Timing of Lung Transplant Referral in Patients with Severe COVID-19 Lung Injury Supported by ECMO

Severe respiratory failure caused by COVID-19 often requires mechanical ventilation, including extracorporeal membrane oxygenation (ECMO). In rare cases, lung transplantation (LTx) may be considered as a last resort. However, uncertainties remain about patient selection and optimal timing for referral and listing. This retrospective study analyzed patients with severe COVID-19 who were supported by veno-venous ECMO and listed for LTx between July 2020 and June 2022. Out of the 20 patients in the study population, four who underwent LTx were excluded. The clinical characteristics of the remaining 16 patients were compared, including nine who recovered and seven who died while awaiting LTx. The median duration from hospitalization to listing was 85.5 days, and the median duration on the waitlist was 25.5 days. Younger age was significantly associated with a higher likelihood of recovery without LTx after a median of 59 days on ECMO, compared to those who died at a median of 99 days. In patients with severe COVID-19-induced lung damage supported by ECMO, referral to LTx should be delayed for 8-10 weeks after ECMO initiation, particularly for younger patients who have a higher probability of spontaneous recovery and may not require LTx.

Intra-subject variability in oscillometry correlates with acute rejection and CLAD post-lung transplant

Background

Chronic lung allograft dysfunction (CLAD) is the major cause of death post-lung transplantation, with acute cellular rejection (ACR) being the biggest contributing risk factor. Although patients are routinely monitored with spirometry, FEV₁ is stable or improving in most ACR episodes. In contrast, oscillometry is highly sensitive to respiratory mechanics and shown to track graft injury associated with ACR and its improvement following treatment. We hypothesize that intra-subject variability in oscillometry measurements correlates with ACR and risk of CLAD.

Methods

Of 289 bilateral lung recipients enrolled for oscillometry prior to laboratory-based spirometry between December 2017 and March 2020, 230 had ≥ 3 months and 175 had ≥ 6 months of follow-up. While 37 patients developed CLAD, only 29 had oscillometry at time of CLAD onset and were included for analysis. These 29 CLAD patients were time-matched with 129 CLAD-free recipients. We performed multivariable regression to investigate the associations between variance in spirometry/oscillometry and the A-score, a cumulative index of ACR, as our predictor of primary interest. Conditional logistic regression models were built to investigate associations with CLAD.

Results

Multivariable regression showed that the A-score was positively associated with the variance in oscillometry measurements. Conditional logistic regression models revealed that higher variance in the oscillometry metrics of ventilatory inhomogeneity, X5, AX, and R5-19, was independently associated with increased risk of CLAD (p < 0.05); no association was found for variance in %predicted FEV₁.

Conclusion

Oscillometry tracks graft injury and recovery post-transplant. Monitoring with oscillometry could facilitate earlier identification of graft injury, prompting investigation to identify treatable causes and decrease the risk of CLAD.

A hood shield reduces postdoffing contamination during simulated COVID-19 airway management: an exploratory, simulation-based randomized study

PURPOSE

SARS-CoV-2 poses a significant occupational health threat to health care workers performing aerosol-generating medical procedures, with a threefold increased risk of a positive test and predicted infection compared with the general population. Nevertheless, the personal protective equipment (PPE) configuration that provides better protection with lower contamination rates is still unknown.

METHODS

We enrolled 40 practitioners with airway management training (anesthesiologists, anesthesia assistants/nurses) in an exploratory, simulation-based randomized study. We evaluated the performance of a novel, locally designed hood (n = 20) in terms of protection from surrogate contamination using an ultraviolet (UV) marker during a standardized urgent intubation procedure and a simulated episode of coughing in a high-fidelity simulation setting compared with standard PPE (n = 20). The primary outcome was the presence of residual UV fluorescent contamination on any base clothing or exposed skin of the upper body after doffing PPE assessed by a blinded evaluator.

RESULTS

The proportion of participants with residual contamination on any base clothing or exposed skin of the upper body after doffing was less than half in the hood PPE group compared with the standard PPE group (8/20 [40%] vs 18/20 [90%], respectively; P = 0.002).

