Cumulative epinephrine dose during cardiac arrest and neurologic outcome after extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Epinephrine is recommended without an apparent ceiling dosage during cardiac arrest. However, excessive alpha- and beta-adrenergic stimulation may contribute to unnecessarily high aortic afterload, promote post-arrest myocardial dysfunction, and result in cerebral microvascular insufficiency in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). METHODS: This was a retrospective cohort study of adults (≥ 18 years) who received ECPR at large academic ECMO center from 2018 to 2022. Patients were grouped based on the amount of epinephrine given during cardiac arrest into low (≤ 3 mg) and high (> 3 mg) groups. The primary endpoint was neurologic outcome at hospital discharge, defined by cerebral performance category (CPC). Multivariable logistic regression was used to assess the relationship between cumulative epinephrine dosage during arrest and neurologic outcome. RESULTS: Among 51 included ECPR cases, the median age of patients was 60 years, and 55% were male. The mean cumulative epinephrine dose administered during arrest was 6.2 mg but ranged from 0 to 24 mg. There were 18 patients in the low-dose (≤ 3 mg) and 25 patients in the high-dose (> 3 mg) epinephrine groups. Favorable neurologic outcome at discharge was significantly greater in the low-dose (55%) compared to the high-dose (24%) group (p = 0.025). After adjusting for age, those who received higher doses of epinephrine during the arrest were more likely to have unfavorable neurologic outcomes at hospital discharge (odds ratio 4.6, 95% CI 1.3, 18.0, p = 0.017). CONCLUSION: After adjusting for age, cumulative epinephrine doses above 3 mg during cardiac arrest may be associated with unfavorable neurologic outcomes after ECPR and require further investigation.

SleepWell24, a Smartphone Application to Promote Adherence to Positive Airway Pressure Therapy: Feasibility and Acceptability in a Randomized Controlled Trial.

OBJECTIVE: To investigate the feasibility and acceptability of SleepWell24, a multicomponent, evidence-based smartphone application, to improve positive airway pressure therapy (PAP) adherence, among patients with obstructive sleep apnea (OSA) naive to PAP. METHODS: In a single-blind randomized controlled trial, SleepWell24, with a companion activity monitor was compared to usual care plus the activity monitor and its associated app. SleepWell24 provides objective feedback on PAP usage and sleep/physical activity patterns, and chronic disease management. Patients were recruited from two sleep medicine centers and followed over the first 60 days of PAP. Feasibility and acceptability were measured by recruitment/retention rates, app usage, differences in post-trial Treatment Evaluation Questionnaire (TEQ) scores, and patient interviews. Exploratory, intent-to-treat logistic and linear mixed models estimated PAP adherence and clinical outcomes. RESULTS: Of 103 eligible participants, 87 were enrolled (SleepWell24 n = 40, control n = 47; mean 57.6y [SD = 12.3], 44.8% female). Retention was ≥95% across arms. There were no significant differences in TEQ scores. SleepWell24 participants engaged with the app on 62.9% of trial days. PAP use was high across both arms (SleepWell24 vs. Control: mean hours 5.98 vs. 5.86). There were no differences in PAP adherence or clinical outcomes. CONCLUSIONS: SleepWell24 was feasible and acceptable among PAP-naive patients with OSA. CLINICAL TRIAL REGISTRATION: NCT03156283https://www.clinicaltrials.gov/study/NCT03156283.

Anticoagulation Prescribing Patterns in Intensive Care Unit Patients Admitted with Prehospital Direct Oral Anticoagulant Therapy: A Single Academic Center Experience.

