Acute Hyperglycemia and In-Hospital Mortality in Spontaneous Intracerebral Hemorrhage.

Hyperglycemia is reported to predict worse outcome in patients with stroke, including intracerebral hemorrhage (ICH). In 83 consecutive cases of ICH at a tertiary stroke center, hyperglycemia (serum glucose >7 mmol/L) compared to normoglycemia at presentation was associated with higher rates of in-hospital mortality (51.2% vs. 26.2%, OR 2.3, CI 1.2-7.6, p = 0.02). The association with in-hospital mortality withstood adjustment for age, ICH volume, intraventricular hemorrhage, and infratentorial ICH location, but not baseline Glasgow Coma Scale. Acute hyperglycemia is associated with in-hospital mortality in spontaneous ICH patients, though this may be an indirect, rather than a causal relationship.

Patient and family engagement in patient care and research in Canadian intensive care units: a national survey.

PURPOSE: While patient and family engagement may improve clinical care and research, current practices for engagement in Canadian intensive care units (ICUs) are unknown. METHODS: We developed and administered a cross-sectional questionnaire to ICU leaders of current engagement practices, facilitators, and barriers to engagement, and whether engagement was a priority, using to an ordinal Likert scale from 1 to 10. RESULTS: The response rate was 53.4% (124/232). Respondents were from 11 provinces and territories, mainly from medical surgical ICUs (76%) and community hospitals (70%). Engagement in patient care included bedside care (84%) and bedside rounds (66%), presence during procedures/crises (65%), and survey completion (77%). Research engagement included ethics committees (36%), protocol review (31%), and knowledge translation (30%). Facilitators of engagement in patient care included family meetings (87%), open visitation policies (81%), and engagement as an institutional priority (74%). Support from departmental (43%) and hospital (33%) leadership was facilitator of research engagement. Time was the main barrier to engagement in any capacity. Engagement was a higher priority in patient care vs research (median [interquartile range], 8 [7-9] vs 3 [1-7]; P < 0.001) and in pediatric vs adult ICUs (10 [9-10] vs 8 [7-9]; P = 0.003). Research engagement was significantly higher in academic vs other ICUs (7 [5-8] vs 2 [1-4]; P < 0.001), and pediatric vs adult ICUs (7 [5-8] vs 3 [1-6]; P = 0.01). CONCLUSIONS: Organizational strategies and institutional support were key facilitators of engagement. Engagement in patient care was a higher priority than engagement in research.

RéSUMé: OBJECTIF: Bien que l'engagement des patients et des familles puisse améliorer les soins cliniques et la recherche, les pratiques actuelles en matière d'engagement dans les unités de soins intensifs (USI) canadiennes sont inconnues. MéTHODE: Nous avons élaboré et administré un questionnaire transversal à l'intention des dirigeants des USI portant sur les pratiques d'engagement actuelles, les facilitateurs et les obstacles à l'engagement, ainsi que la priorisation de l'engagement, en utilisant une échelle de Likert ordinale de 1 à 10. RéSULTATS: Le taux de réponse était de 53,4 % (124/232). Les répondants provenaient de 11 provinces et territoires, principalement d'USI médico-chirurgicales (76%) et d'hôpitaux communautaires (70%). L'engagement dans les soins aux patients comprenait les soins au chevet du patient (84%) et les tournées au chevet (66%), la présence pendant les interventions ou les crises (65%), et la complétion des questionnaires (77%). La participation à la recherche comprenait les comités d'éthique (36%), l'examen des protocoles (31%) et le transfert des connaissances (30%). Les facilitateurs à l'engagement dans les soins aux patients comprenaient les réunions familiales (87%), les politiques de visites ouvertes (81%) et l'engagement en tant que priorité institutionnelle (74%). Le soutien des directions de département (43%) et d'hôpital (33%) a été un facilitateur de l'engagement en recherche. Le temps était le principal obstacle à l'engagement à quelque titre que ce soit. L'engagement était une priorité plus élevée dans les soins aux patients qu'en recherche (médiane [écart interquartile], 8 [7­9] vs 3 [1­7]; P < 0,001) et dans les USI pédiatriques vs adultes (10 [9­10] vs 8 [7­9]; P = 0,003). L'engagement en matière de recherche était significativement plus élevé dans les USI universitaires vs autres (7 [5­8] vs 2 [1­4]; P < 0,001), et pédiatriques vs pour adultes (7 [5­8] vs 3 [1­6]; P = 0,01). CONCLUSION: Les stratégies organisationnelles et le soutien institutionnel ont été des facilitateurs clés de l'engagement. L'engagement dans les soins aux patients était une priorité plus élevée que l'engagement dans la recherche.

