Unexpected and unexplained increase in death due to neurological disorders in 2012 in England and Wales: is cytomegalovirus implicated?

In early 2012 deaths (all-cause mortality) in England and Wales showed an unexpected and unexplained increase which continued for 18 months before abating. The highest percentage increase in deaths was noted to be for neurological degenerations (mainly dementia, Alzheimer's, Parkinson's). This study seeks to understand why increased deaths should focus on these conditions and if an unrecognized infectious outbreak could be implicated. Cause of death statistics for England and Wales were compared for 2012 versus 2011 as was the diagnosis for first outpatient appointment and inpatient admissions for these conditions. Deaths for dementia, Alzheimer's and Parkinson's showed a 15% increase with associated age specificity. The increase could not be explained by changes in the coding relating to cause of death. The increase coincided with increased GP referral (as first outpatient attendance) and inpatient admission for a range of neurological conditions. These increases were also observed on previous occasions of a similar event where deaths peaked in 2003 and 2008. A cascade of debility leading to immobility and institutionalization along with specific immune impairments appears to render those suffering from neurological degenerations sensitive to infectious outbreaks and more specifically to the particular agent behind these events. These and other studies point to outbreaks of a previously uncharacterized agent with the outbreak peaking in 2003, 2008 and 2012 (and in other years prior to these dates). Cytomegalovirus is a potential candidate and the necessary research to test this hypothesis is outlined.

Measles in a South African paediatric intensive care unit: again!

AIM

The aim of this study is to evaluate the outcomes of children with measles-related disease (MRD) admitted to a paediatric intensive care unit (PICU) and the effect on PICU resources and elective surgery of a recent measles epidemic.

METHODS

This was a retrospective observational study of all patients admitted to the PICU of Red Cross War Memorial Children's Hospital, Cape Town, South Africa, with MRD from January to December 2010. Patient admission characteristics, duration of PICU admission and mortality were recorded. Costs were calculated using bed days utilised and estimated daily PICU admission cost.

RESULTS

A total of 1274 children were admitted over the study period, 58 (4.6%) with MRD (median (interquartile range) age 7 (5-9) months). Pneumonia was the most common reason for admission (81%) and the main cause of mortality. Non-MRD mortality was 8.8% compared with MRD mortality of 31% (P < 0.0001). Standardised mortality for non-MRD was 0.7 versus 1.7 in MRD (P = 0.002). HIV comorbidity and being underweight for age were associated with increased mortality. Patients with MRD occupied 379 bed days with a median (interquartile range) duration of stay of 5.5 (3.0-9.0) days at an estimated overall cost of R4,813,300 (approximately $543,900). During the study period, 67 children booked for elective surgery, and 87 other referrals were refused PICU admission.

CONCLUSIONS

MRD was associated with significant morbidity and mortality, and substantial strain on scarce PICU resources.

Eszopiclone and dexmedetomidine depress ventilation in obese rats with features of metabolic syndrome

STUDY OBJECTIVES

Obesity alters the therapeutic window of sedative/hypnotic drugs and increases the probability of respiratory complications. The current experiments used an established rodent model of obesity to test the hypothesis that the sedative/hypnotic drugs eszopiclone and dexmedetomidine alter ventilation differentially in obese rats compared with lean/fit rats.

DESIGN

This study used a within-groups/between-groups experimental design.

SETTING

University of Michigan.

PARTICIPANTS

Experiments were conducted using lean/fit rats (n = 21) and obese rats (n = 21) that have features of metabolic syndrome.

INTERVENTIONS

Breathing was measured with whole-body plethysmography after systemic administration of vehicle (control), the nonbenzodiazepine, benzodiazepine site agonist eszopiclone, or the alpha-2 adrenergic receptor agonist dexmedetomidine.

MEASUREMENTS AND RESULTS

Data were analyzed using two-way analysis of variance and appropriate post hoc comparisons. At baseline, the obese/metabolic syndrome rats had increased respiratory rates (21.6%), lower tidal volumes/body weight (-24.1%), and no differences in minute ventilation compared to lean/fit rats. In the obese rats, respiratory rate was decreased by dexmedetomidine (-29%), but not eszopiclone. In the lean and the obese rats, eszopiclone decreased tidal volume (-12%). Both sedative/hypnotic drugs caused a greater decrease in minute ventilation in the obese (-26.3%) than lean (-18%) rats. Inspiratory flow rate (VT / TI) of the obese rats was decreased by dexmedetomidine (-10.6%) and eszopiclone (-18%). Duty cycle (TI / TTOT) in both rat lines was decreased by dexmedetomidine (-16.5%) but not by eszopiclone.

