1
|
Vail EA, Chun RH, Tsai SD, Souter MJ, Lele AV. Anesthetic Management of Organ Recovery Procedures: Opportunities to Increase Clinician Engagement and Disseminate Evidence-based Practice. J Neurosurg Anesthesiol 2024; 36:174-176. [PMID: 37000806 DOI: 10.1097/ana.0000000000000915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/18/2023] [Indexed: 04/01/2023]
Affiliation(s)
| | - Rebekah H Chun
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Michael J Souter
- Departments of Anesthesiology and Pain Medicine and Neurological Surgery University of Washington, Seattle, WA
| | - Abhijit V Lele
- Departments of Anesthesiology and Pain Medicine and Neurological Surgery University of Washington, Seattle, WA
| |
Collapse
|
2
|
Kohn R, Ashana DC, Vranas KC, Viglianti EM, Hauschildt K, Chen C, Vail EA, Moroz L, Gershengorn HB. The Association of Pregnancy With Outcomes Among Critically Ill Reproductive-Aged Women: A Propensity Score-Matched Retrospective Cohort Analysis. Chest 2024:S0012-3692(24)00400-8. [PMID: 38513965 DOI: 10.1016/j.chest.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/04/2024] [Accepted: 03/16/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The maternal mortality rate in the United States is unacceptably high. However, the relative contribution of pregnancy to these outcomes is unknown. Studies comparing outcomes among pregnant vs nonpregnant critically ill patients show mixed results and are limited by small sample sizes. RESEARCH QUESTION What is the association of pregnancy with critical illness outcomes? STUDY DESIGN AND METHODS We performed a retrospective cohort study of women 18 to 55 years of age who received invasive mechanical ventilation (MV) on hospital day 0 or 1 or who demonstrated sepsis on admission (infection with organ failure) discharged from Premier Healthcare Database hospitals from 2008 through 2021. The exposure was pregnancy. The primary outcome was in-hospital mortality. We created propensity scores for pregnancy (using patient and hospital characteristics) and performed 1:1 propensity score matching without replacement within age strata (to ensure exact age matching). We performed multilevel multivariable mixed-effects logistic regression for propensity-matched pairs with pair as a random effect. RESULTS Three thousand ninety-three pairs were included in the matched MV cohort, and 13,002 pairs were included in the sepsis cohort. The characteristics of both cohorts were well balanced (all standard mean differences, < 0.1). Among matched pairs, unadjusted mortality was 8.0% vs 13.8% for MV and 1.4% vs 2.3% for sepsis among pregnant and nonpregnant patients, respectively. In adjusted regression, pregnancy was associated with lower odds of in-hospital mortality (MV: OR, 0.50; 95% CI, 0.41-0.60; P < .001; sepsis: OR, 0.52; 95% CI, 0.40-0.67; P < .001). INTERPRETATION In this large US cohort, critically ill pregnant women receiving MV or with sepsis showed better survival than propensity score-matched nonpregnant women. These findings must be interpreted in the context of likely residual confounding.
Collapse
Affiliation(s)
- Rachel Kohn
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA.
| | | | - Kelly C Vranas
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA; Department of Medicine, Oregon Health & Science University, Portland, OR; Center to Improve Veteran Involvement in Care, Portland, OR
| | - Elizabeth M Viglianti
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI; Department of Internal Medicine, VA Ann Arbor, Ann Arbor, MI
| | - Katrina Hauschildt
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Catherine Chen
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Emily A Vail
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Leslie Moroz
- Department of Obstetrics and Gynecology, Yale University, New Haven, CT
| | - Hayley B Gershengorn
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL; Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| |
Collapse
|
3
|
Vail EA, Feng R, Sieber F, Carson JL, Ellenberg SS, Magaziner J, Dillane D, Marcantonio ER, Sessler DI, Ayad S, Stone T, Papp S, Donegan D, Mehta S, Schwenk ES, Marshall M, Jaffe JD, Luke C, Sharma B, Azim S, Hymes R, Chin KJ, Sheppard R, Perlman B, Sappenfield J, Hauck E, Tierney A, Horan AD, Neuman MD. Long-term Outcomes with Spinal versus General Anesthesia for Hip Fracture Surgery: A Randomized Trial. Anesthesiology 2024; 140:375-386. [PMID: 37831596 DOI: 10.1097/aln.0000000000004807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
BACKGROUND The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated with better long-term survival and functional recovery than general anesthesia. METHODS A prespecified analysis was conducted of long-term outcomes of a completed randomized superiority trial that compared spinal anesthesia versus general anesthesia for hip fracture repair. Participants included previously ambulatory patients 50 yr of age or older at 46 U.S. and Canadian hospitals. Patients were randomized 1:1 to spinal or general anesthesia, stratified by sex, fracture type, and study site. Outcome assessors and investigators involved in the data analysis were masked to the treatment arm. Outcomes included survival at up to 365 days after randomization (primary); recovery of ambulation among 365-day survivors; and composite endpoints for death or new inability to ambulate and death or new nursing home residence at 365 