OBJECTIVE: To describe the current prescribing practices of direct oral anticoagulants (DOACs) in intensive care unit (ICU) patients and the associated clinical outcomes, including the incidence of major bleeding episodes and the need for intervention (endoscopic, surgical, or interventional radiology guided). DESIGN: Observational, retrospective chart review. SETTING AND PARTICIPANTS: Single large academic center study. Participants included patients with critical illness who were admitted to the intensive care units (ICU) at Mayo Clinic from January 1st, 2012, until May 4th, 2018. Adult ICU patients with a DOAC (apixaban, rivaroxaban, dabigatran, or edoxaban) listed as one of the active medications at the time of hospital admission were included. RESULTS: 37 249 patients in medical and surgical intensive care units were screened for the study period. After excluding patients who did not qualify, 558 unique encounters were included. The median age was 69 (IQR 59-78) years; most patients were male, white Caucasians, and had a median SOFA score of 4. After excluding the patients who had major bleeding episodes in the first 24 hours, 188 (39%) were continued on the same DOAC therapy, 204 (42%) were discontinued without transitioning to another agent, and 95 (20%) were transitioned to another agent. Finally, 410 (84%) were dismissed on DOAC therapy at the end of hospitalization. The difference in the continuation rate of the same DOAC agent beyond 24 hours, discontinuation without transition to an alternate agent, or discontinuation of DOAC with a transition to an alternate anticoagulation agent was not statistically significant (P = .60). A total of 52 major bleeding events were identified. Gastrointestinal bleeding was the most common bleeding complication [n (%): 34 (65)], followed by intra-abdominal and peri-procedural bleeding [7 (13.5) and 7 (13.5)]. Thirty-three (65%) patients had a major bleeding complication requiring intervention. CONCLUSIONS: Our single-center retrospective study describes the current prescribing practices and preliminary outcomes in ICU patients with prehospital use of DOACs. Up to 20% of the patients were transitioned to a different agent within 24 hours of ICU admission, whereas a significant proportion of patients (42%) had anticoagulation discontinued altogether. Most patients who suffered a major bleeding episode required either endoscopic or surgical intervention to control bleeding.

Implementation and evaluation of sepsis surveillance and decision support in medical ICU and emergency department.

OBJECTIVE: To improve the timely diagnosis and treatment of sepsis many institutions implemented automated sepsis alerts. Poor specificity, time delays, and a lack of actionable information lead to limited adoption by bedside clinicians and no change in practice or clinical outcomes. We aimed to compare sepsis care compliance before and after a multi-year implementation of a sepsis surveillance coupled with decision support in a tertiary care center. DESIGN: Single center before and after study. SETTING: Large academic Medical Intensive Care Unit (MICU) and Emergency Department (ED). POPULATION: Patients 18 years of age or older admitted to *** Hospital MICU and ED from 09/4/2011 to 05/01/2018 with severe sepsis or septic shock. INTERVENTIONS: Electronic medical record-based sepsis surveillance system augmented by clinical decision support and completion feedback. MEASUREMENTS AND MAIN RESULTS: There were 1950 patients admitted to the MICU with the diagnosis of severe sepsis or septic shock during the study period. The baseline characteristics were similar before (N = 854) and after (N = 1096) implementation of sepsis surveillance. The performance of the alert was modest with a sensitivity of 79.9%, specificity of 76.9%, positive predictive value (PPV) 27.9%, and negative predictive value (NPV) 97.2%. There were 3424 unique alerts and 1131 confirmed sepsis patients after the sniffer implementation. During the study period average care bundle compliance was higher; however after taking into account improvements in compliance leading up to the intervention, there was no association between intervention and improved care bundle compliance (Odds ratio: 1.16; 95% CI: 0.71 to 1.89; p-value 0.554). Similarly, the intervention was not associated with improvement in hospital mortality (Odds ratio: 1.55; 95% CI: 0.95 to 2.52; p-value: 0.078). CONCLUSIONS: A sepsis surveillance system incorporating decision support or completion feedback was not associated with improved sepsis care and patient outcomes.

Outcome after intubation for septic shock with respiratory distress and hemodynamic compromise: an observational study.