CONCLUSIONS

Dexmedetomidine, in contrast to eszopiclone, decreased minute ventilation in the obese/metabolic syndrome rats by depressing both duty cycle and inspiratory flow rate. The results show for the first time that the obese phenotype differentially modulates the respiratory effects of eszopiclone and dexmedetomidine. These differences in breathing are consistent with previously documented differences in sleep between lean/fit and obese rats. These findings also encourage future studies of obese/metabolic syndrome rats that quantify the effect of sedative/hypnotic drugs on respiratory mechanics as well as hypoxic and hypercapnic ventilatory responses. Continued findings of favorable homology between obese humans and rodents will support the interpretation that these obese rats offer a unique animal model for mechanistic studies.

Assessment of limb muscle strength in critically ill patients: a systematic review

OBJECTIVES

To determine the reliability of volitional and nonvolitional limb muscle strength assessment in critically ill patients and to provide guidelines for the implementation of limb muscle strength assessment this population.

DATA SOURCES

The following computerized bibliographic databases were searched with MeSH terms and keywords or combinations: MEDLINE through PubMed and Embase through Embase.com.

STUDY SELECTION

Articles were screened by two independent reviewers. Included studies were all performed in humans and were original articles. The research population exists of adult, critically ill patients or ICU survivors of either sex, and those admitted to a medical, surgical, respiratory, or mixed ICU. A study was included if reliability of muscle strength measurements was determined in this population.

DATA EXTRACTION

Data on baseline characteristics (country, study population, eligibility, age, setting and method, and equipment of limb muscle strength assessment) and reliability scores were obtained by two independent reviewers.

DATA SYNTHESIS

Data of six observational studies were analyzed. Interrater reliability of the Medical Research Council scale for individual muscle groups varied from "fair" or "substantial" (weighted κ, 0.23-0.64) to "very good" agreement (weighted κ, 0.80-0.96). Interrater reliability of the Medical Research Council-sum score was found to be very good in all four studies (intraclass correlation coefficients, 0.86-0.99 or Pearson product moment correlation coefficient = 0.96). Interrater reliability of handheld dynamometry was comparable between two studies (intraclass correlation coefficients, 0.62-0.96). Interrater reliability of handgrip dynamometry was very good in two studies (intraclass correlation coefficients, 0.89-0.97). Intrarater reliability of handheld dynamometry and handgrip dynamometry was assessed in one study, and results were very good (intraclass correlation coefficients > 0.81). No studies were obtained on reliability of nonvolitional muscle strength assessment.

CONCLUSIONS

Voluntary muscle strength measurement has proven reliable in critically ill patients provided that strict guidelines on adequacy and standardized test procedures and positions are followed.

Consumption of Cisatracurium in different age groups, using a closed loop computer controlled system

Background

We devised this study to quantify the effect of age on the consumption of cisatracurium under general anaesthesia, using a computer controlled closed loop infusion system. We further investigated this effect on, sufentanil and propofol consumption.

Methods

74 patients of physical status I and II, requiring general anaesthesia for elective abdominal surgery, were assigned to three groups. Patients in group 1 were aged from 20 to 45, group 2 were from 46 to 64, and group 3 above 65 years old. General Anesthesia was maintained with propofol and muscle paralysis was maintained using a closed-loop computer controlled infusion of cisatracurium. For analgesia, intermittent bolus of sufentanil 10 μg was given.