CONCLUSIONS

Compared with standard PPE, enhanced PPE with a locally designed prototype hood was associated with reduced contamination of the upper torso and fewer body areas being exposed to droplets after a simulated aerosol-generating scenario without designed airflow.

STUDY REGISTRATION

ClinicalTrials.gov (NCT04373096); registered 4 May 2020.

Evaluation and Management of Dyspnea in Hypermobile Ehlers-Danlos Syndrome and Generalized Hypermobility Spectrum Disorder: Protocol for a Pilot and Feasibility Randomized Controlled Trial

BACKGROUND

Dyspnea is a prevalent symptom in individuals with hypermobile Ehlers-Danlos Syndrome (hEDS) and generalized hypermobility spectrum disorder (G-HSD), yet its contributors have not been identified. One known contributor to dyspnea is respiratory muscle weakness. The feasibility and effectiveness of inspiratory muscle training (IMT) in combination with standard-of-care rehabilitation (aerobic, resistance, neuromuscular stabilization, and balance and proprioception exercises) in improving respiratory muscle strength and patient-reported outcomes in patients with hEDS or G-HSD have not been evaluated.

OBJECTIVE

This study aims to evaluate dyspnea, respiratory muscle strength, and patient-reported outcome measures (PROMs) in hEDS or G-HSD compared with healthy controls and to assess the feasibility of a randomized controlled trial of IMT and standard-of-care rehabilitation for improving respiratory muscle strength, exercise capacity, and PROMs compared with standard-of-care rehabilitation in hEDS and G-HSD.

METHODS

The study will include 34 participants with hEDS or G-HSD and 17 healthy, age- and sex-matched controls to compare respiratory muscle structure and function and PROMs. After baseline assessments, participants with hEDS or G-HSD will be randomized into the intervention group and provided IMT combined with Ehlers-Danlos Syndrome standard-of-care rehabilitation or into the usual care group, and provided only standard-of-care rehabilitation for 8 weeks. The intervention group will be prescribed IMT in their home environment using the POWERbreathe K5 IMT device (POWERbreathe International Ltd). IMT will comprise 2 daily sessions of 30 breaths for 5 days per week, with IMT progressing from 20% to 60% of the baseline maximal inspiratory pressure (MIP) over an 8-week period. Feasibility will be assessed through rates of recruitment, attrition, adherence, adverse events, and participant satisfaction. The primary pilot outcome is MIP change over an 8-week period in hEDS or G-HSD. Secondary outcomes will include the evaluation of dyspnea using Medical Research Council Scale and 18-point qualitative dyspnea descriptors; diaphragmatic thickening fraction using ultrasound; respiratory muscle endurance; pulmonary function; prefrontal cortical activity using functional near-infrared spectroscopy; aerobic capacity during cardiopulmonary exercise testing; quality of life using Short Form-36; and scores from the Depression, Anxiety, and Stress scale-21. These measures will also be performed once in healthy controls to compare normative values. Multivariable regression will be used to assess the contributors to dyspnea. Paired 2-tailed t tests will be used to assess the changes in MIP and secondary measures after 8 weeks of IMT.

RESULTS

Study recruitment began in August 2021 and, with several disruptions owing to COVID-19, is expected to be completed by December 2023.

CONCLUSIONS

This study will provide a better understanding of the factors associated with dyspnea and the feasibility and effectiveness of IMT combined with standard-of-care rehabilitation. IMT may be a novel therapeutic strategy for improving respiratory muscle function and patient-reported outcomes in individuals with hEDS or G-HSD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04972565; https://clinicaltrials.gov/ct2/show/NCT04972565.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44832.

Validity of non-contact methods for diagnosis of Obstructive Sleep Apnea: a systematic review and meta-analysis

STUDY OBJECTIVE

Obstructive Sleep Apnea (OSA) is associated with increased perioperative cardiac, respiratory and neurological complications. Pre-operative OSA risk assessment is currently done through screening questionnaires with high sensitivity but poor specificity. The objective of this study was to evaluate the validity and diagnostic accuracy of portable, non-contact devices in the diagnosis of OSA as compared with polysomnography.

DESIGN

This study is a systematic review of English observational cohort studies with meta-analysis and risk of bias assessment.

SETTING

Pre-operative, including in the hospital and clinic setting.