days. Patients were included in the analysis as randomized. RESULTS A total of 1,600 patients were enrolled between February 12, 2016, and February 18, 2021; 795 were assigned to spinal anesthesia, and 805 were assigned to general anesthesia. Among 1,599 patients who underwent surgery, vital status information at or beyond the final study interview (conducted at approximately 365 days after randomization) was available for 1,427 (89.2%). Survival did not differ by treatment arm; at 365 days after randomization, there were 98 deaths in patients assigned to spinal anesthesia versus 92 deaths in patients assigned to general anesthesia (hazard ratio, 1.08; 95% CI, 0.81 to 1.44, P = 0.59). Recovery of ambulation among patients who survived a year did not differ by type of anesthesia (adjusted odds ratio for spinal vs. general, 0.87; 95% CI, 0.67 to 1.14; P = 0.31). Other outcomes did not differ by treatment arm. CONCLUSIONS Long-term outcomes were similar with spinal versus general anesthesia. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rui Feng
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Derek Dillane
- Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Trevor Stone
- Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven Papp
- Division of Orthopedics, Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada
| | - Derek Donegan
- Department of Orthopedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Samir Mehta
- Department of Orthopedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mitchell Marshall
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York
| | - J Douglas Jaffe
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Charles Luke
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Balram Sharma
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Syed Azim
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - Robert Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Ki-Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Richard Sheppard
- Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut
| | | | - Joshua Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Ellen Hauck
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Ann Tierney
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Annamarie D Horan
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
4
|
Bosch NA, Vail EA, Law AC, Homer-Bouthiette C, Walkey AJ, Moitra VK. Practice Patterns and Outcomes of Potassium Repletion Thresholds during Critical Illness. Ann Am Thorac Soc 2024; 21:456-463. [PMID: 38134433 PMCID: PMC10913769 DOI: 10.1513/annalsats.202308-750oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/20/2023] [Indexed: 12/24/2023] Open
Abstract
Rationale: Potassium repletion is common in critically ill patients. However, practice patterns and outcomes related to different intensive care unit (ICU) potassium repletion strategies are unclear. Objectives: 1) Describe potassium repletion practices in critically ill adults; 2) compare the effectiveness of potassium repletion strategies; and 3) compare effectiveness and safety of specific potassium repletion thresholds on patient outcomes. Methods: This was a retrospective analysis of the PINC AI Healthcare Database (2016-2022), including all critically ill adults admitted to an ICU on Hospital Day 1 and with a serum potassium concentration measured on Hospital Day 2. We determined the frequency of potassium repletion (any formulation) at each measured serum potassium concentration in each ICU, then classified ICUs as having threshold-based (a large increase in potassium repletion rates at a specific serum potassium concentration) or probabilistic (linear relationship between serum concentration and the repletion probability) patterns of repletion. Between patients in threshold-based and probabilistic repletion ICUs, we compared outcomes (primary outcome: potassium repletion frequency). We reported unadjusted percentages per exposure group and the adjusted odds ratios (from hierarchical regression models) for each outcome. Among patients in threshold-based ICUs with the most common repletion thresholds (3.5 mEq/L and 4.0 mEq/L), we conducted regression discontinuity analyses to examine the effectiveness of potassium repletion at each potassium threshold. Results: We included 190,490 patients in 88 ICUs; 35.0% received at least one dose of potassium on the same calendar day. Rates of potassium repletion were similar between 22 threshold-based strategy ICUs (33.5%) and 22 probabilistic strategy ICUs (36.4%). There was no difference in the adjusted risk of potassium repletion between patients admitted to threshold-based strategy ICUs versus probabilistic strategy ICUs (adjusted odds ratio, 1.09; 95% confidence interval [CI], 0.76-1.57). In regression discontinuity analysis, crossing the 3.5 mEq/L threshold from high to low potassium levels resulted in a 39.1% (95% CI, 23.7-42.4) absolute increase in potassium repletion but no change in other outcomes. Similarly, crossing the 4.0 mEq/L threshold resulted in a 36.4% (95% CI, 22.4-42.2) absolute increase in potassium repletion but no change in other outcomes. Conclusions: Potassium repletion is common in critically ill patients and occurs over a narrow range of "normal" potassium levels (3.5-4.0 mEq/L); use of a threshold-based repletion strategy to guide potassium repletion in ICU patients is not associated with clinically meaningful differences in outcomes.