Results

Cisatracurium consumption in group 1, 2 and 3 were 1.8 ± 0.3, 1.6 ± 0.4 and 1.3 ± 0.4 μg/kg/min respectively. There was significant difference of cisatracurium consumption between group 1 and 3 (P = 0.002), and the consumption of cisatracurium in group 3 was less as compared with group 2 (P = 0.04). The average recovery index of patients in group 1, 2 and 3 were 8.8 ± 2.6, 11.5 ± 2.9 and 12.7 ± 2.5 minutes respectively. There were difference between group 1 and 2 (P = 0.02). As compared with group 1, the recovery index was still longer in group 3 (P = 0.001). Patients in group 1, 2 and 3 consumed an average sufentanil 0.4 ± 0.1, 0.4 ± 0.1 and 0.3 ± 0.1 μg/kg/hr, respectively. There were statistical significant between group 1 and 3 (P < 0.0001), and the same trend was found between group 2 and 3 (P = 0.03). The Consumption of propofol in group 1, 2 and 3 were 5.1 ± 0.4, 4.3 ± 0.6 and 3.1 ± 0.5 mg/kg/hr. The difference in the propofol consumption was found statistically significant when comparing between any two groups.

Conclusion

We concluded that the sensitivity of anesthetic agents increased with age. Less medication was required to achieve a desirable effect in older patients specially those above 65 years of age, and the drug effect was prolonged.

Trial registration

ClinicalTrials.gov Identifier: NCT01785446.

Comparing the monitoring of patients transferred from a critical care unit to hospital wards at after-hours with day transfers: an exploratory, prospective cohort study

AIMS

To investigate possible factors related to patient monitoring to explain the higher mortality rates associated with after-hours transfers compared with daytime transfers from critical care units to the wards.

BACKGROUND

International research suggests that patients transferred from critical care units after-hours have a higher mortality rate than transfers during daytime, although the reasons remain unknown.

DESIGN

A prospective exploratory study.

METHODS

Twenty-nine patients transferred from a UK critical care unit to a ward within the same hospital after-hours for 10 weeks beginning April 2009 were compared with 29 transfers during daytime hours matched on potentially confounding characteristics. UK Critical Care Unit transfer guidelines have remained unchanged since data collection. Outcomes were as follows: (i) frequency of nursing observations; (ii) time periods from transfer to first medical review; (iii) time period from transfer to first clinical observations; (iv) frequency of transfer to an inappropriate ward; (v) delayed transfers from Critical Care Unit to ward.

RESULTS

Using Wilcoxon's Rank test (two tail) to compare paired data from the matched groups, observations were recorded significantly less frequently within the first 12 hours for after-hours transfers. Time from transfer to first clinical observations was significantly longer for after-hour transfer patients. The delay from when the patient was ready for ward care and actual transfer was also longer for the after-hours transfer group.

CONCLUSIONS

Surveillance differences, including time to the first set of observations and frequency of observations in the first 12 hours, are potential factors that may explain the differential mortality associated with after-hours transfers.

Clinical impact of sacroplasty on patient mobility

PURPOSE

To evaluate the effect of sacroplasty on patient mobility and pain when performed as a treatment for sacral insufficiency fractures.

MATERIALS AND METHODS

Imaging with computed tomography (CT), magnetic resonance imaging, or bone scan confirmed the diagnosis of sacral insufficiency fractures. Baseline clinical mobility scale (CMS) score and visual analog scale (VAS) pain score were recorded. Sacroplasty was performed under CT guidance. Follow-up CMS and VAS scores were assessed at 4, 24, and 48 weeks.

RESULTS

Eighteen elderly patients (age 80 y ± 8.5; 17 women) were treated. Repeated-measures analysis of variance was conducted to assess changes in CMS and VAS scores over time. Pairwise comparisons revealed a significant increase in average CMS score between baseline and all three follow-up points-4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)-indicating improvement in mobility over time. Pairwise comparisons revealed significant differences in mean VAS scores between baseline and all three follow-up time points-4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)-indicating improvement in overall pain level over time.

CONCLUSIONS

Treatment with CT-guided sacroplasty for sacral insufficiency fractures in this elderly population resulted in significant improvement in patient mobility.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists

BACKGROUND AND OBJECTIVES

residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution.

METHODS

This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate > 20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study.

RESULTS

The incidence of PORC was 43% (n = 179) for TOFR < 0.9, and 15% (n = 61) for TOFR < 0.7. The incidence of TOFR < 0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR < 0.9 was found in 46% (n = 126) of the patients receiving neostigmine.