BACKGROUND: Acute respiratory failure in septic patients contributes to higher in-hospital mortality. Intubation may improve outcome but there are no specific criteria for intubation. Intubation of septic patients with respiratory distress and hemodynamic compromise may result in clinical deterioration and precipitate cardiovascular failure. The decision to intubate is complex and multifactorial. The purpose of this study was to evaluate the impact of intubation in patients with respiratory distress and predominant hemodynamic instability within 24 h after ICU admission for septic shock. METHODS: We conducted a retrospective analysis of a prospective registry of adult patients with septic shock admitted to the medical ICU at Mayo Clinic, between April 30, 2014 and December 31, 2017. Septic shock was defined by persistent lactate > 4 mmol/L, mean arterial pressure < 65 mmHg, or vasopressor use after 30 mL/kg fluid boluses and suspected or confirmed infection. Patients who remained hospitalized in the ICU at 24 h were separated into intubated while in the ICU and non-intubated groups. The primary outcome was hospital mortality. The first analysis used linear regression models and the second analysis used time-dependent propensity score matching to match intubated to non-intubated patients. RESULTS: Overall, 358 (33%) ICU patients were eventually intubated after their ICU admission and 738 (67%) were not. Intubated patients were younger, transferred more often from an outside facility, more critically ill, had more lung infection, and achieved blood pressure goals more often, but lactate normalization within 6 h occurred less often. Among those who remained hospitalized in the ICU 24 h after sepsis diagnosis, the crude in-hospital mortality was higher in intubated than non-intubated patients, 89 (26%) vs. 82 (12%), p < 0.001, as was the ICU mortality and ICU and hospital length of stay. After adjustment, intubation showed no effect on hospital mortality but resulted in fewer hospital-free days through day 28. One-to-one propensity resulted in similar conclusion. CONCLUSIONS: Intubation within 24 h of sepsis was not associated with hospital mortality but resulted in fewer 28-day hospital-free days. Although intubation remains a high-risk procedure, we did not identify an increased risk in mortality among septic shock patients with predominant hemodynamic compromise.

Impact of time to antibiotic on hospital stay, intensive care unit admission, and mortality in febrile neutropenia.

PURPOSE: To determine if time to antibiotics (TTA) improves outcomes of hospital length of stay, admission to the intensive care unit, and 30-day mortality in adult patients with febrile neutropenia. METHODS: This retrospective cohort study evaluated the impact of time to antibiotic, in the treatment of febrile neutropenia, on hospital length of stay, admission to the intensive care unit, and 30-day mortality. Cases included were patients 18 years or older hospitalized with febrile neutropenia from August 1, 2006 to July 31, 2016. To adjust for other characteristics associated with hospital length of stay, admission to the intensive care unit, and 30-day mortality, a multivariate analysis was performed. RESULTS: A total of 3219 cases of febrile neutropenia were included. The median hospital length of stay was 7.0 days (IQR 4.1-13.3), rate of intensive care unit admission was 13.6%, and 30-day mortality was 6.6%. Multivariate analysis demonstrated time to antibiotics was not associated with hospital length of stay but was associated with admission to the intensive care unit admission and 30-day mortality. Delays in time to antibiotic of up to 3 hours did not impact outcomes. CONCLUSIONS: A shorter time to antibiotic is important in treatment of febrile neutropenia; however, moderate delays in antibiotic administration did not impact outcomes. Further investigation is needed in order to determine if other indicators of infection, in addition to fever, or other supportive management, in addition to antibiotics, are indicated in the early identification and management of infection in patients with neutropenia.

Sleep-disordered breathing and stroke: therapeutic approaches.

The majority of stroke patients have clinically significant obstructive sleep apnea (OSA). Also, recent evidence demonstrates that OSA serves as an independent risk factor for stroke. Treatment of OSA following stroke is associated with neurologic and functional improvements, as well as long-term reduced risk of cardiovascular events. Identification of stroke patients at risk of OSA and subsequent diagnosis and treatment is essential in stroke recovery and reducing recurrent stroke risk. Continuous positive airway pressure (CPAP), the standard modality of treating OSA, is highly effective, but is often inadequately tolerated by stroke patients. Education and medical provider support are essential in establishing CPAP use in this population. However, in cases where CPAP therapy is not feasible, it is important for clinicians to be familiar with alternative modalities in treating OSA.