Collapse
Affiliation(s)
- Nicholas A. Bosch
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Emily A. Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Penn Center for Perioperative Outcomes Research and Transformation, Philadelphia, Pennsylvania; and
| | - Anica C. Law
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Collin Homer-Bouthiette
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Allan J. Walkey
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Vivek K. Moitra
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| |
Collapse
|
5
|
Vail EA, Tam VW, Sonnenberg EM, Lavu NR, Reese PP, Abt PL, Martin ND, Hasz RD, Olthoff KM, Kerlin MP, Christie JD, Neuman MD, Potluri VS. Characterizing proximity and transfers of deceased organ donors to donor care units in the United States. Am J Transplant 2024:S1600-6135(24)00133-3. [PMID: 38346499 DOI: 10.1016/j.ajt.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/23/2024] [Accepted: 02/06/2024] [Indexed: 02/15/2024]
Abstract
Some United States organ procurement organizations transfer deceased organ donors to donor care units (DCUs) for recovery procedures. We used Organ Procurement and Transplantation Network data, from April 2017 to June 2021, to describe the proximity of adult deceased donors after brain death to DCUs and understand the impact of donor service area (DSA) boundaries on transfer efficiency. Among 19 109 donors (56.1% of the cohort) in 25 DSAs with DCUs, a majority (14 593 [76.4%]) were in hospitals within a 2-hour drive. In areas with DCUs detectable in the study data set, a minority of donors (3582 of 11 532 [31.1%]) were transferred to a DCU; transfer rates varied between DSAs (median, 27.7%, range, 4.0%-96.5%). Median hospital-to-DCU driving times were not meaningfully shorter among transferred donors (50 vs 51 minutes for not transferred, P < .001). When DSA boundaries were ignored, 3241 cohort donors (9.5%) without current DCU access were managed in hospitals within 2 hours of a DCU and thus potentially eligible for transfer. In summary, approximately half of United States deceased donors after brain death are managed in hospitals in DSAs with a DCU. Transfer of donors between DSAs may increase DCU utilization and improve system efficiency.
Collapse
Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Vicky W Tam
- Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Renal-Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Niels D Martin
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Richard D Hasz
- Gift of Life Donor Program, Philadelphia, Pennsylvania, USA
| | - Kim M Olthoff
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Meeta P Kerlin
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vishnu S Potluri
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Renal-Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
6
|
Vail EA, Schaubel DE, Potluri VS, Abt PL, Martin ND, Reese PP, Neuman MD. Deceased Organ Donor Management and Organ Distribution From Organ Procurement Organization-Based Recovery Facilities Versus Acute-Care Hospitals. Prog Transplant 2023; 33:283-292. [PMID: 37941335 PMCID: PMC10691289 DOI: 10.1177/15269248231212918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Introduction: Organ recovery facilities address the logistical challenges of hospital-based deceased organ donor management. While more organs are transplanted from donors in facilities, differences in donor management and donation processes are not fully characterized. Research Question: Does deceased donor management and organ transport distance differ between organ procurement organization (OPO)-based recovery facilities versus hospitals? Design: Retrospective analysis of Organ Procurement and Transplant Network data, including adults after brain death in 10 procurement regions (April 2017-June 2021). The primary outcomes were ischemic times of transplanted hearts, kidneys, livers, and lungs. Secondary outcomes included transport distances (between the facility or hospital and the transplant program) for each transplanted organ. Results: Among 5010 deceased donors, 51.7% underwent recovery in an OPO-based recovery facility. After adjustment for recipient and system factors, mean differences in ischemic times of any transplanted organ were not significantly different between donors in facilities and hospitals. Transplanted hearts recovered from donors in facilities were transported further than hearts from hospital donors (median 255 mi [IQR 27, 475] versus 174 [IQR 42, 365], P = .002); transport distances for livers and kidneys were significantly shorter (P < .001 for both). Conclusion: Organ recovery procedures performed in OPO-based recovery facilities were not associated with differences in ischemic times in transplanted organs from organs recovered in hospitals, but differences in organ transport distances exist. Further work is needed to determine whether other observed differences in donor management and organ distribution meaningfully impact donation and transplantation outcomes.