CONCLUSIONS

When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

Trazodone increases the respiratory arousal threshold in patients with obstructive sleep apnea and a low arousal threshold

STUDY OBJECTIVES

The effect of common sedatives on upper airway physiology and breathing during sleep in obstructive sleep apnea (OSA) has been minimally studied. Conceptually, certain sedatives may worsen OSA in some patients. However, sleep and breathing could improve with certain sedatives in patients with OSA with a low respiratory arousal threshold. This study aimed to test the hypothesis that trazodone increases the respiratory arousal threshold in patients with OSA and a low arousal threshold. Secondary aims were to examine the effects of trazodone on upper airway dilator muscle activity, upper airway collapsibility, and breathing during sleep.

DESIGN

Patients were studied on 4 separate nights according to a within-subjects cross-over design.

SETTING

Sleep physiology laboratory.

PATIENTS

Seven patients with OSA and a low respiratory arousal threshold.

INTERVENTIONS

In-laboratory polysomnograms were obtained at baseline and after 100 mg of trazodone was administered, followed by detailed overnight physiology experiments under the same conditions. During physiology studies, continuous positive airway pressure was transiently lowered to measure arousal threshold (negative epiglottic pressure prior to arousal), dilator muscle activity (genioglossus and tensor palatini), and upper airway collapsibility (Pcrit).

MEASUREMENTS AND RESULTS

Trazodone increased the respiratory arousal threshold by 32 ± 6% (-11.5 ± 1.4 versus -15.3 ± 2.2 cmH2O, P < 0.01) but did not alter the apnea-hypopnea index (39 ± 12 versus 39 ± 11 events/h sleep, P = 0.94). Dilator muscle activity and Pcrit also did not systematically change with trazodone.

CONCLUSIONS

Trazodone increases the respiratory arousal threshold in patients with obstructive sleep apnea and a low arousal threshold without major impairment in dilator muscle activity or upper airway collapsibility. However, the magnitude of change in arousal threshold was insufficient to overcome the compromised upper airway anatomy in these patients.

Clinical and molecular genetics of the phosphodiesterases (PDEs)

Cyclic nucleotide phosphodiesterases (PDEs) are enzymes that have the unique function of terminating cyclic nucleotide signaling by catalyzing the hydrolysis of cAMP and GMP. They are critical regulators of the intracellular concentrations of cAMP and cGMP as well as of their signaling pathways and downstream biological effects. PDEs have been exploited pharmacologically for more than half a century, and some of the most successful drugs worldwide today affect PDE function. Recently, mutations in PDE genes have been identified as causative of certain human genetic diseases; even more recently, functional variants of PDE genes have been suggested to play a potential role in predisposition to tumors and/or cancer, especially in cAMP-sensitive tissues. Mouse models have been developed that point to wide developmental effects of PDEs from heart function to reproduction, to tumors, and beyond. This review brings together knowledge from a variety of disciplines (biochemistry and pharmacology, oncology, endocrinology, and reproductive sciences) with emphasis on recent research on PDEs, how PDEs affect cAMP and cGMP signaling in health and disease, and what pharmacological exploitations of PDEs may be useful in modulating cyclic nucleotide signaling in a way that prevents or treats certain human diseases.

The combination of haloperidol, dexamethasone, and ondansetron for prevention of postoperative nausea and vomiting in laparoscopic sleeve gastrectomy: a randomized double-blind trial

BACKGROUND

Many patients may experience postoperative nausea and vomiting (PONV) following laparoscopic sleeve gastrectomy (LSG). We evaluated the efficacy of the combination of haloperidol, dexamethasone, and ondansetron for prevention of PONV after LSG.

METHODS

Ninety patients were included in this prospective, randomized, double-blinded, three-arm study (group O: ondansetron 8 mg; group DO: dexamethasone 8 mg and ondansetron 8 mg; group HDO: haloperidol 2 mg, dexamethasone 8 mg, and ondansetron). Nausea, vomiting, rescue antiemetic use, morphine consumption, adverse events, and volume of intravenous fluids infused were recorded at regular intervals for 36 h postoperatively.

RESULTS

The incidence of nausea was lower 0-2 h postoperatively in group HDO compared to group O (23.7 versus 56.7 %, p = 0.016) and at 12-24 h postoperatively was lower in group HDO (23.3 %) and group DO (26.7 %) compared to group O (60 %) (p = 0.008 and p = 0.009, respectively). At 0-36 h postoperatively, nausea was lower in group HDO compared to group O (53.3 versus 86.7 %, p = 0.013). Vomiting at 0-36 h postoperatively was lower in group HDO compared to group O (20 versus 53.3 %, p = 0.015). Rescue antiemetic drug and morphine consumption were less used in group HDO compared to group O (p <0.01). The volume of fluids infused in group O was approximately 1 l greater than in group HDO (p = 0.026).