PATIENTS

Adult patients undergoing sleep apnea assessment using polysomnography and an experimental non-contact tool.

INTERVENTIONS

A novel non-contact device, which does not utilize any monitor that makes direct contact with the patient's body, in conjunction with polysomnography.

MEASUREMENTS

Primary outcomes included pooled sensitivity and specificity of the experimental device in the diagnosis of obstructive sleep apnea, in comparison to gold-standard polysomnography.

RESULTS

Twenty-eight of 4929 screened studies were included in the meta-analysis. A total of 2653 patients were included with the majority being patients referred to a sleep clinic (88.8%). Average age was 49.7(SD±6.1) years, female sex (31%), average body mass index of 29.5(SD±3.2) kg/m², average apnea-hypopnea index (AHI) of 24.7(SD±5.6) events/h, and pooled OSA prevalence of 72%. Non-contact technology used was mainly video, sound, or bio-motion analysis. Pooled sensitivity and specificity of non-contact methods in moderate to severe OSA diagnosis (AHI > 15) was 0.871 (95% CI 0.841,0.896, I² 0%) and 0.8 (95% CI 0.719,0.862), respectively (AUC 0.902). Risk of bias assessment showed an overall low risk of bias across all domains except for applicability concerns (none were conducted in the perioperative setting).

CONCLUSION

Available data indicate contactless methods have high pooled sensitivity and specificity for OSA diagnosis with moderate to high level of evidence. Future research is needed to evaluate these tools in the perioperative setting.

Pregnancy outcomes with donor oocyte embryos in patients diagnosed with adenomyosis using the Morphological Uterus Sonographic Assessment criteria

OBJECTIVE

To use the Morphological Uterus Sonographic Assessment (MUSA) criteria to evaluate the impact of adenomyosis on the live birth rate after donor egg embryo transfer.

DESIGN

Retrospective cohort study.

SETTING

Tertiary fertility care center.

PATIENT(S)

A total of 100 patients who received 223 donor embryo transfers from January 2014-2020. All patients underwent ultrasound before their first transfer.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Our study was powered (80%) to assess the primary outcome of live birth rate; the secondary outcomes included the clinical pregnancy, biochemical pregnancy, and miscarriage rates.

RESULT(S)

Only 22 of 100 patients were diagnosed with adenomyosis on the original ultrasound report. When the MUSA criteria were applied, 76 patients had at least 1 possible ultrasonographic feature of adenomyosis; all 76 patients had an interrupted junctional zone. The second most common feature of adenomyosis was a globular and/or enlarged uterus (89.4%). Adjusted modeling demonstrated that a single ultrasound feature, 2 or more features, specific features, or the location of features did not affect the live birth outcome. A per-centimeter increase in the diameter of focal lesions was significantly associated with a decrease in the odds of live birth by the factor of 0.91.

CONCLUSION(S)

To our knowledge, our study is the first to characterize adenomyosis using the MUSA criteria in the donor oocyte population. Overall, our data were reassuring in that the ultrasonographic features of adenomyosis may not impact reproductive outcomes. However, we identified that the location and size of focal lesions may be important and should be studied further.

Association of Days Alive and at Home at Day 90 After Intensive Care Unit Admission With Long-term Survival and Functional Status Among Mechanically Ventilated Patients

IMPORTANCE

Many conventional end points in randomized clinical trials of interventions for critically ill patients do not account for patient-centered concerns such as time at home, physical function, and quality of life after critical illness.

OBJECTIVE

To establish whether days alive and at home at day 90 (DAAH90) is associated with long-term survival and functional outcomes in mechanically ventilated patients.

DESIGN, SETTING, AND PARTICIPANTS

The RECOVER prospective cohort study was conducted from February 2007 to March 2014, using data from 10 intensive care units (ICUs) in Canada. Patients were included in the baseline cohort if they were aged 16 years or older and underwent invasive mechanical ventilation for 7 or more days. The follow-up cohort analyzed here comprised RECOVER patients who were alive and had functional outcomes ascertained at 3, 6, and 12 months. Secondary data analysis occurred from July 2021 to August 2022.

EXPOSURES

Composite of survival and days alive and at home at day 90 after ICU admission (DAAH90).

