Nighttime Extubation Does Not Increase Risk of Reintubation, Length of Stay, or Mortality: Experience of a Large, Urban, Teaching Hospital.

BACKGROUND: In the intensive care unit (ICU), extubation failure has been associated with greater resource utilization and worsened clinical outcomes. Most recently, nighttime extubation (NTE) has been reported as a risk factor for increased ICU and hospital mortality. We hypothesized that, in a large, urban, university-affiliated hospital with multidisciplinary assessment for extubation, rigorously protocolized extubation algorithms, and expert airway managers available at all times of day for assessment of high-risk extubations, NTE would not confer additional risk of adverse clinical outcomes. METHODS: This was a retrospective cohort study of mechanically ventilated adults at a single university-affiliated hospital. NTE was defined as occurring between 7:00 PM and 6:59 AM the following day. All data were extracted from the institution's electronic medical record. Multivariable regression analyses were used to assess associations between NTE and reintubation, ICU and hospital length of stay (LOS), and mortality with adjustments for demographic and clinical covariates defined a priori. Palliative, unplanned, and routine postoperative extubations were excluded in sensitivity analyses. RESULTS: Of 2241 patients, 204 of 2241 (9.1%) underwent NTE. The rates of reintubation (NTE 6.9% versus daytime extubation [DTE] 12.4%; adjusted odds ratio [95% confidence interval {CI}], 0.78 [0.43-1.41]; P = .41) and in-hospital mortality (NTE 3.4% versus DTE 5.9%; adjusted odds ratio [95% CI], 0.72 [0.28-1.84]; P = .49) were not found to differ. NTE, compared to DTE, was associated with shorter duration of mechanical ventilation (median [interquartile range], 1 [0-1] days vs 2 [1-4] days; adjusted ratio of geometric means [RGMs] [95% CI], 0.64 [0.54-0.70]; P < .001), ICU (2 [1-5] days vs 4 [2-10] days; adjusted RGMs [95% CI], 0.65 [0.57-0.75]; P < .001), and hospital LOS (6 [3-18] days vs 13 [6-25] days; adjusted RGMs [95% CI], 0.64 [0.56-0.74]; P < .001). These results were unchanged in sensitivity analyses. CONCLUSIONS: Patients who underwent NTE were not at increased risk of reintubation or in-hospital mortality. In addition, NTE was associated with a shortened duration of mechanical ventilation and hospital LOS. In health care systems with similar critical care delivery models, NTE may coincide with reduced resource utilization in appropriately selected patients.

Gastroparesis: A Review of Current Diagnosis and Treatment Options.

Gastroparesis (GP) is a chronic neuromuscular disorder of the upper gastrointestinal tract. The incidence of GP is not well described; however, the number of individuals affected by symptoms of GP in the United States is estimated to be over 4 million. The etiology of GP is diverse. Approximately 25% of cases are associated with diabetes, whereas nearly 50% are classified as idiopathic; many of these latter cases likely represent a postinfectious process. Connective tissue disorders, autoimmune disorders, prior gastric surgery, ischemia, and medications make up the vast majority of the remaining cases. The pathophysiology of GP is also diverse. Abnormalities in fundic tone, antroduodenal dyscoordination, a weak antral pump, gastric dysrhythmias, and abnormal duodenal feedback all contribute to delays in gastric emptying and symptom expression. Characteristic symptoms of GP include nausea, vomiting, epigastric pain, early satiety, and weight loss. The diagnosis of GP is made using a combination of characteristic symptoms in conjunction with objective evidence of delayed gastric emptying in the absence of mechanical obstruction. Once the diagnosis is made, treatment options include dietary modification, medications to accelerate gastric emptying, antiemetic agents, gastric electrical stimulation, and surgery. In the following sections we will provide an overview of the health care impact of GP, describe the underlying pathophysiology, and review treatment options using an evidence-based approach.

IBS patients' willingness to take risks with medications.

OBJECTIVES: We explored irritable bowel syndrome (IBS) patients' impulsivity and risk-taking behavior and their willingness to take medication risks. METHODS: A validated questionnaire assessed the illness experience of IBS patients. A standard gamble evaluated respondents' willingness to take medication risks. RESULTS: IBS patients with severe symptoms were more willing to take significant medication risks than those with mild or moderate symptoms. Impulsivity scores were not associated with an increased likelihood of taking medication risks. Age, gender, and years of IBS symptoms were not associated with medication risk-taking behavior. IBS patients reported they would accept a median 1% risk of sudden death for a 99% chance of cure for their symptoms using a hypothetical medication. CONCLUSIONS: IBS patients are willing to take significant medication risks to cure their symptoms. To counsel patients effectively, physicians must determine and understand IBS patients' risk aversion.