CONCLUSION

The combination of haloperidol, dexamethasone, and ondansetron reduced PONV and the necessity of rescue antiemetics and also reduced morphine consumption and the volume of fluids infused postoperatively.

Measurement of endotracheal tube secretions volume by micro computed tomography (MicroCT) scan: an experimental and clinical study

BACKGROUND

Biofilm accumulates within the endotracheal tube (ETT) early after intubation. Contaminated secretions in the ETT are associated with increased risk for microbial dissemination in the distal airways and increased resistance to airflow. We evaluated the effectiveness of micro computed tomography (MicroCT) for the quantification of ETT inner volume reduction in critically ill patients.

METHODS

We injected a known amount of gel into unused ETT to simulate secretions. We calculated the volume of gel analyzing MicroCT scans for a length of 20 cm. We then collected eleven ETTs after extubation of critically ill patients, recording clinical and demographical data. We assessed the amount of secretions by MicroCT and obtained ETT microbiological cultures.

RESULTS

Gel volumes assessed by MicroCT strongly correlated with injected gel volumes (p < 0.001, r2 = 0.999).MicroCT revealed the accumulation of secretions on all the ETTs (median 0.154, IQR:0.02-0.837 mL), corresponding to an average cross-sectional area reduction of 1.7%. The amount of secretions inversely correlated with patients' age (p = 0.011, rho = -0.727) but not with days of intubation, SAPS2, PaO2/FiO2 assessed on admission. Accumulation of secretions was higher in the cuff region (p = 0.003). Microbial growth occurred in cultures from 9/11 ETTs, and did not correlate with secretions amount. In 7/11 cases the same microbes were identified also in tracheal aspirates.

CONCLUSIONS

MicroCT appears as a feasible and precise technique to measure volume of secretions within ETTs after extubation. In patients, secretions tend to accumulate in the cuff region, with high variability among patients.

[Sheehan's syndrome after obstetric hemorrhage]

Sheehan's syndrome is described as panhypopituitarism secondary to a pituitary hypoperfusion during or just after obstetric hemorrhage. Advances in obstetric care make this syndrome quite unusual, but some cases are reported in underdeveloped countries. Clinical presentation may change depending on the severity of the hormone deficiencies. The diagnosis is clinical, but abnormalities are observed in the magnetic resonance in up to 70% of patients. We present a case of a woman with hypotension, hypothermia and edemas in relation to a previous massive postpartum hemorrhage. Failure in lactation was the clue to the diagnosis. A review of its main features, its diagnosis and treatment in the current literature is also presented.

Caffeine accelerates recovery from general anesthesia

General anesthetics inhibit neurotransmitter release from both neurons and secretory cells. If inhibition of neurotransmitter release is part of an anesthetic mechanism of action, then drugs that facilitate neurotransmitter release may aid in reversing general anesthesia. Drugs that elevate intracellular cAMP levels are known to facilitate neurotransmitter release. Three cAMP elevating drugs (forskolin, theophylline, and caffeine) were tested; all three drugs reversed the inhibition of neurotransmitter release produced by isoflurane in PC12 cells in vitro. The drugs were tested in isoflurane-anesthetized rats. Animals were injected with either saline or saline containing drug. All three drugs dramatically accelerated recovery from isoflurane anesthesia, but caffeine was most effective. None of the drugs, at the concentrations tested, had significant effects on breathing rates, O2 saturation, heart rate, or blood pressure in anesthetized animals. Caffeine alone was tested on propofol-anesthetized rats where it dramatically accelerated recovery from anesthesia. The ability of caffeine to accelerate recovery from anesthesia for different chemical classes of anesthetics, isoflurane and propofol, opens the possibility that it will do so for all commonly used general anesthetics, although additional studies will be required to determine whether this is in fact the case. Because anesthesia in rodents is thought to be similar to that in humans, these results suggest that caffeine might allow for rapid and uniform emergence from general anesthesia in human patients.