Pre-hospital use of direct oral anticoagulants agents is associated with a lower risk of major bleeding events in critically ill patients: A single academic center experience.

BACKGROUND: The last decade has witnessed significant advancements in direct oral anticoagulants (DOACs), transforming the landscape of anticoagulation therapy. With the uptrend in DOACs use, critical care physicians are encountering more patients with pre-hospital DOACs prescription. Safety and real world outcomes-related data on DOACs use in critically ill patients are scarce. OBJECTIVE: We assess the risk of major bleeding (MB) events and patient-centered outcomes with pre-hospital use of direct oral anticoagulant agents (DOACs) compared to warfarin therapy. METHODS: Observational study in a single large academic center from January 1st, 2012, through May 4th, 2018. We included adult critically ill patients with warfarin or one of the DOACs, as active medications at the time of hospital admission. The primary outcome was major bleeding (MB), based on the ISTH criteria RESULTS: 99,481 patients were screened; 558 and 3037 patients were included in the final analysis for the DOAC and warfarin groups, respectively. Multivariable analysis showed that the pre-hospital use of DOACs was associated with lower odds for major bleeding events, GI bleeding, need for endoscopic intervention, hemorrhagic shock, any blood transfusion; but higher odds of intracranial bleeding, as compared to warfarin use. There was no difference in hospital length of stay or ICU-free days. CONCLUSIONS: Pre-hospital use of DOACs among critically ill patients is associated with lower major bleeding events, GI bleeding, need for endoscopic intervention, and blood transfusion but a higher risk for intracranial bleeding.

The Resident Learning Journey in the Medical Intensive Care Unit.

Background: The medical intensive care unit (MICU) offers rich resident learning opportunities, but traditional teaching strategies can be difficult to employ in this fast-paced, high-acuity environment. Resident perspectives of learning within this environment may improve our understanding of the common challenges residents face and inform novel approaches to transform the MICU educational experience. Objective: We conducted a qualitative study of internal medicine residents to better understand their approach to learning the critical care activities that they are entrusted to perform in the MICU. Methods: Using a thematic analysis approach, we conducted six focus group interviews with 15 internal medicine residents, separated by postgraduate year. A trained investigator led each interview, which was audio-recorded and transcribed verbatim for analysis. Our diverse research team, representing different career stages across the continuum of learning to minimize interpretive bias, identified codes and subsequent themes inductively. We refined these themes through group discussion and sensitizing social learning theory concepts using Wenger's community of practice and organized them to create learner archetypes and a conceptual framework of resident learning in the MICU. Results: We identified three thematic resident learning categories: learning goals and motivation, clinical engagement, and interprofessional collaboration. We distinguished three learner archetypes, the novice, experiential learner, and practicing member, to describe progressive resident development within the interprofessional MICU team, the challenges they frequently encounter, and potential teaching strategies to facilitate learning. Conclusion: We developed a conceptual framework that describes the resident's journey to becoming a trusted, collaborating member of the interprofessional MICU team. We identified common developmental challenges residents face and offer educational strategies that may support their progress. These findings should inform future efforts to develop novel teaching strategies to promote resident learning in the MICU.

Vitamin D Status and Severe COVID-19 Disease Outcomes in Hospitalized Patients.

