Disruption of the circadian rhythm of melatonin: A biomarker of critical illness severity.

Circadian dysrhythmias occur commonly in critically ill patients reflecting variable effects of underlying illness, ICU environment, and treatments. We retrospectively analyzed the relationship between clinical outcomes and 24-h urinary 6-sulfatoxymelatonin (aMT6s) excretion profiles in 37 critically ill patients with shock and/or respiratory failure. Nonlinear regression was used to fit a 24-h cosine curve to each patient's aMT6s profile, with rhythmicity determined by the zero-amplitude test. From these curves we determined acrophase, amplitude, phase, and night/day ratio. After assessing unadjusted relationships, we identified the optimal multivariate models for hospital survival and for discharge to home (vs. death or transfer to another facility). Normalized aMT6s rhythm amplitude was greater (p = 0.005) in patients discharged home than in those who were not, while both groups exhibited a phase delay. Patients with rhythmic aMT6s excretion were more likely to survive (OR 5.25) and be discharged home (OR 8.89; p < 0.05 for both) than patients with arrhythmic profiles, associations that persisted in multivariate modelling. In critically ill patients with shock and/or respiratory failure, arrhythmic and/or low amplitude 24-h aMT6s rhythms were associated with worse clinical outcomes, suggesting a role for the melatonin-based rhythm as a novel biomarker of critical illness severity.

Sepsis associated acute kidney injury.

Sepsis is defined as organ dysfunction resulting from the host's deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.

Improving medical and pharmacy student confidence in medication management and attitudes about interprofessional collaboration by utilizing an interprofessional module.

Adverse drug events are common and often preventable. Educating the interprofessional workforce to appropriately manage medications as part of a team is a priority. An interprofessional medication management module for graduating medical and pharmacy students was developed. The module was case-based and co-led by physicians and pharmacists. Students completed pre- and post-module surveys regarding their attitudes about interprofessional collaboration, confidence in managing medications, and self-reported ability to perform the tasks laid out in the minimum geriatrics competencies as a result of the module. Eighteen medical and 13 pharmacy students participated over a two-year period. There was statistically significant improvement in students' attitudes about interprofessional collaboration with regards to understanding their role and the role of others on the interprofessional team, and about teamwork between medical and pharmacy students. There was also statistically significant improvement in confidence with regards to the 3 medication management competencies after completion of the module. The vast majority of students agreed that the module improved their self-reported ability to manage medications. An interprofessional medication management module is an effective way to improve medical and pharmacy students' attitudes about interprofessional collaboration and confidence in medication management.

Implementation of a Professional Society Core Curriculum and Integrated Maintenance of Certification Program.

Medical professional societies exist to foster collaboration, guide career development, and provide continuing medical education opportunities. Maintenance of certification is a process by which physicians complete formal educational activities approved by certifying organizations. The American Thoracic Society (ATS) established an innovative maintenance of certification program in 2012 as a means to formalize and expand continuing medical education offerings. This program is unique as it includes explicit opportunities for collaboration and career development in addition to providing continuing medical education and maintenance of certification credit to society members. In describing the development of this program referred to as the "Core Curriculum," the authors highlight the ATS process for content design, stages of curriculum development, and outcomes data with an eye toward assisting other societies that seek to program similar content. The curriculum development process described is generalizable and positively influences individual practitioners and professional societies in general, and as a result, provides a useful model for other professional societies to follow.

Patient safety room of horrors: a novel method to assess medical students and entering residents' ability to identify hazards of hospitalisation.

BACKGROUND: Patient safety curricula in undergraduate medical education (UME) are often didactic format with little focus on skills training. Despite recent focus on safety, practical training in residency education is also lacking. Assessments of safety skills in UME and graduate medical education (GME) are generally knowledge, and not application-focused. We aimed to develop and pilot a safety-focused simulation with medical students and interns to assess knowledge regarding hazards of hospitalisation. METHODS: A simulation demonstrating common hospital-based safety threats was designed. A case scenario was created including salient patient information and simulated safety threats such as the use of upper-extremity restraints and medication errors. After entering the room and reviewing the mock chart, learners were timed and asked to identify and document as many safety hazards as possible. Learner satisfaction was assessed using constructed-response evaluation. Descriptive statistics, including per cent correct and mean correct hazards, were performed. RESULTS: All 86 third-year medical students completed the encounter. Some hazards were identified by a majority of students (fall risk, 83% of students) while others were rarely identified (absence of deep venous thrombosis prophylaxis, 13% of students). Only 5% of students correctly identified pressure ulcer risk. 128 of 131 interns representing 49 medical schools participated in the GME implementation. Incoming interns were able to identify a mean of 5.1 hazards out of the 9 displayed (SD 1.4) with 40% identifying restraints as a hazard, and 20% identifying the inappropriate urinary catheter as a hazard. CONCLUSIONS: A simulation showcasing safety hazards was a feasible and effective way to introduce trainees to safety-focused content. Both students and interns had difficulty identifying common hazards of hospitalisation. Despite poor performance, learners appreciated the interactive experience and its clinical utility.

