (34.2 ± 27.4 vs. 21.6 ± 26.0, P = 0.006).

CONCLUSIONS

The upper airway appears to be less susceptible to OSA during SWS than during REM and other NREM sleep. This may be related to phase-specific influences on both dynamic upper airway control as well as loop gain. Gender and age appear to modify this effect.

Body mass index, gender, and ethnic variations alter the clinical implications of the epworth sleepiness scale in patients with suspected obstructive sleep apnea

INTRODUCTION

The Epworth Sleepiness Scale (ESS) is often used in the evaluation of obstructive sleep apnea (OSA), though questions remain about the influence gender, ethnicity, and body morphometry have in the responses to this questionnaire. The aim of this study was to examine differences in ESS scores between various demographic groups of patients referred for polysomnography, and the relationship of these score to sleep-disordered breathing

METHODS

Nineteen hundred consecutive patients referred for polysomnographic diagnosis of OSA completed questionnaires, including demographic data and ESS. OSA was determined based on a respiratory disturbance index (RDI) ≥15 by polysomnography.

RESULTS

In this high risk population for OSA, the ESS was 10.7 ± 5.6. The highest ESS scores were seen in obese males; non-obese females and non-obese Caucasian males scored the lowest. ESS was weakly correlated with RDI (r = 0.17, P < 0.0001). The sensitivity of ESS for the diagnosis of OSA was 54% and the specificity was 57%. The positive (PPV) and negative (NPV) predictive values were 64% and 47%, respectively. In obese subjects, the sensitivity and specificity were 55% and 53%, compared with 47% and 63% in non-obese subjects. In obese, Hispanic males, the sensitivity, specificity, and PPV were 59%, 54%, and 84%, respectively. In non-obese, Caucasian females, the sensitivity, specificity, and NPV were 43%, 59%, and 72%.

CONCLUSIONS

The ESS appears to be affected by many factors, including gender, ethnicity, and body morphometry. The ability of the ESS to predict OSA is modest, despite a significant correlation with the severity of OSA. The test characteristics improve significantly when applied to select populations, especially those at risk for OSA.