Chlorhexidine (di)gluconate locking device for central line infection prevention in intensive care unit patients: a multi-unit, pilot randomized controlled trial.

PURPOSE: Intensive care unit (ICU) patients are at risk for central line-associated bloodstream infection (CLABSI) with significant attributable mortality and increased hospital length of stay, readmissions, and costs. Chlorhexidine (di)gluconate (CHG) is used as a disinfectant for central line insertion; however, the feasibility and efficacy of using CHG as a locking solution is unknown. METHODS: Patients with a central venous access device (CVAD) in situ were randomized to standard care or a CHG lock solution (CHGLS) within 72 hours of ICU admission. The CHG solution was instilled in the lumen of venous catheters not actively infusing. CVAD blood cultures were taken at baseline and every 48 hours. The primary outcome was feasibility including recruitment rate, consent rate, protocol adherence, and staff uptake. Secondary outcomes included CVAD colonization, bacteraemia, and clinical endpoints. RESULTS: Of 3,848 patients screened, 122 were eligible for the study and consent was obtained from 82.0% of the patients or substitute decision makers approached. Fifty participants were allocated to each group. Tracking logs indicated that the CHGLS was used per protocol 408 times. Most nurses felt comfortable using the CHGLS. The proportion of central line colonization was significantly higher in the standard care group with 40 (29%) versus 26 (18.7%) in the CHGLS group (P=0.009). CONCLUSIONS: Using a device that delivers CHG into CVADs was feasible in the ICU. Findings from this trial will inform a full-scale randomized controlled trial and provide preliminary data on the effectiveness of CHGLS. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03309137, registered on October 13, 2017.

Assessing the Quality of Evidence Presented at the Annual Conferences of Diabetes Canada.

OBJECTIVES: Annual general meetings (AGMs) are often seen and promoted as great sources of contemporary information for the modern health-care professional. The quality of research evidence presented at these conferences, however, remains unclear. This paper evaluates the level of evidence (LoE) of research presented at the 2015 to 2019 AGMs of Diabetes Canada (DC). METHODS: Using the framework we first published to evaluate the LoE presented at the Canadian Society of Nephrology (CSN) AGMs, 2 authors independently assigned eligible abstracts a study type and grade. Research assistants separately recorded corresponding author and city affiliations. RESULTS: Of 832 published abstracts, 68% (N=568) met the inclusion criteria. These abstracts were classified as follows: 12% Level I (highest quality); 30% Level II; 36% Level III; 14% Level IV and 8% Level V (lowest quality). The LoE remained consistent over the 5-year study period, as observed by the Jonckheere-Terpstra test (p=0.754). The LoE of DC AGMs was similar to that of CSN AGMs (p=0.125). The number of authors was positively associated with improved LoE (p<0.001). CONCLUSIONS: Based on our novel auditing methodology, the LoE of DC AGMs is on par with other analyzed national AGMs. Adoption of this metric for all AGMs would aid in identifying unfavourable trends and alert planning and abstract selection committees of trends in LoE. Such studies will increase transparency for stakeholders and facilitate quality improvement initiatives.

CardiO Cycle: a pilot feasibility study of in-bed cycling in critically ill patients post cardiac surgery.

BACKGROUND: In-bed cycling is a novel modality for the initiation of early mobilization in the intensive care unit. No study has investigated its use in the critically ill, off-track post cardiac surgery population. Before conducting an effectiveness trial, feasibility data are needed. The aim of this study was to determine the feasibility of in-bed cycling in a population of off-track cardiac surgery patients. METHODS: We conducted a prospective feasibility study in a 16-bed adult cardiac surgery intensive care unit in Ontario, Canada. Previously ambulatory adults (≥ 18 years) who were mechanically ventilated for ≥ 72 h were enrolled within 3 to 7 days post cardiac surgery. Twenty minutes of in-bed cycling was delivered by ICU physiotherapists 5 days/week. The primary outcome, feasibility, was the percent of patient-cycling sessions that occurred when cycling was appropriate. The secondary outcome was cycling safety, measured as cycling discontinuation due to predetermined adverse events. RESULTS: We screened 2074 patients, 29 met eligibility criteria, and 23 (92%) consented. Patients were male (78.26%) with a median [IQR] age of 76 [11] years, underwent isolated coronary bypass (39.1%), and had a median EuroScore II of 5.4 [7.8]. The mean (SD) time post-surgery to start of cycling was 5.9 (1.4) days. Patients were cycled on 80.5% (136/169) of eligible days, with limited physiotherapy staffing accounting for 48.5% of the missed patient-cycling sessions. During 136 sessions of cycling, 3 adverse events occurred in 3 individual patients. The incidence of an adverse event was 2.2 per 100 patient-cycling sessions (95% CI 0.50, 6.4). CONCLUSIONS: In-bed cycling with critically ill cardiac surgery patients is feasible with adequate physiotherapy staffing and appears to be safe. Future studies are needed to determine the effectiveness of this intervention in a larger sample. TRIAL REGISTRATION: This trial was registered with Clinicaltrials.gov ( NCT02976415 ). Registered November 29, 2016.