Collapse
Affiliation(s)
- Emily A. Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Perelman School of Medicine, Blockley Hall, Philadelphia, PA, USA
| | - Vishnu S. Potluri
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
| | - Peter L. Abt
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
- Division of Transplantation, Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Niels D. Martin
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
7
|
Stundner O, Adams MCB, Fronczek J, Kaura V, Li L, Allen ML, Vail EA. Academic anaesthesiology: a global perspective on training, support, and future development of early career researchers. Br J Anaesth 2023; 131:871-881. [PMID: 37684165 PMCID: PMC10636519 DOI: 10.1016/j.bja.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 09/10/2023] Open
Abstract
As anaesthesiologists face increasing clinical demands and a limited and competitive funding environment for academic work, the sustainability of academic anaesthesiologists has never been more tenuous. Yet, the speciality needs academic anaesthesiologists in many roles, extending beyond routine clinical duties. Anaesthesiologist educators, researchers, and administrators are required not only to train future generations but also to lead innovation and expansion of anaesthesiology and related specialities, all to improve patient care. This group of early career researchers with geographically distinct training and practice backgrounds aim to highlight the diversity in clinical and academic training and career development pathways for anaesthesiologists globally. Although multiple routes to success exist, one common thread is the need for consistent support of strong mentors and sponsors. Moreover, to address inequitable opportunities, we emphasise the need for diversity and inclusivity through global collaboration and exchange that aims to improve access to research training and participation. We are optimistic that by focusing on these fundamental principles, we can help build a more resilient and sustainable future for academic anaesthesiologists around the world.
Collapse
Affiliation(s)
- Ottokar Stundner
- Department of Anesthesiology and Intensive Care, Innsbruck Medical University, Innsbruck, Austria.
| | - Meredith C B Adams
- Departments of Anesthesiology, Biomedical Informatics, Pharmacology & Physiology, and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jakub Fronczek
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Vikas Kaura
- Leeds Institute of Medical Research at St James's, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Li Li
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Megan L Allen
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital and Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Emily A Vail
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
8
|
Vail EA, Bosch NA, Law AC, Gershengorn HB, Wunsch H, Walkey AJ. Adoption of a Novel Vasopressor Agent in Critically Ill Adults. Ann Am Thorac Soc 2023; 20:1662-1667. [PMID: 37590119 DOI: 10.1513/annalsats.202306-540rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/17/2023] [Indexed: 08/19/2023] Open
Affiliation(s)
- Emily A Vail
- University of Pennsylvania Philadelphia, Pennsylvania
- Penn Center for Perioperative Outcomes Research and Transformation Philadelphia, Pennsylvania
| | | | | | - Hayley B Gershengorn
- University of Miami Miami, Florida
- Albert Einstein College of Medicine Bronx, New York
| | - Hannah Wunsch
- Sunnybrook Health Sciences Centre Toronto, Ontario, Canada
- University of Toronto Toronto, Ontario, Canada
| | - Allan J Walkey
- Boston University Boston, Massachusetts
- Center for Implementation and Improvement Sciences Boston, Massachusetts
| |
Collapse
|
9
|
Ashana DC, Chen C, Hauschildt K, Moroz L, Vail EA, Viglianti EM, Vranas KC, Gershengorn HB. The Epidemiology of Maternal Critical Illness between 2008 and 2021. Ann Am Thorac Soc 2023; 20:1531-1537. [PMID: 37315330 PMCID: PMC10559136 DOI: 10.1513/annalsats.202301-071rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/12/2023] [Indexed: 06/16/2023] Open
Affiliation(s)
- Deepshikha Charan Ashana
- Duke UniversityDurham, North Carolina
- Duke–Margolis Center for Health PolicyDurham, North Carolina
| | - Catherine Chen
- University of Texas Southwestern Medical CenterDallas, Texas
| | | | | | - Emily A. Vail
- University of PennsylvaniaPhiladelphia, Pennsylvania
| | | | - Kelly C. Vranas
- Oregon Health & Science UniversityPortland, Oregon
- VA Portland Health Care SystemPortland, Oregon
| | - Hayley B. Gershengorn
- University of Miami Miller School of MedicineMiami, Florida