MAIN OUTCOMES AND MEASURES

Functional outcomes at 3, 6, and 12 months were evaluated with the Functional Independence Measure (FIM), the 6-Minute Walk Test (6MWT), the Medical Research Council (MRC) Scale for Muscle Strength, and the 36-Item Short Form Health Survey physical component summary (SF-36 PCS). Mortality was evaluated at 1 year from ICU admission. Ordinal logistic regression was used to describe the association between DAAH90 tertiles and outcomes. Cox proportional hazards regression models were used to examine the independent association of DAAH90 tertiles with mortality.

RESULTS

The baseline cohort comprised 463 patients. Their median age was 58 years (IQR, 47-68 years), and 278 patients (60.0%) were men. In these patients, Charlson Comorbidity Index score, Acute Physiology and Chronic Health Evaluation II score, ICU intervention (eg, kidney replacement therapy or tracheostomy), and ICU length of stay were independently associated with lower DAAH90. The follow-up cohort comprised 292 patients. Their median age was 57 years (IQR, 46-65 years), and 169 patients (57.9%) were men. Among patients who survived to day 90, lower DAAH90 was associated with higher mortality at 1 year after ICU admission (tertile 1 vs tertile 3: adjusted hazard ratio [HR], 0.18 [95% CI, 0.07-0.43]; P < .001). At 3 months of follow-up, lower DAAH90 was independently associated with lower median scores on the FIM (tertile 1 vs tertile 3, 76 [IQR, 46.2-101] vs 121 [IQR, 112-124.2]; P = .04), 6MWT (tertile 1 vs tertile 3, 98 [IQR, 0-239] vs 402 [IQR, 300-494]; P < .001), MRC (tertile 1 vs tertile 3, 48 [IQR, 32-54] vs 58 [IQR, 51-60]; P < .001), and SF-36 PCS (tertile 1 vs tertile 3, 30 [IQR, 22-38] vs 37 [IQR, 31-47]; P = .001) measures. Among patients who survived to 12 months, being in tertile 3 vs tertile 1 for DAAH90 was associated with higher FIM score at 12 months (estimate, 22.4 [95% CI, 14.8-30.0]; P < .001), but this association was not present for ventilator-free days (estimate, 6.0 [95% CI, -2.2 to 14.1]; P = .15) or ICU-free days (estimate, 5.9 [95% CI, -2.1 to 13.8]; P = .15) at day 28.

CONCLUSIONS AND RELEVANCE

In this study, lower DAAH90 was associated with greater long-term mortality risk and worse functional outcomes among patients who survived to day 90. These findings suggest that the DAAH90 end point reflects long-term functional status better than standard clinical end points in ICU studies and may serve as a patient-centered end point in future clinical trials.

Opioid use in older orthopedic rehabilitation inpatients: a retrospective study

BACKGROUND

While there is much evidence about pain management for orthopedic patients in the immediate perioperative setting, little is known about how opioids are used during inpatient rehabilitation, particularly in older adults. A safe upper limit of 50 mg oral morphine equivalents (OME) is frequently cited in guidelines.

AIM

The aim of this study was to characterize the dosing of opioids in an older adult population undergoing inpatient orthopedic rehabilitation (IOR).

DESIGN

Retrospective observational study.

SETTING

Inpatient units at an academic rehabilitation hospital in Toronto, Canada.

POPULATION

All adults aged ≥50 years old admitted for orthopedic rehabilitation between November 2019 and June 2021 following acute care admissions for either a surgical or non-surgical orthopedic indication.

METHODS

Participants were divided into groups of prior opioids users, new opioids users, and opioid non-users during IOR. Demographic, clinical, and medication administration data were collected through the electronic health record and manual chart review. Average daily opioid dose for the first seven days of each stay was characterized using OME. Linear regression was used to assess for variables independently associated with opioid dose.

RESULTS

A total of 643 patients undergoing orthopedic rehabilitation were included: 125 (19.4%) were prior opioid users, 416 (64.7%) were new opioid users, and 102 (15.9%) were non-users, with median age respectively of 72, 79, and 83. Median daily OME over the first week for prior users was 30.3 and for new users was 6.9. Opioid dose was inversely associated with age and admission for a non-surgical indication; it was positively associated with reported pain (as defined by day 3 pain score) and admission for knee replacement.