Chlorhexidine locking device for central line infection prevention in ICU patients: protocol for an open-label pilot and feasibility randomized controlled trial.

BACKGROUND: Critically ill patients in the intensive care unit (ICU) are at risk for central line-associated bloodstream infection (CLABSI) with an incidence up to 6.9 per 1000 catheter days. CLABSI has a significant attributable mortality and increases in-hospital length of stay, readmissions, and costs. Chlorhexidine gluconate (CHG), a broad-spectrum biocide, has been shown to effectively reduce infections including CLABSI; however, few trials have utilized CHG for prevention of central line infections. Our preclinical work has demonstrated a device that diffuses CHG into the intravenous lock solution of central venous catheters and decreases bacterial growth on the catheter lumen. We designed a clinical trial to test the feasibility of using a CHG device in an ICU patient population. METHODS: The proposed pilot trial will be a single centre, open-label, two-arm, parallel group feasibility randomized controlled trial (RCT). Participants will have a central line in situ and will be enrolled within 72 h of admittance to 3 ICUs at a single academic hospital. Exclusion criteria will include suspected infection, chronic indwelling catheters, and CHG allergy. Informed consent will be obtained from eligible participants or their substitute decision maker prior to randomization. Participants will be randomized to receive either usual care or the CHG locking device. Blood cultures will be drawn from all participants every 48 h. The primary objective of this study will be to determine the feasibility of using this protocol to conduct a larger trial. Feasibility will be assessed through the following outcomes: (1) consent rate, (2) recruitment rate, (3) protocol adherence, and (4) comfort level with the device. The secondary objective of this study will be to establish the preliminary efficacy of the device. DISCUSSION: This study will be the first human RCT to investigate a CHG locking device for the prevention of central line infections. Findings from this trial will inform the feasibility of conducting a large RCT and provide preliminary data on the efficacy of a CHG locking device. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03309137, registered on October 13, 2017.

Identification of hemostatic markers that define the pre-DIC state: A multi-center observational study.

BACKGROUND: A limitation of diagnostic scoring systems for disseminated intravascular coagulation (DIC) is that once DIC is identified, it may be in a state of irreversible deterioration. OBJECTIVES: To identify hemostatic markers that can identify the pre-DIC state. METHODS: This was a multi-center observational study of 357 septic patients. The incidence of DIC was determined using the International Society on Thrombosis and Haemostasis (ISTH) DIC Score. Markers of interest include components of the DIC score: protein C (PC), antithrombin (AT), and citrullinated histones (H3Cit), which is a marker of NETosis. RESULTS: Out of 357 sepsis patients, 236 patients did not develop DIC (without-DIC), 79 patients had DIC on Day 1 (overt-DIC), and 42 patients developed DIC after Day 1 (pre-DIC). Compared to without-DIC patients, pre-DIC patients had decreased platelet count, increased international normalized ratio (INR), decreased PC and AT, and increased H3Cit. In contrast, D-dimer and fibrinogen levels did not differ between pre-DIC and without-DIC patients. Using receiver operating characteristics (ROC) analysis, we found that platelet count and INR in combination with PC and AT could discriminate pre-DIC from without-DIC. The area under the curve in the ROC analysis was 0.83 (95% confidence interval, 0.76 to 0.89). CONCLUSION: Our study suggests that platelets and INR in combination with PC and AT can identify the pre-DIC state in septic patients. In contrast, D-dimer increased and fibrinogen decreased in the late (ie, overt) stages of DIC. Our data also suggest that NETosis contributes to the onset of DIC in sepsis.

Assessing the Quality of Evidence Presented at Annual General Meetings: A 5-Year Retrospective Study.