BACKGROUND: Vitamin D deficiency may increase the risk of severe COVID-19 disease. OBJECTIVES: To determine if 25-hydroxyvitamin D [25(OH)D] levels in patients hospitalized for COVID-19 were associated with the clinical outcomes of days on oxygen, duration of hospitalization, ICU admission, need for assisted ventilation, or mortality. METHODS: We conducted a retrospective study of 92 patients admitted to the hospital with SARS-CoV-2 infection between April 16, 2020 and October 17, 2020. Multivariable regression was performed to assess the independent relationship of 25(OH)D values on outcomes, adjusting for significant covariates and the hospitalization day the level was tested. RESULTS: About 15 patients (16.3%) had 25(OH)D levels <20 ng/mL. Only 1 patient (3.4%) who had documented vitamin D supplementation prior to admission had 25(OH)D <20 ng/mL. Serum 25(OH)D concentrations were not significantly associated with any of our primary outcomes of days on oxygen, duration of hospitalization, intensive care unit (ICU) admission, need for mechanical ventilation, or mortality in any of the adjusted multivariable models. Adjusting for the hospital day of 25(OH)D sampling did not alter the relationship of 25(OH)D with any outcomes. CONCLUSION: Vitamin D status was not related to any of the primary outcomes reflecting severity of COVID-19 in hospitalized patients. However, our sample size may have lacked sufficient power to demonstrate a small effect of vitamin D status on these outcomes.

Improvement in Mortality With Early Fluid Bolus in Sepsis Patients With a History of Congestive Heart Failure.

OBJECTIVE: To determine whether rapid administration of a crystalloid bolus of 30 mL/kg within 3 hours of presentation harms or benefits hypotensive patients with sepsis with a history of congestive heart failure (CHF). PATIENTS AND METHODS: A retrospective cohort study using Medicare claims data enhanced by medical record data from members of the High Value Healthcare Collaborative from July 1, 2013, to June 30, 2015, examining patients with a history of CHF who did (fluid bundle compliant [FBC]) or did not (NFBC) receive a volume bolus of 30 mL/kg within 3 hours of presentation to the emergency department. A proportional Cox hazard model was used to evaluate the association of FBC with 1-year survival. RESULTS: Of the 211 patients examined, 190 were FBC and 21 were NFBC. The FBC patients had higher average hierarchical condition category scores but were otherwise similar to NFBC patients. The NFBC patients had higher adjusted in-hospital and postdischarge mortality rates. The risk-adjusted 1-year mortality rate was higher for NFBC patients (hazard ratio, 2.18; 95% CI, 1.2 to 4.0; P=.01) than for FBC patients. CONCLUSION: In a retrospective claim data-based study of elderly patients with a history of CHF presenting with severe sepsis or septic shock, there is an association of improved mortality with adherence to the initial fluid resuscitation guidelines as part of the 3-hour sepsis bundle.

Rationale, design, and development of SleepWell24: A smartphone application to promote adherence to positive airway pressure therapy among patients with obstructive sleep apnea.

BACKGROUND: Positive airway pressure (PAP) therapy is the gold standard treatment for obstructive sleep apnea (OSA), a chronic disorder that affects 6-13% of the adult population. However, adherence to PAP therapy is challenging, and current approaches to improve adherence have limited efficacy and scalability. METHODS/DESIGN: To promote PAP adherence, we developed SleepWell24, a multicomponent, evidence-based smartphone application that delivers objective biofeedback concerning PAP use and sleep/physical activity patterns via cloud-based PAP machine and wearable sensor data, and behavior change strategies and troubleshooting of PAP therapy interface use. This randomized controlled trial will evaluate the feasibility, acceptability, and initial efficacy of SleepWell24 compared to a usual care control condition during the first 60 days of PAP therapy among patients newly diagnosed with OSA. DISCUSSION: SleepWell24 is an innovative, multi-component behavior change intervention, designed as a self-management approach to addressing the psychosocial determinants of adherence to PAP therapy among new users. The results will guide lengthier future trials that assess numerous patient-centered and clinical outcomes.

Pharmacologic Treatment of Intensive Care Unit Delirium and the Impact on Duration of Delirium, Length of Intensive Care Unit Stay, Length of Hospitalization, and 28-Day Mortality.