- Albert Einstein College of MedicineBronx, New York
| |
Collapse
|
10
|
Vail EA, Schaubel DE, Abt PL, Martin ND, Reese PP, Neuman MD. Organ Transplantation Outcomes of Deceased Organ Donors in Organ Procurement Organization-Based Recovery Facilities Versus Acute-Care Hospitals. Prog Transplant 2023; 33:110-120. [PMID: 36942433 PMCID: PMC10150267 DOI: 10.1177/15269248231164176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Recovery of donated organs at organ procurement organization (OPO)-based recovery facilities has been proposed to improve organ donation outcomes, but few data exist to characterize differences between facilities and acute-care hospitals. RESEARCH QUESTION To compare donation outcomes between organ donors that underwent recovery procedures in OPO-based recovery facilities and hospitals. DESIGN Retrospective study of Organ Procurement and Transplantation Network data. From a population-based sample of deceased donors after brain death April 2017 to June 2021, donation outcomes were examined in 10 OPO regions with organ recovery facilities. Primary exposure was organ recovery procedure in an OPO-based organ recovery. Primary outcome was the number of organs transplanted per donor. Multivariable regression models were used to adjust for donor characteristics and managing OPO. RESULTS Among 5010 cohort donors, 2590 (51.7%) underwent recovery procedures in an OPO-based facility. Donors in facilities differed from those in hospitals, including recovery year, mechanisms of death, and some comorbid diseases. Donors in OPO-based facilities had higher total numbers of organs transplanted per donor (mean 3.5 [SD1.8] vs 3.3 [SD1.8]; adjusted mean difference 0.27, 95% confidence interval 0.18-0.36). Organ recovery at an OPO-based facility was also associated with more lungs, livers, and pancreases transplanted. CONCLUSION Organ recovery procedures at OPO-based facilities were associated with more organs transplanted per donor than in hospitals. Increasing access to OPO-based organ recovery facilities may improve rates of organ transplantation from deceased organ donors, although further data are needed on other important donor management quality metrics.
Collapse
Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter L Abt
- Division of Transplantation, Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
11
|
Bass GA, Kaplan LJ, Ryan ÉJ, Cao Y, Lane-Fall M, Duffy CC, Vail EA, Mohseni S. The snapshot audit methodology: design, implementation and analysis of prospective observational cohort studies in surgery. Eur J Trauma Emerg Surg 2023; 49:5-15. [PMID: 35840703 PMCID: PMC10606835 DOI: 10.1007/s00068-022-02045-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE For some surgical conditionns and scientific questions, the "real world" effectiveness of surgical patient care may be better explored using a multi-institutional time-bound observational cohort assessment approach (termed a "snapshot audit") than by retrospective review of administrative datasets or by prospective randomized control trials. We discuss when this might be the case, and present the key features of developing, deploying, and assessing snapshot audit outcomes data. METHODS A narrative review of snapshot audit methodology was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Manuscripts were selected from domains including: audit design and deployment, statistical analysis, surgical therapy and technique, surgical outcomes, diagnostic testing, critical care management, concomitant non-surgical disease, implementation science, and guideline compliance. RESULTS Snapshot audits all conform to a similar structure: being time-bound, non-interventional, and multi-institutional. A successful diverse steering committee will leverage expertise that includes clinical care and data science, coupled with librarian services. Pre-published protocols (with specified aims and analyses) greatly helps site recruitment. Mentored trainee involvement at collaborating sites should be encouraged through manuscript contributorship. Current funding principally flows from medical professional organizations. CONCLUSION The snapshot audit approach to assessing current care provides insights into care delivery, outcomes, and guideline compliance while generating testable hypotheses.
Collapse
Affiliation(s)
- Gary A Bass
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA.
- Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia, PA, USA.
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, 3400 Spruce St, 5 Dulles, Philadelphia, PA, 19104, USA.