CONCLUSIONS

Opioids are frequently but heterogeneously used in older adults undergoing IOR. Median OME use in this cohort of older adults was substantially lower than the 50 OME threshold suggested in guidelines, particularly for new opioid users.

CLINICAL REHABILITATION IMPACT

Older adults require much lower opioid doses than younger patients. Pain management in older orthopedic rehabilitation inpatients is distinct from the perioperative setting and deserves tailored guidance, with a focus on using the lowest effective dose.

Association Between the FRAIL Scale and Postoperative Complications in Older Surgical Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Several frailty screening tools have been shown to predict mortality and complications after surgery. However, these tools were developed for in-person evaluation and cannot be used during virtual assessments before surgery. The FRAIL (fatigue, resistance, ambulation, illness, and loss of weight) scale is a brief assessment that can potentially be conducted virtually or self-administered, but its association with postoperative outcomes in older surgical patients is unknown. The objective of this systematic review and meta-analysis (SRMA) was to determine whether the FRAIL scale is associated with mortality and postoperative outcomes in older surgical patients.

METHODS

Systematic searches were conducted of multiple literature databases from January 1, 2008, to December 17, 2022, to identify English language studies using the FRAIL scale in surgical patients and reporting mortality and postoperative outcomes, including postoperative complications, postoperative delirium, length of stay, and functional recovery. These databases included Medline, Medline ePubs/In-process citations, Embase, APA (American Psychological Association) PsycInfo, Ovid Emcare Nursing, (all via the Ovid platform), Cumulative Index to Nursing and Allied Health Literature (CINAHL) EbscoHost, the Web of Science (Clarivate Analytics), and Scopus (Elsevier). The risk of bias was assessed using the quality in prognosis studies tool.

RESULTS

A total of 18 studies with 4479 patients were included. Eleven studies reported mortality at varying time points. Eight studies were included in the meta-analysis of mortality. The pooled odds ratio (OR) of 30-day, 6-month, and 1-year mortality for frail patients was 6.62 (95% confidence interval [CI], 2.80-15.61; P < .01), 2.97 (95% CI, 1.54-5.72; P < .01), and 1.54 (95% CI, 0.91-2.58; P = .11), respectively. Frailty was associated with postoperative complications and postoperative delirium, with an OR of 3.11 (95% CI, 2.06-4.68; P < .01) and 2.65 (95% CI, 1.85-3.80; P < .01), respectively. The risk of bias was low in 16 of 18 studies.

CONCLUSIONS

As measured by the FRAIL scale, frailty was associated with 30-day mortality, 6-month mortality, postoperative complications, and postoperative delirium.

Pelvic floor symptoms in cisgender women with Ehlers-Danlos syndrome: an international survey study

INTRODUCTION AND HYPOTHESIS

Ehlers-Danlos Syndrome (EDS) is a group of inherited connective tissue disorders associated with abnormal collagen, and is more prevalent in women than in men. The aim of this cross-sectional study was to characterize pelvic floor symptoms in cisgender women with EDS and to describe their impact on quality of life.

METHODS

An online questionnaire on obstetric and gynecological experiences of cisgender women with EDS was disseminated through EDS patient societies and social media. This study was a sub-analysis of the broader questionnaire and focused on pelvic floor disorders, whereby self-reported symptoms and validated questionnaires were used to assess pelvic floor symptom severity (Pelvic Floor Distress Inventory, PFDI-20), impact on quality of life (Pelvic Floor Impact Questionnaire, PFIQ-7), and sexual function (Female Sexual Function Index, FSFI-6). Groups based on age and EDS type were compared using Kruskal-Wallis and Chi-squared tests.

RESULTS

A total of 1,303 participants were included in the analysis. Pelvic floor symptom prevalence included: stress urinary incontinence in 60%, urgency urinary incontinence in 54%, fecal incontinence in 24%, and pelvic organ prolapse in 21%. Bladder symptoms were reported to be the most bothersome. The impact of prolapse symptoms on quality of life was higher in women under age 40 than in older participants (p<0.001). Pelvic pain was reported in 71%. Pain ratings were highest for dysmenorrhea, muscle and joint pain, and backache (median 7 out of 10 for each). Almost half of participants screened positive for possible sexual dysfunction and 36% reported dyspareunia more than half the time.