OBJECTIVE: To determine whether treatment of delirium affects outcomes. PATIENTS AND METHODS: A retrospective cohort study of patients admitted to the medical intensive care unit (ICU) from July 1, 2015, through June 30, 2016, was conducted. Patients with ICU delirium, defined by a positive Confusion Assessment Method for the ICU score, were included. Patients were stratified into 4 treatment groups based on exposure to melatonin and antipsychotic agents during ICU stay: no pharmacologic treatment, melatonin only, antipsychotics only, and both melatonin and antipsychotics. A time-dependent cause-specific hazards model with death as a competing risk was used to evaluate the effect of melatonin or antipsychotic drug use for delirium on duration of ICU delirium, length of ICU stay, and length of hospitalization. A logistic regression was used to evaluate 28-day mortality. Covariates significantly associated with exposure to melatonin and antipsychotics were included in the minimally adjusted model. Covariates significantly associated in the minimally adjusted model were included in a final adjusted model. RESULTS: A total of 449 admissions to the medical ICU were included in the analysis. Exposure to melatonin or antipsychotic agents did not reduce the duration of ICU delirium, ICU/hospital length of stay, or 28-day mortality. However, antipsychotic use only was associated with longer hospitalization. CONCLUSION: Antipsychotic drugs for the treatment ICU delirium may not provide the benefit documented in earlier literature. Further investigation on patient selection, type of antipsychotic, and dosing is needed.

Practical Implementation of Failure Mode and Effects Analysis for Extracorporeal Membrane Oxygenation Activation.

Extracorporeal membrane oxygenation (ECMO) is used to treat severe hypoxemic respiratory failure and as a rescue therapy for patients with cardiopulmonary arrest within a narrow window of time. A failure modes and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to delays in initiating ECMO. FMEA determined these highest-risk failure modes that were contributing to process failure: (1) ECMO candidacy not determined in time, (2) no or incomplete evaluation for ECMO prior to consult or arrest, (3) ECMO team not immediately available, and (4) cannulation not completed in time. When implemented collectively, a total of 4 interventions addressed more than 95% of the system failures. These interventions were (1) ECMO response pager held by a team required for decision, (2) distribution of institutionally defined inclusion/exclusion criteria, (3) educational training for clinicians consulting the ECMO team, and (4) establishment of a mobile ECMO insertion cart.

Risks associated with use of stimulant medications in patients with obstructive sleep apnea and cardiomyopathy: a case-control study.

OBJECTIVES: Stimulant medications are indicated in patients with obstructive sleep apnea (OSA) who experience sleepiness despite optimal control of sleep-disordered breathing. The safety of stimulant medications in patients with OSA and co-morbid cardiomyopathy is unknown. We performed a case-control study to assess cardiovascular outcomes and mortality risk associated with stimulant use in this group of patients. METHODS: A total of 162 subjects with OSA and cardiomyopathy were identified. Subjects who used stimulant medications for ≥1 month were designated as cases. Age-and-sex-matched controls not taking these medications were randomly chosen from the same cohort. Outcomes assessed were mortality, implantable cardioverter-defibrillator (ICD) and pacemaker insertion. RESULTS: Twenty-two cases and 44 controls were included in the analyses. Mean age was 62.6 ± 15 years, 72% were male. Median duration of medication use was 27 months (range 1-98). There were four deaths among cases versus eight among controls. Four cases had a pacemaker and six had an ICD inserted, compared to six and eight respectively in the control group. Age (p = 0.01) and positive airway pressure (PAP) compliance (p = 0.01), but not stimulant medication use (p = 1.00) were associated with mortality on univariate analysis. In multiple logistic regression analyses accounting for body mass index, apnea-hypopnea index/respiratory disturbance index, PAP compliance, ejection fraction and duration of follow up, use of stimulant medication was not associated with mortality (p = 0.50), pacemaker (p = 0.20) or ICD (p = 0.90) implantation. CONCLUSIONS: Stimulant medications were not associated with elevated risk of mortality, pacemaker or ICD implantation in this case-control study, even after accounting for multiple confounders.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty.