Rapidly reversible, sedation-related delirium versus persistent delirium in the intensive care unit.

RATIONALE: Intensive care unit (ICU) delirium is associated with ventilator, ICU, and hospital days; discharge functional status; and mortality. Whether rapidly reversible, sedation-related delirium (delirium that abates shortly after sedative interruption) occurs with the same frequency and portends the same prognosis as persistent delirium (delirium that persists despite a short period of sedative interruption) is unknown. OBJECTIVES: To compare rapidly reversible, sedation-related delirium and persistent delirium. METHODS: This was a prospective cohort study of 102 adult, intubated medical ICU subjects in a tertiary care teaching hospital. Confusion Assessment Method for the ICU evaluation was performed before and after daily interruption of continuous sedation (DIS). Investigators were blinded to each other's assessments and as to whether evaluations were before or after DIS. The primary outcome was proportion of days with no delirium versus rapidly reversible, sedation-related delirium versus persistent delirium. Secondary outcomes were ventilator, ICU, and hospital days; discharge disposition; and 1-year mortality. MEASUREMENTS AND MAIN RESULTS: The median proportion of ICU days with delirium was 0.57 before versus 0.50 after DIS (P < 0.001). The Confusion Assessment Method for the ICU indicated patients are 10.5 times more likely to have delirium before DIS versus after (P < 0.001). Rapidly reversible, sedation-related delirium showed fewer ventilator (P < 0.001), ICU (P = 0.001), and hospital days (P < 0.001) than persistent delirium. Subjects with no delirium and rapidly reversible, sedation-related delirium were more likely to be discharged home (P < 0.001). Patients with persistent delirium had increased 1-year mortality versus those with no delirium and rapidly reversible, sedation-related delirium (P < 0.001). CONCLUSIONS: Rapidly reversible, sedation-related delirium does not signify the same poor prognosis as persistent delirium. Degree of sedation should be considered in delirium assessments. Coordinating delirium assessments with daily sedative interruption will improve such assessments' ability to prognosticate ICU delirium outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT 00919698).

Pharmacist contributions as members of the multidisciplinary ICU team.

Critical care pharmacy services in the ICU have expanded from traditional dispensing responsibilities to being recognized as an essential component of multidisciplinary care for critically ill patients. Augmented by technology and resource utilization, this shift in roles has allowed pharmacists to provide valuable services in the form of assisting physicians and clinicians with pharmacotherapy decision-making, reducing medication errors, and improving medication safety systems to optimize patient outcomes. Documented improvements in the management of infections, anticoagulation therapy, sedation, and analgesia for patients receiving mechanical ventilation and in emergency response help to justify the need for clinical pharmacy services for critically ill patients. Contributions to quality improvement initiatives, scholarly and research activities, and the education and training of interdisciplinary personnel are also valued services offered by clinical pharmacists. Partnering with physician and nursing champions can garner support from hospital administrators for the addition of clinical pharmacy critical care services. The addition of a pharmacist to an interprofessional critical care team should be encouraged as health-care systems focus on improving the quality and efficiency of care delivered to improve patient outcomes.

Impact of ventilator adjustment and sedation-analgesia practices on severe asynchrony in patients ventilated in assist-control mode.

OBJECTIVES: Breath-stacking asynchrony during assist-control-mode ventilation may be associated with increased tidal volume and alveolar pressure that could contribute to ventilator-induced lung injury. Methods to reduce breath stacking have not been well studied. The objective of this investigation was to evaluate 1) which interventions were used by managing clinicians to address severe breath stacking; and 2) how effective these measures were. SETTING: Sixteen-bed medical ICU. PATIENTS AND INTERVENTIONS: Physiological study in consecutively admitted patients without severe brain injury, who had severe breath stacking defined as an asynchrony index greater than or equal to 10% of total breaths. During 30 minutes before (baseline) and after any intervention employed by the managing clinician, the ventilator flow, airway pressure, and volume/time waveforms were continuously recorded and analyzed to detect normal and stacked breaths. The initial approach taken was assigned to one of three categories: no intervention, increase of sedation-analgesia, or change of ventilator setting. Nonparametric Wilcoxon-Mann-Whitney tests and multiple regression were used for statistical analysis. Quantitative data are presented as median [25-75]. MAIN RESULTS: Sixty-six of 254 (26%) mechanically ventilated patients exhibited severe breath-stacking asynchrony. A total of 100 30-minute sequences were recorded and analyzed in 30 patients before and after 50 clinical decisions for ongoing management (no intervention, n=8; increasing sedation/analgesia, n=16; ventilator adjustment, n=26). Breath-stacking asynchrony index was 44 [27-87]% at baseline. Compared with baseline, the decrease of asynchrony index was greater after changing the ventilator setting (-99 [-92, -100]%) than after increasing the sedation-analgesia (-41 [-66, 7]%, p<0.001) or deciding to tolerate the asynchrony (4 [-4, 12]%, p<0.001). Pressure-support ventilation and increased inspiratory time were independently associated with the reduction of asynchrony index. CONCLUSIONS: Compared with increasing sedation-analgesia, adapting the ventilator to patient breathing effort reduces breath-stacking asynchrony significantly and often dramatically. These results support an algorithm beginning with ventilator adjustment to rationalize the management of severe breath-stacking asynchrony in ICU patients.