Respiratory complications in the pediatric postanesthesia care unit

This article focuses on common respiratory complications in the postanesthesia care unit (PACU). Approximately 1 in 10 children present with respiratory complications in the PACU. The article highlights risk factors and at-risk populations. The physiologic and pathophysiologic background and causes for respiratory complications in the PACU are explained and suggestions given for an optimization of the anesthesia management in the perioperative period. Furthermore, the recognition, prevention, and treatment of these complications in the PACU are discussed.

The 2011 ACGME standards: impact reported by graduating residents on the working and learning environment

OBJECTIVE

Changes in Accreditation Council for Graduate Medical Education (ACGME) requirements, including duty hours, were implemented in July 2011. This study examines graduating pediatrics residents' perception of the impact of these standards.

METHODS

A national, random sample survey of 1000 graduating pediatrics residents was performed in 2012; a total of 634 responded. Residents were asked whether 9 areas of their working and learning environments had changed with the 2011 standards. Three combined change scores were created for: 1) patient care, 2) senior residents, and 3) program effects, with scores ranging from -1 (worse) to 1 (improved). Respondents were also asked about hours slept and perceived change in hours slept.

RESULTS

Most respondents felt that several areas had worsened, including continuity of care and senior resident workload, or not changed, including supervision and sleep. Mean change scores that included all study variables except those related to sleep all showed worsening: patient care (mean -0.37); senior residents (mean -0.36), and program effects (mean -0.06) (P < .01). Respondents reported a mean of 6.7 hours of sleep in a 24-hour period, with the majority (71%) reporting this amount of sleep has not changed with the 2011 standards.

CONCLUSIONS

In the year after implementation of the 2011 ACGME standards, graduating pediatrics residents report no changes or a worsening in multiple components of their working and learning environments, as well as no changes in the amount of sleep they receive each day.

Does relative value unit-based compensation shortchange the acute care surgeon?

BACKGROUND

Studies have demonstrated that relative value units (RVUs) do not appropriately reflect cognitive effort or time spent in patient care, but RVU continues to be used as a standardized system to track productivity. It is unknown how well RVU reflects the effort of acute care surgeons. Our objective was to determine if RVUs adequately reflect increased surgeon effort required to treat emergent versus elective patients receiving similar procedures.

METHODS

A retrospective analysis using The American College of Surgeons' National Surgical Quality Improvement Program 2011 data set was conducted. The control group consisted of patients undergoing elective colectomy, hernia repair, or biliary procedures as identified by Current Procedural Terminology. Comparison was made to emergent cases after being stratified to laparoscopic or open technique. Generalized linear models and logistic regression were used to assess specific outcomes, controlling for demographics and comorbidities of interest. The RVUs, operative time, and length of stay (LOS) were primary variables, with major/minor complications, mortality, and readmissions being evaluated as the relevant outcomes.

RESULTS

A total of 442,149 patients in the National Surgical Quality Improvement Program underwent one of the operative procedures of interest; 27,636 biliary (91% laparoscopic; 8.5% open), 28,722 colorectal (40.3% laparoscopic, 59.7% open), and 31,090 hernia (26.6% laparoscopic, 73.4% open) operations. Emergent procedures were found to have average RVU values that were identical to their elective case counterparts. Complication rates were higher and LOS were increased in emergent cases. Odds ratios for complications and readmissions in emergent cases were twice those of elective procedures. Mortality was skewed toward emergent cases.

CONCLUSION

Our data indicate that the emergent operative management for various procedures is similarly valued despite increased LOS, more complications, higher mortality risk, and subsequently increased physician attention. Our findings suggest that the RVU system for acute care surgeons may need to be reevaluated to better capture the additional work involved in emergent patient care.

Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer?

BACKGROUND

The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has never been applied as a prognostic measure after trauma. The aim of our study was to identify hospital admission factors predicting discharge disposition in geriatric trauma patients.

METHODS

We performed a 1-year prospective study at our Level 1 trauma center. All trauma patients 65 years or older were enrolled. FI was calculated using 50 preadmission variables. Patient's discharge disposition was dichotomized as favorable outcome (discharge home, rehabilitation) or unfavorable outcomes (discharge to skilled nursing facility, death). Multivariate logistic regression was performed to identify factors that predict unfavorable outcome.