INTRODUCTION: Health care professionals rely on annual general meetings (AGMs) to obtain up-to-date information and practice guidelines relevant to their specialty. The majority of such information at meetings is presented through abstract sessions. However, the quality of the evidence presented during such abstract sessions is unclear. Standardized measures were applied to assess the quality of evidence of abstracts presented at the Canadian Society of Nephrology AGM over a 5-year period. METHODS: Two authors independently reviewed all CSN AGM abstracts presented from 2012 to 2016. Using a schema published in 2011 by the Oxford Centre for Evidence-Based Medicine (OCEBM), each abstract was subsequently ranked based on the quality of evidence. Schema categories ranged from level I, representing the highest evidence quality, to level V, representing the lowest. The number of authors and the authors' institution affiliations were also collected from the abstracts, where available, or if affiliations were unclear, an internet search of the author was performed. RESULTS: Six hundred forty-two articles were screened. In total, 70% (n = 450) met the inclusion criteria. When assessed, 15% of articles were level I (highest quality), 17% level II, 53% level III, 12% level IV, and 3% level V (lowest quality). A Jonckheere-Terpstra test demonstrated a significant trend of increasing quality of evidence (P < .05) and collaboration (P < .005) over the 5-year study period. There was a significant correlation between level of evidence and collaboration across years reviewed in the study, rs(98) = -0.226, P < .001. DISCUSSION: The results indicate a consistent increase in quality of evidence and collaborative submissions over time. To the authors' knowledge, this is the first assessment and analysis of AGM presentation quality within internal medicine and its subspecialties. Documenting and monitoring changes in the quality of evidence with a standardized framework may offer valuable insight pertaining to the medical field and the research community.

Mortality Risk Profiles for Sepsis: A Novel Longitudinal and Multivariable Approach.

To determine if a set of time-varying biological indicators can be used to: 1) predict the sepsis mortality risk over time and 2) generate mortality risk profiles. DESIGN: Prospective observational study. SETTING: Nine Canadian ICUs. SUBJECTS: Three-hundred fifty-six septic patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical data and plasma levels of biomarkers were collected longitudinally. We used a complementary log-log model to account for the daily mortality risk of each patient until death in ICU/hospital, discharge, or 28 days after admission. The model, which is a versatile version of the Cox model for gaining longitudinal insights, created a composite indicator (the daily hazard of dying) from the "day 1" and "change" variables of six time-varying biological indicators (cell-free DNA, protein C, platelet count, creatinine, Glasgow Coma Scale score, and lactate) and a set of contextual variables (age, presence of chronic lung disease or previous brain injury, and duration of stay), achieving a high predictive power (conventional area under the curve, 0.90; 95% CI, 0.86-0.94). Including change variables avoided misleading inferences about the effects of day 1 variables, signifying the importance of the longitudinal approach. We then generated mortality risk profiles that highlight the relative contributions among the time-varying biological indicators to overall mortality risk. The tool was validated in 28 nonseptic patients from the same ICUs who became septic later and was subject to 10-fold cross-validation, achieving similarly high area under the curve. CONCLUSIONS: Using a novel version of the Cox model, we created a prognostic tool for septic patients that yields not only a predicted probability of dying but also a mortality risk profile that reveals how six time-varying biological indicators differentially and longitudinally account for the patient's overall daily mortality risk.

Attitudes toward the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain: A qualitative study.

BACKGROUND: Chronic noncancer pain (CNCP) refers to all pain disorders, not due to cancer, that persist for ≥3 months. The point prevalence of CNCP in the general population of Western countries is between 19 and 33 percent. Opioids are commonly prescribed for CNCP and are associated with both benefits and harms. The Canadian Guideline for Safe and Effective Use of Opioids for CNCP was published in 2010 to provide guidance for optimal opioid prescribing in patients with CNCP. OBJECTIVES: To investigate the attitudes toward, and use of, the Canadian Opioids Guideline among pain physicians. DESIGN: A qualitative study using one-on-one, semistructured interviews with 12 pain physicians in Ontario, Canada, and thematic analysis of verbatim transcripts. RESULTS: Major themes that emerged from interviews included: (1) generally positive attitudes toward the 2010 Canadian Opioids Guideline, but limited use-half (six of 12) reported they did not use the guideline in practice; (2) strongly contrasting views regarding the 200 mg/d morphine equivalent watchful dose; (3) recognition of gaps in the guideline, especially recommendations for urine drug screening and pain severity-specific therapy; (4) the guideline is excessively long and the format suboptimal; and (5) improved dissemination and education are needed to enhance guideline uptake. CONCLUSIONS: Despite its merits, the Canadian Opioids Guideline suffers from information gaps and from limited uptake, at least in part due to suboptimal format and suboptimal dissemination.