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are also intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patients' satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The Guideline Development Group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty Executive Summary.

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline executive summary is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patient satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The guideline development group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Mediastinal lymphangioma: Mayo Clinic experience of 25 cases.

OBJECTIVE: To describe the clinical findings, treatment outcomes, disease recurrence rates, and survival of patients with pathologically confirmed mediastinal and cervicomediastinal lymphangioma. PATIENTS AND METHODS: There are 2 patient cohorts. Cohort A consisted of 12 Mayo Clinic patients with pathologically confirmed medilastinal or cervicomediastinal lymphangioma identified from 1986 to 1999. Cohort B consisted of 13 additional patients with mediastinal lymphangioma who had been previously reported from the Mayo Clinic (from 1976 to 1986). All patients were retrospectively identified, and follow-up was performed by either telephone or medical record review. RESULTS: The mean age at the time of diagnosis was 36.5 years, with a male-female ratio of 1:3. All but 3 patients were symptomatic at presentation, with dyspnea being the most common symptom. Computed tomographic scans commonly revealed a homogeneous, low-attenuation mass that often Involved vascular or airway structures. Although 3 patients were initially observed, all patients had surgical intervention because of symptoms or enlargement of the mass. Thoracotomy with resection was the most common surgical intervention. Five recurrences were noted. Recurrence was minimized by complete excision of the lymphangioma. On follow-up that spanned 23 years, 75% of patients were alive. These survival rates were not statistically different from the expected survival rates of the same age- and sex-matched controls. Only 1 death was attributed to complication from lymphangioma. CONCLUSION: Mediastinal and cervicomediastinal lymphangioma are rare lesions that can be treated successfully with surgical excision. Prognosis appears to be excellent because no difference in survival was found between patients and age- and sex-matched controls.

Diagnostic accuracy and clinical relevance of an inflammatory biomarker panel for sepsis in adult critically ill patients.

The objective of this study was to assess the diagnostic accuracy of C-reactive protein (CRP), procalcitonin (PCT), and cellular immune markers levels in sepsis. This was a prospective observational study in adult intensive care unit (ICU) patients, between 2012 and 2014. The 8-color flow cytometric biomarker panel included CD64, CD163, and HLA-DR. Index test results were compared with sepsis, using receiver operating characteristic curve analyses. Multivariate logistic regression assessed the relationship of sets of markers with the probability of sepsis. Of 219 enrolled patients, 120 had sepsis. C-statistic was the highest for CRP (0.86) followed by neutrophil CD64 expression (0.83), procalcitonin (0.82), and Acute Physiology and Chronic Health Evaluation (APACHE) IV (0.72). After adjustment for APACHE IV, the combination of CRP, PCT, and neutrophil CD64 measure remained a significant predictor of sepsis with an excellent AUC (0.90). In a targeted ICU population at increased risk of sepsis, CRP, PCT, and neutrophil CD64 combined improve the diagnostic accuracy of sepsis.

Obstructive sleep apnea-hypopnea syndrome.

OSAHS should be an expected condition in many patients encountered by primary care providers. The diagnosis may arise because of patient daytime dysfunction, partner prompting, or in the course of managing comorbidities adversely influenced by the hemodynamic, neural, humoral,and inflammatory consequences of repetitive desaturations and arousals.OSAHS should be suspected in patients who exhibit habitually loud snoring, witnessed apneas/choking/gasping during sleep, hypertension, neck circumferences of 17 inches or greater, obesity, and laterally narrowed oropharynxes. Diagnosis is established by polysomnography. CPAP is the treatment of choice for most patients. Education, follow-up, and heated humidification may help bolster compliance. Lifestyle modifications, oral appliances, and upper surgeries are additional treatment options.