RESULTS

A total of 100 patients were enrolled, with a mean (SD) age of 76.51 (8.5) years, 59% being males, median Injury Severity Score (ISS) of 14 (range, 9-18), median head Abbreviated Injury Scale (h-AIS) score of 2 (2-3), and median Glasgow Coma Scale (GCS) score of 13 (12-15). Of the patients, 69% had favorable outcome, and 31% had unfavorable outcome. On univariate analysis, FI was found to be a significant predictor for unfavorable outcome (odds ratio, 1.8; 95% confidence interval, 1.2-2.3). After adjusting for age, ISS, and GCS score in a multivariate regression model, FI remained a strong predictor for unfavorable discharge disposition (odds ratio, 1.3; 95% confidence interval, 1.1-1.8).

CONCLUSION

The concept of frailty can be implemented in geriatric trauma patients with similar results as those of nontrauma and nonsurgical patients. FI is a significant predictor of unfavorable discharge disposition and should be an integral part of the assessment tools to determine discharge disposition for geriatric trauma patients.

LEVEL OF EVIDENCE

Prognostic study, level II.

Consensus guidelines for the management of postoperative nausea and vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

Negative pressure pulmonary edema after reversing rocuronium-induced neuromuscular blockade by sugammadex

Negative pressure pulmonary edema (NPPE) is a rare complication that accompanies general anesthesia, especially after extubation. We experienced a case of negative pressure pulmonary edema after tracheal extubation following reversal of rocuronium-induced neuromuscular blockade by sugammadex. In this case, the contribution of residual muscular block on the upper airway muscle as well as large inspiratory forces created by the respiratory muscle which has a low response to muscle relaxants, is suspected as the cause.

Determinants of ventilator associated pneumonia and its impact on prognosis: A tertiary care experience

Background:

Ventilator associated pneumonia (VAP) is a major cause of poor outcome among patients in the intensive care units (ICU) world-wide. We sought to determine the factors associated with development of VAP and its prognosis among patients admitted to different ICUs of a Tertiary Care Hospital in India.

Methodology:

We did a matched case control study during October 2009 to May 2011 among patients, ≥18 years with mechanical ventilation. Patients who developed pneumonia after 48 h of ventilation were selected in the case group and those who did not develop pneumonia constituted the control group. Patients’ history, clinical and laboratory findings were recorded and analyzed.

Results:

There were 52 patients included in each group. Among cases, early onset ventilator associated pneumonia (EVAP) occurred in 27 (51.9%) and late onset ventilator associated pneumonia (LVAP) in 25 (48.1%). Drug resistant organisms contributed to 76.9% of VAP. Bacteremia (P = 0.002), prior use of steroid/immunosuppressant (P = 0.004) and re-intubations (P = 0.021) were associated with the occurrence of VAP. The association of Acinetobacter (P = 0.025) and Pseudomonas (P = 0.047) for LVAP was found to be statistically significant. Duration of mechanical ventilation (P = 0.001), ICU stay (P = 0.049) and requirement for tracheostomy (P = 0.043) were significantly higher in VAP. Among each case and control groups, 19 (36.5%) expired.

Conclusion:

We found a higher proportion of LVAP compared with EVAP and a higher proportion of drug resistant organisms among LVAP, especially Pseudomonas and Acinetobacter. Drug resistant Pseudomonas was associated with higher mortality.

Addressing the Mandate for Hand-off Education

The Accreditation Council for Graduate Medical Education requires that residency programs teach residents about handoffs and ensure their competence in this communication skill. Development of hand-off curricula for anesthesia residency programs is hindered by the paucity of evidence regarding how to conduct, teach, and evaluate handoffs in the various settings where anesthesia practitioners work. This narrative review draws from literature in anesthesia and other disciplines to provide recommendations for anesthesia resident hand-off curriculum development and evaluation.

Renal transplantation: relationship between hospital/surgeon volume and postoperative severe sepsis/graft-failure. a nationwide population-based study

BACKGROUND AND OBJECTS: We explored the relationship between hospital/surgeon volume and postoperative severe sepsis/graft-failure (including death).