CONCLUSIONS

This large, observational study demonstrated that cisgender women with EDS report a high prevalence of pelvic floor symptoms that appear to be more severe than in the general population.

Comparing vitamin B2 versus 5% dextrose in water for optimal ureteric jet visualisation at the time of pelvic reconstructive surgery: A randomised controlled trial

OBJECTIVE

To compare preoperative vitamin B2 versus intraoperative cystoscopy distension using 5% dextrose in water (D5W) for ureteric jet visualisation during pelvic reconstructive surgery.

DESIGN

Double-blinded, randomised controlled trial.

SETTING

Three tertiary hospitals in Toronto, Canada.

POPULATION

Adult women undergoing pelvic reconstructive surgery.

METHODS

Patients were randomised to receive 100 mg of vitamin B2 preoperatively versus bladder distension with D5W intraoperatively.

MAIN OUTCOMES

The primary outcome was the rate of accurate detection of bilateral ureteric jets during cystoscopy. Secondary outcomes included the time elapsed until visualisation, use of intravenous furosemide or fluorescein to assist with visualisation, surgeon satisfaction, and positive urine culture 1 week after surgery.

RESULTS

The intervention was completed by 236 patients (vitamin B2 n = 117, D5W n = 119). Preoperative characteristics were similar across groups. Accurate detection of both ureteric jets was high in both groups (vitamin B2 97.4% vs. D5W 90.8%, p = 0.051). The vitamin B2 group had significantly lower use of fluorescein rescue compared with the D5W group (3.4% vs. 11.8%, respectively, p = 0.025). Surgeon satisfaction while using vitamin B2 was significantly higher (p < 0.001). There were no significant differences in the time elapsed until visualisation, the use of furosemide, or the incidence of positive urine culture at 1 week after surgery.

CONCLUSIONS

Both preoperative vitamin B2 and intraoperative cystoscopy distension with D5W are highly available and inexpensive methods to detect ureteric jets with high accuracy at the time of pelvic reconstructive surgery. Vitamin B2 was shown to have lower rates of fluorescein rescue for visualisation and higher rates of surgeon satisfaction.

Automated digital counselling with social network support as a novel intervention for patients with heart failure: protocol for randomised controlled trial

INTRODUCTION

Heart failure (HF) symptoms improve through self-care, for which adherence remains low among patients despite the provision of education for these behaviours by clinical teams. Open Access Digital Community Promoting Self-Care, Peer Support and Health Literacy (ODYSSEE-vCHAT) combines automated digital counselling with social network support to improve mortality and morbidity, engagement with self-care materials, and health-related quality of life.

METHODS AND ANALYSIS

Use of ODYSSEE-vCHAT via Internet-connected personal computer by 162 HF patients will be compared with a control condition over 22 months. The primary outcome is a composite index score of all-cause mortality, all-cause emergency department visits, and HF-related hospitalisation at trial completion. Secondary outcomes include individual components of the composite index, engagement with self-care materials, and patient-reported measures of physical and psychosocial well-being, disease management, health literacy, and substance use. Patients are recruited from tertiary care hospitals in Toronto, Canada and randomised on a 1:1 ratio to both arms of the trial. Online assessments occur at baseline (t=0), months 4, 8 and 12, and trial completion. Ordinal logistic regression analyses and generalised linear models will evaluate primary and secondary outcomes.

ETHICS AND DISSEMINATION

The trial has been approved by the research ethics boards at the University Health Network (20-5960), Sunnybrook Hospital (5117), and Mount Sinai Hospital (21-022-E). Informed consent of eligible patients occurs in person or online. Findings will be shared with key stakeholders and the public. Results will allow for the preparation of a Canada-wide phase III trial to evaluate the efficacy of ODYSSEE-vCHAT in improving clinical outcomes and raising the standard of outpatient care.

TRIAL REGISTRATION NUMBER

NCT04966104.