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA
| | - Éanna J Ryan
- Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Yang Cao
- Department of Clinical Epidemiology and Biostatistics, Orebro University, Orebro, Sweden
| | - Meghan Lane-Fall
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, 3400 Spruce St, 5 Dulles, Philadelphia, PA, 19104, USA
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA, 19104, USA
| | - Caoimhe C Duffy
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, 3400 Spruce St, 5 Dulles, Philadelphia, PA, 19104, USA
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA, 19104, USA
| | - Emily A Vail
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, 3400 Spruce St, 5 Dulles, Philadelphia, PA, 19104, USA
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA, 19104, USA
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| |
Collapse
|
12
|
Vail EA, Lane-Fall MB. How Did They Get There? What Perspectives From the Top Tell Us About Developing Women Leaders in Academic Anesthesiology. Anesth Analg 2023; 136:2-5. [PMID: 36534712 DOI: 10.1213/ane.0000000000006241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Emily A Vail
- From the Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania.,Penn Center for Perioperative Outcomes, Research and Transformation, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Meghan B Lane-Fall
- From the Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania.,Penn Center for Perioperative Outcomes, Research and Transformation, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| |
Collapse
|
13
|
Bosch NA, Law AC, Vail EA, Gillmeyer KR, Gershengorn HB, Wunsch H, Walkey AJ. Inhaled Nitric Oxide vs Epoprostenol During Acute Respiratory Failure: An Observational Target Trial Emulation. Chest 2022; 162:1287-1296. [PMID: 35952768 PMCID: PMC9899639 DOI: 10.1016/j.chest.2022.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/14/2022] [Accepted: 08/01/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The inhaled vasodilators nitric oxide and epoprostenol may be initiated to improve oxygenation in mechanically ventilated patients with severe acute respiratory failure (ARF); however, practice patterns and head-to-head comparisons of effectiveness are unclear. RESEARCH QUESTION What are the practice patterns and comparative effectiveness for inhaled nitric oxide and epoprostenol in severe ARF? STUDY DESIGN AND METHODS Using a large US database (Premier Healthcare Database), we identified adult patients with ARF or ARDS who were mechanically ventilated and started on inhaled nitric oxide, epoprostenol, or both. Leveraging large hospital variation in the choice of initial inhaled vasodilator, we compared the effectiveness of inhaled nitric oxide with that of epoprostenol by limiting analysis to patients admitted to hospitals that exclusively used either inhaled nitric oxide or epoprostenol. The primary outcome of successful extubation was modeled using multivariate Fine-Grey competing risk (death or hospice discharge) time-to-event models. RESULTS Among 11,200 patients (303 hospitals), 6,366 patients (56.8%) received inhaled nitric oxide first, 4,720 patients (42.1%) received inhaled epoprostenol first, and 114 patients (1.0%) received both therapies on the same day. One hundred four hospitals (34.3%; 1,666 patients) exclusively used nitric oxide and 118 hospitals (38.9%; 1,812 patients) exclusively used epoprostenol. No differences were found in the likelihood of successful extubation between patients admitted to nitric oxide-only hospitals vs those admitted to epoprostenol-only hospitals (subdistribution hazard ratio, 0.97; 95% CI, 0.80-1.18). Also no differences were found in total hospital costs or death. Results were robust to multiple sensitivity analyses. INTERPRETATION Large variation exists in the use of initial inhaled vasodilator for respiratory failure across US hospitals. Comparative effectiveness analyses identified no differences in outcomes based on inhaled vasodilator type.
Collapse
Affiliation(s)
- Nicholas A Bosch
- Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA.
| | - Anica C Law
- Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Emily A Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kari R Gillmeyer
- Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL; Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Allan J Walkey
- Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA; Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, MA
| |
Collapse
|
14
|
Vail EA, Tung A. A Roadmap to Optimize Intraoperative Mechanical Ventilation. Anesth Analg 2022; 135:967-970. [PMID: 36269986 PMCID: PMC9589916 DOI: 10.1213/ane.0000000000006158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Emily A Vail
- From the Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania
- Penn Center for Perioperative Outcomes Research and Transformation, Philadelphia, Pennsylvania
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Illinois
| |
Collapse
|
15
|
Vail EA, Avidan MS. Trials with 'non-significant' results are not insignificant trials: a common significance threshold distorts reporting and interpretation of trial results. Br J Anaesth 2022; 129:643-646. [PMID: 35871898 DOI: 10.1016/j.bja.2022.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/09/2022] [Accepted: 06/23/2022] [Indexed: 11/02/2022] Open
Abstract
We discuss a newly published study examining how phrases are used in clinical trials to describe results when the estimated P-value is close to (slightly above or slightly below) 0.05, which has been arbitrarily designated by convention as the boundary for 'statistical significance'. Terms such as 'marginally significant', 'trending towards significant', and 'nominally significant' are well represented in biomedical literature, but are not actually scientifically meaningful. Acknowledging that 'statistical significance' remains a major determinant of publication, we propose that scientific journals de-emphasise the use of P-values for null hypothesis significance testing, a purpose for which they were never intended, and avoid the use of these ambiguous and confusing terms in scientific articles. Instead, investigators could simply report their findings: effect sizes, P-values, and confidence intervals (or their Bayesian equivalents), and leave it to the discerning reader to infer the clinical applicability and importance. Our goal should be to move away from describing studies (or trials) as positive or negative based on an arbitrary P-value threshold, and rather to judge whether the scientific evidence provided is informative or uninformative.