METHODS

The Taiwan National Health Insurance Research Database claims data for all patients with end-stage renal disease patients who underwent kidney transplantation between January 1, 1999, and December 31, 2007, were reviewed. Surgeons and hospitals were categorized into two groups based on their patient volume. The two primary outcomes were severe sepsis and graft failure (including death). The logistical regressions were done to compute the Odds ratios (OR) of outcomes after adjusting for possible confounding factors. Kaplan-Meier analysis was used to calculate the cumulative survival rates of graft failure after kidney transplantation during follow-up (1999-2008).

RESULTS

The risk of developing severe sepsis in a hospital in which surgeons do little renal transplantation was significant (odds ratio [OR]; p = 0.0115): 1.65 times (95% CI: 1.12-2.42) higher than for a hospital in which surgeons do many. The same trend was true for hospitals with a low volume of renal transplantations (OR = 2.39; 95% CI: 1.62-3.52; p < 0.0001). The likelihood of a graft failure (including death) within one year for the low-volume surgeon group was 3.1 times higher than for the high-volume surgeon group (p < 0.0001); the trend was similar for hospital volume. Female patients had a lower risk than did male patients, and patients ≥ 55 years old and those with a higher Charlson comorbidity index score, had a higher risk of severe sepsis.

CONCLUSIONS

We conclude that the risk of severe sepsis and graft failure (including death) is higher for patients treated in hospitals and by surgeons with a low volume of renal transplantations. Therefore, the health authorities should consider exporting best practices through educational outreach and regulation and then providing transparent information for public best interest.

Efficiency of a pneumatic device in controlling cuff pressure of polyurethane-cuffed tracheal tubes: a randomized controlled study

Background

The primary objective of this study was to determine the efficiency of a pneumatic device in controlling cuff pressure (P_cuff) in patients intubated with polyurethane-cuffed tracheal tubes. Secondary objectives were to determine the impact of continuous control of P_cuff, and cuff shape on microaspiration of gastric contents.

Methods

Prospective randomized controlled study. All patients requiring intubation and mechanical ventilation ≥48 h were eligible. The first 32 patients were intubated with tapered polyurethane-cuffed, and the 32 following patients were intubated with cylindrical polyurethane-cuffed tracheal tubes. Patients randomly received 24 h of continuous control of P_cuff using a pneumatic device (Nosten®), and 24 h of routine care of P_cuff using a manometer. Target P_cuff was 25 cmH₂O. P_cuff was continuously recorded, and pepsin was quantitatively measured in all tracheal aspirates during these periods.

Results

The pneumatic device was efficient in controlling P_cuff (med [IQ] 26 [24, 28] vs 22 [20, 28] cmH₂O, during continuous control of P_cuff and routine care, respectively; p = 0.017). In addition, percentage of patients with underinflation (31% vs 68%) or overinflation (53% vs 100%) of tracheal cuff, and percentage of time spent with underinflation (0.9 [0, 17] vs 14% [4, 30]) or overinflation (0 [0, 2] vs 32% [9, 54]) were significantly (p < 0.001) reduced during continuous control of P_cuff compared with routine care.

No significant difference was found in microaspiration of gastric content between continuous control of P_cuff compared with routine care, or between patients intubated with tapered compared with cylindrical polyurethane-cuffed tracheal tubes.

Conclusion

The pneumatic device was efficient in controlling P_cuff in critically ill patients intubated with polyurethane-cuffed tracheal tubes.

Trial registration

The Australian New Zealand Clinical Trials Registry (NCT01351259)

An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation

BACKGROUND

Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope.

PURPOSE

The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field.

METHODS

A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members.

RESULTS

An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed.

CONCLUSIONS

The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

The promise of wearable activity sensors to define patient recovery

The recent emergence of mobile health--the use of mobile telecommunication and wireless devices to improve health outcomes, services, and research--has inspired a patient-centric approach to monitor health metrics. Sensors embedded in wearable devices are utilized to acquire greater self-knowledge by tracking basic parameters such as blood pressure, heart rate, and body temperature as well as data related to exercise, diet, and psychological state. To that end, recent studies on utilizing wireless fitness activity trackers to monitor and promote functional recovery in patients suggest that collecting up-to-date performance data could help patients regain functional independence and help hospitals determine the appropriate length of stay for a patient. This manuscript examines existing functional assessment scales, discusses the use of activity tracking sensors in evaluating functional independence, and explores the growing application of wireless technology in measuring and promoting functional recovery.