Utility of bile acids in large airway bronchial wash versus bronchoalveolar lavage as biomarkers of microaspiration in lung transplant recipients: a retrospective cohort study

Background

Bronchoalveolar lavage (BAL) is a key tool in respiratory medicine for sampling the distal airways. BAL bile acids are putative biomarkers of pulmonary microaspiration, which is associated with poor outcomes after lung transplantation. Compared to BAL, large airway bronchial wash (LABW) samples the tracheobronchial space where bile acids may be measurable at more clinically relevant levels. We assessed whether LABW bile acids, compared to BAL bile acids, are more strongly associated with poor clinical outcomes in lung transplant recipients.

Methods

Concurrently obtained BAL and LABW at 3 months post-transplant from a retrospective cohort of 61 lung transplant recipients were analyzed for taurocholic acid (TCA), glycocholic acid (GCA), and cholic acid by mass spectrometry and 10 inflammatory proteins by multiplex immunoassay. Associations between bile acids with inflammatory proteins and acute lung allograft dysfunction were assessed using Spearman correlation and logistic regression, respectively. Time to chronic lung allograft dysfunction and death were evaluated using multivariable Cox proportional hazards and Kaplan–Meier methods.

Results

Most bile acids and inflammatory proteins were higher in LABW than in BAL. LABW bile acids correlated with inflammatory proteins within and between sample type. LABW TCA and GCA were associated with acute lung allograft dysfunction (OR = 1.368; 95%CI = 1.036–1.806; P = 0.027, OR = 1.064; 95%CI = 1.009–1.122; P = 0.022, respectively). No bile acids were associated with chronic lung allograft dysfunction. Adjusted for risk factors, LABW TCA and GCA predicted death (HR = 1.513; 95%CI = 1.014–2.256; P = 0.042, HR = 1.597; 95%CI = 1.078–2.366; P = 0.020, respectively). Patients with LABW TCA in the highest tertile had worse survival compared to all others.

Conclusions

LABW bile acids are more strongly associated than BAL bile acids with inflammation, acute lung allograft dysfunction, and death in lung transplant recipients. Collection of LABW may be useful in the evaluation of microaspiration in lung transplantation and other respiratory diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02131-5.

What are we missing? The quality of intraoperative handover before and after introduction of a checklist

PURPOSE

Intraoperative handovers are common in anesthesia practice and are associated with increased patient morbidity and mortality. Checklists may improve transfer of information during handovers. This before-and-after study sought to examine the effect of a checklist on intraoperative handover. We hypothesized that introducing a handover checklist would improve our primary outcome of completeness of data transfer.

METHODS

From February to August 2016, anesthesia providers (residents, fellows, and consultants) at a single tertiary academic center participated in a handover study. Baseline handovers between anesthesia care providers were videotaped, analyzed, and compared with anesthetic records. An intraoperative handover checklist was then introduced, and handovers completed with it were videotaped. The completeness of handovers was compared between the baseline routine and checklist groups. The primary outcome was completeness of information transfer.

RESULTS

Sixty-seven anesthesia providers participated in the study. Use of the intraoperative handover checklist improved completeness of handover by 6% (95% confidence interval [CI], 2 to 10; P < 0.01). There was no relationship observed between the provider (consultants/fellows vs resident) of the handovers and the degree of completeness (95% CI, 3 to 8; P = 0.33). Complexity had a significant impact on the handover completeness with low or high complexity cases more completely handed over than those of medium complexity both before and after the intervention-a 6% increase for low complexity (95% CI, 1 to 11; P = 0.02) and a 9% increase for high complexity (95% CI, 3 to 14; P < 0.01).

CONCLUSION

Use of a checklist during intraoperative handovers improved completeness of data transfer. Handover checklists should be considered to improve handover completeness.

Types of clinical reasoning in a summative clerkship oral examination

INTRODUCTION

Dual-process theory characterizes clinical reasoning (CR) as Type 1 (intuitive) and Type 2 (analytical) thinking. This study examined CR on a summative clinical clerkship structured clinical oral examination (SCOE).

METHODS AND SUBJECTS

511 clinical clerks at the University of Toronto underwent SCOEs. Type 1, Type 2, and Global CR performance were compared to other internal medicine clerkship assessments using descriptive statistics and Spearman correlations.