Collapse
Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| |
Collapse
|
16
|
Stephens T, Vail EA, Billings J. Silver linings: will the COVID-19 pandemic instigate long overdue mental health support services for healthcare workers? Br J Anaesth 2022; 128:912-914. [PMID: 35428511 PMCID: PMC8940569 DOI: 10.1016/j.bja.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/17/2022] Open
Abstract
A study in this month’s journal adds to the growing body of evidence regarding the potential mental health impacts on frontline healthcare staff working during the COVID-19 pandemic. As clinical academics representing critical care, nursing, and medicine, and a psychologist guiding support for frontline health and social workers, we offer our perspectives on this study. We discuss the balance between pragmatic and rigorous data collection on this topic and offer perspectives on the observed differential impact on nurses. Finally, we suggest that the pandemic might have a positive effect by instigating more robust mental health support services for National Health Service workers.
Collapse
|
17
|
Abstract
Observational studies in critical care medicine offer a popular and practical approach to questions of treatment effectiveness. Although observational research is widely understood to be susceptible to design and interpretation challenges, one well-described source of bias-immortal time bias (ITB)-is frequently present yet often overlooked. ITB may be introduced by study design oversights or mishandled during data analysis. When present, ITB can create inappropriate estimates of the benefit or harm of an exposure or intervention. Studies examining treatments in critically ill patients may be particularly susceptible to ITB, with consequences for clinical adoption and design and initiation of randomized trials. In this Critical Care Perspective, we illustrate the persistent problem of ITB in observational research using recent studies of hydrocortisone, ascorbic acid, and thiamine therapy in patients with sepsis and septic shock. Of the eight studies examined, none contained enough design or reporting elements to rule out the presence of ITB. To mitigate the influence of ITB in future observational studies, we present a novel checklist to help readers assess the features of study design, analysis, and reporting that introduce ITB or obscure its presence. We recommend that commonly used tools designed to evaluate observational research studies should include an ITB assessment.
Collapse
Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care and.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesia and.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Allan J Walkey
- Division of Pulmonary, Allergy, Sleep and Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
18
|
Vail EA, Wunsch H, Pinto R, Bosch NA, Walkey AJ, Lindenauer PK, Gershengorn HB. Use of Hydrocortisone, Ascorbic Acid, and Thiamine in Adults with Septic Shock. Am J Respir Crit Care Med 2020; 202:1531-1539. [PMID: 32706593 DOI: 10.1164/rccm.202005-1829oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: In December 2016, a single-center study describing significant improvements in mortality among a small group of patients with severe sepsis and septic shock treated with hydrocortisone, high-dose ascorbic acid, and thiamine (HAT therapy) was published online.Objectives: This study aims to describe the administration of HAT therapy among U.S. adults with septic shock before and after study publication and to compare outcomes between patients who received and did not receive HAT therapy.Methods: We performed a retrospective cohort study of 379 acute care hospitals in the Premier Healthcare Database including patients discharged from October 1, 2015, to September 30, 2018. Exposure was quarter year of hospital discharge; postpublication was defined as January 2017 onward (July 2017 for effectiveness analyses). The primary outcome was receipt of HAT at least once during hospitalization. We conducted unadjusted segmented regression analyses to examine temporal trends in HAT administration. In patients with early septic shock, we compared the association of early HAT therapy (within 2 d of hospitalization) with hospital mortality using multivariable modeling and propensity score matching.Measurements and Main Results: Among 338,597 patients, 3,574 (1.1%) received HAT therapy, 98.7% in the postpublication period. HAT administration increased from 0.03% of patients (95% confidence interval [CI], 0.02-0.04) before publication to 2.65% (95% CI, 2.46-2.83) in the last quarter, with a significant step up in use after December 2016 (P < 0.001). Receipt of early HAT was associated with higher hospital mortality (28.2% vs. 19.7%; P < 0.001; adjusted odds ratio, 1.17 [95% CI, 1.02-1.33]; primary propensity-matched model adjusted odds ratio, 1.19 [95% CI, 1.02-1.40]).Conclusions: Publication of a single-center retrospective study was associated with significantly increased administration of HAT. Among patients with early septic shock, receipt of HAT was not associated with mortality benefit.