Temporal disorganization of circadian rhythmicity and sleep-wake regulation in mechanically ventilated patients receiving continuous intravenous sedation.

OBJECTIVES: Sleep is regulated by circadian and homeostatic processes and is highly organized temporally. Our study was designed to determine whether this organization is preserved in patients receiving mechanical ventilation (MV) and intravenous sedation. DESIGN: Observational study. SETTING: Academic medical intensive care unit. PATIENTS: Critically ill patients receiving MV and intravenous sedation. METHODS: Continuous polysomnography (PSG) was initiated an average of 2.0 (1.0, 3.0) days after ICU admission and continued ≥ 36 h or until the patient was extubated. Sleep staging and power spectral analysis were performed using standard approaches. We also calculated the electroencephalography spectral edge frequency 95% SEF95, a parameter that is normally higher during wakefulness than during sleep. Circadian rhythmicity was assessed in 16 subjects through the measurement of aMT6s in urine samples collected hourly for 24-48 hours. Light intensity at the head of the bed was measured continuously. MEASUREMENTS AND RESULTS: We analyzed 819.7 h of PSG recordings from 21 subjects. REM sleep was identified in only 2/21 subjects. Slow wave activity lacked the normal diurnal and ultradian periodicity and homeostatic decline found in healthy adults. In nearly all patients, SEF95 was consistently low without evidence of diurnal rhythmicity (median 6.3 [5.3, 7.8] Hz, n = 18). A circadian rhythm of aMT6s excretion was present in most (13/16, 81.3%) patients, but only 4 subjects had normal timing. Comparison of the SEF95 during the melatonin-based biological night and day revealed no difference between the 2 periods (P = 0.64). CONCLUSIONS: The circadian rhythms and PSG of patients receiving mechanical ventilation and intravenous sedation exhibit pronounced temporal disorganization. The finding that most subjects exhibited preserved, but phase delayed, excretion of aMT6s suggests that the circadian pacemaker of such patients may be free-running.

What is the most effective way to communicate results after endoscopy?

BACKGROUND: The growing demand for endoscopy associated with colorectal cancer screening has resulted in busier endoscopy units and an increase in the practice of open-access endoscopy, in which patients are referred for procedures without prior consultation by the gastroenterologist, all of which may result in less-informed patients. OBJECTIVE: We sought to determine whether providing patients with a written copy of their standard endoscopy report at the conclusion of their procedure enhanced recall of the findings and recommendations. DESIGN: Eighty consecutive outpatients who presented to 3 endoscopists were randomized to receive the results of their upper or lower endoscopy via standard verbal report (VR) or by standard VR followed by receipt of a computer-generated endoscopy report (VR+WR) from the Olympus ImageManager report generator. The endoscopist communicated the VR after a standard postprocedure recovery period of 30 to 60 minutes and routinely discussed all findings and recommendations as mentioned in the WR. The endoscopist was blinded as to whether the patient subsequently received the WR. Recall of the endoscopic procedure was assessed by using a piloted 11-question survey instrument to be filled out 3 days after the procedure. Results were calculated by using the Fisher exact and Wilcoxon rank sum tests. PATIENTS: Referral for endoscopy from University of Chicago physicians. RESULTS: Seventy-eight of 80 patients (98%) approached about the study agreed to participate. The response rate was 77%. Patients in the VR+WR group overall had a greater composite score than patients in the VR group (8.9/10 vs 7.7/10, P<.01). Patients in the VR+WR group were also significantly more likely to recall the recommendations for therapy or follow-up (72% vs 42%, P<.01) and the name of the endoscopist (97% vs 74%, P<.05). LIMITATIONS: Patients with an education beyond the 10th-grade level were not formally accessed in this study. Because of this, we could not evaluate whether differences in educational attainment affected patient understanding of endoscopy procedure details and findings. CONCLUSIONS: A computer-generated endoscopy report (WR) significantly improved patient recall of endoscopic procedure information compared with a VR alone. Despite this, patients were unable to recall 28% of recommendations. Additional study to determine if such enhanced physician-patient communication improves patient satisfaction or follow-up, and whether more specific patient-directed results further improve recall needs to occur.