RESULTS

Clinical clerks achieved mean marks >75% on the three clinical reasoning stations, on Type 1 and 2 CR tasks, and the overall SCOE. Performance on the SCOE CR stations correlated with each of the other clerkship assessments: written examination, inpatient, and ambulatory clinic assessments. The correlation of performance between Type 1 and Type 2 clinical reasoning tasks was statistically significant but weak (r_s = 0.28). This suggests that defined measures of Type 1 and Type 2 reasoning were indeed assessing distinct constructs.

CONCLUSION

Clinical clerks used both Type 1 and Type 2 reasoning with success. This study's characterization of Type 1 and Type 2 CR as separate domains, distinct from existing measures on the SCOE as well as the other clerkship assessments, can suggest a further addition to multimodal clerkship assessment.

Prediction of fetal death in monochorionic twin pregnancies complicated by Type-III selective fetal growth restriction

OBJECTIVE

Monochorionic diamniotic twin pregnancies complicated by Type-III selective fetal growth restriction (sFGR) are at high risk of fetal death. The aim of this study was to identify predictors of fetal death in these pregnancies.

METHODS

This was an international multicenter retrospective cohort study. Type-III sFGR was defined as fetal estimated fetal weight (EFW) of one twin below the 10^th percentile and intertwin EFW discordance of ≥ 25% in combination with intermittent absent or reversed end-diastolic flow in the umbilical artery of the smaller fetus. Predictors of fetal death were recorded longitudinally throughout gestation and assessed in univariable and multivariable logistic regression models. The classification and regression trees (CART) method was used to construct a prediction model of fetal death using significant predictors derived from the univariable analysis.

RESULTS

A total of 308 twin pregnancies (616 fetuses) were included in the analysis. In 273 (88.6%) pregnancies, both twins were liveborn, whereas 35 pregnancies had single (n = 19 (6.2%)) or double (n = 16 (5.2%)) fetal death. On univariable analysis, earlier gestational age at diagnosis of Type-III sFGR, oligohydramnios in the smaller twin and deterioration in umbilical artery Doppler flow were associated with an increased risk of fetal death, as was larger fetal EFW discordance, particularly between 24 and 32 weeks' gestation. None of the parameters identified on univariable analysis maintained statistical significance on multivariable analysis. The CART model allowed us to identify three risk groups: a low-risk group (6.8% risk of fetal death), in which umbilical artery Doppler did not deteriorate; an intermediate-risk group (16.3% risk of fetal death), in which umbilical artery Doppler deteriorated but the diagnosis of sFGR was made at or after 16 + 5 weeks' gestation; and a high-risk group (58.3% risk of fetal death), in which umbilical artery Doppler deteriorated and gestational age at diagnosis was < 16 + 5 weeks' gestation.

CONCLUSIONS

Type-III sFGR is associated with a high risk of fetal death. A prediction algorithm can help to identify the highest-risk group, which is characterized by Doppler deterioration and early referral. Further studies should investigate the potential benefit of fetal surveillance and intervention in this cohort. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Physiological Effects of Wearing N95 Respirator on Medical Staff During Prolong Work Hours in Covid-19 Departments

OBJECTIVE

The objective of the current study was to determine gas exchange abnormalities and physiological changes among healthcare workers during a 4-hour emergency department (ED) shift while wearing the N95 respirator.

METHODS

Single-center prospective observational study. Comparisons of paired measurements were performed using a non-parametric Wilcoxon matched-pairs signed-rank test. Results: Forty-one subjects were included. Prolonged N95 respirator use was associated with a significant decline in plasma pH (7.35 mmHg vs 7.34 mmHg, P = 0.02), PvO 2 (23.2 mmHg vs 18.6 mmHg, P < 0.001) and a concurrent increase in EtCO 2 (32.5 mmHg vs 38.5 mmHg, P < 0.0001). PvCO 2 and bicarbonate levels did not differ. No significant change was observed for heart rate or oxygen saturation.

CONCLUSION

Using an N95 respirator for prolonged periods by healthcare professionals may provoke changes in gas exchange. The clinical significance of these changes remains to be determined.