Collapse
Affiliation(s)
- Emily A Vail
- Department of Anesthesiology, University of Texas Health San Antonio, San Antonio, Texas
| | - Hannah Wunsch
- Department of Anesthesiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- Department of Anesthesiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas A Bosch
- Division of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston University, Boston, Massachusetts
| | - Allan J Walkey
- Division of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston University, Boston, Massachusetts
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida; and.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
19
|
Vail EA, Nadig NR, Sahetya SK, Vande Vusse LK, Walkey AJ, Liu V, Mathews KS. The Role of Professional Organizations in Fostering the Early Career Development of Academic Intensivists. Ann Am Thorac Soc 2020; 17:412-418. [PMID: 31800295 PMCID: PMC8174059 DOI: 10.1513/annalsats.201908-573ps] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/04/2019] [Indexed: 11/20/2022] Open
Affiliation(s)
- Emily A. Vail
- Assembly on Critical Care Early Career Professionals Working Group, and
- Department of Anesthesiology, University of Texas Health San Antonio, San Antonio, Texas
| | - Nandita R. Nadig
- Assembly on Critical Care Early Career Professionals Working Group, and
- Members in Transition and Training Committee, American Thoracic Society, New York, New York
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Sarina K. Sahetya
- Assembly on Critical Care Early Career Professionals Working Group, and
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lisa K. Vande Vusse
- Assembly on Critical Care Early Career Professionals Working Group, and
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Allan J. Walkey
- Assembly on Critical Care Early Career Professionals Working Group, and
- Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University, Boston, Massachusetts
| | - Vincent Liu
- Assembly on Critical Care Early Career Professionals Working Group, and
- Division of Research, Kaiser Permanente, Oakland, California
| | - Kusum S. Mathews
- Assembly on Critical Care Early Career Professionals Working Group, and
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
20
|
Abstract
OBJECTIVE To describe presenting symptoms and signs according to age group in a cohort of 243 patients with tuberous sclerosis complex (TSC) and identify earlier symptoms and signs that did not lead to immediate diagnosis. PATIENTS AND METHODS We performed a retrospective chart review for 278 patients with TSC who were examined at Children's Hospital Boston in Massachusetts and at the Herscot Center for Tuberous Sclerosis Complex, Massachusetts General Hospital. The presenting symptom or sign was the first symptom or sign to cause suspicion for TSC and lead to diagnosis. Missed symptoms or signs were those that were documented in the patient's chart but did not immediately lead to diagnosis. RESULTS There were 243 patients for whom there were sufficient data for inclusion in this study. Patients were diagnosed with TSC at ages ranging from birth to 73 years. The average age at diagnosis was 7.5 years. Of the patients, 81% were diagnosed before the age of 10. Diagnosis during adolescence and adulthood was not uncommon. The most common presenting symptoms and signs included new onset of seizures, history of seizures, infantile spasms, family history of TSC, cardiac rhabdomyomas, and hypopigmented macules. Of the patients, 39% reported missed symptoms or signs of TSC, most commonly seizures (including infantile spasms) and dermatologic features. CONCLUSIONS Many patients had symptoms or signs of TSC that did not lead to immediate diagnosis. Clinicians should be aware of the myriad potential presenting symptoms and signs of TSC. Early diagnosis may reduce morbidity and mortality.
Collapse
Affiliation(s)
- Brigid A. Staley
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily A. Vail
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth A. Thiele
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
21
|
Abstract
We describe three cases in whom identification of a disease-causing mutation in the TSC1 or TSC2 gene preceded the appearance or detection of symptoms sufficient for a clinical diagnosis of tuberous sclerosis complex (TSC). We suggest that genetic testing be given a more prominent role in the evaluation of individuals with a family history of TSC or symptoms suggestive of TSC and propose that diagnostic criteria be revised to include genetic testing.
Collapse
Affiliation(s)
- E A Vail
- Department of Neurology, Massachusetts General Hospital, Boston, USA
| | | | | | | |
Collapse
|