Strengthening neurosurgical training programs in Sub-saharan Africa: a medical student's perspective.

This article provides a nuanced exploration of the state and exigencies of neurosurgical training in sub-Saharan Africa (SSA), viewed through the discerning lens of a medical student. The region has a pronounced scarcity of neurosurgical services, further compounded by sociocultural intricacies and infrastructural inadequacies, resulting in elevated mortality and morbidity rates. The insufficiency of neurosurgeons, facilities, and training centers, particularly in remote areas, exacerbates this predicament. The imperative to fortify neurosurgical training programs is underscored, necessitating a multifaceted approach inclusive of international collaborations and innovative strategies. The challenges impeding neurosurgical training program implementation range from constrained infrastructure to faculty shortages and financial constraints. Recommendations encompass infrastructural investments, faculty development initiatives, and augmented community engagement. An exploration of neurosurgical training programs across diverse African regions reveals commendable strides and imminent deficits, warranting heightened international collaboration. Furthermore, technological innovations, including virtual reality, robotics, and artificial intelligence, are posited as transformative conduits for augmenting neurosurgical training in SSA. The article concludes with a sagacious compendium of recommendations, encompassing standardized curricula, mentorship paradigms, and stringent evaluation mechanisms, all combining efficaciously fortifying neurosurgical insight in SSA and producing transformative improvements in healthcare outcomes.

Kratom: A growing substance of abuse in the United States.

BACKGROUND: Use of kratom is increasing in the United States due to its perceived safety as a botanical product. This review provides salient information about kratom for the practicing clinician. METHODS: We conducted a literature search of MedLine, UpToDate, and Google using the terms "kratom" and "Mitragyna speciosa" for articles published within the last 10 years. RESULTS: We reviewed > 500 articles. Kratom is derived from the Mitragyna speciosa plant of Southeast Asia. It has grown in popularity within the United States due to its dual effects of acting as a stimulant at low doses and acting as an opioid-like substance at higher dosages. The 2 major active ingredients in kratom, mitragynine and 7-OH mitragynine, act as partial agonists at the mu-opioid receptor. While adverse consequences are normally mild, there are several potentially serious adverse effects, including respiratory depression, especially with chronic, high-dose usage. Furthermore, in case reports, concomitant use of kratom with other substances has been linked to seizures. Unfortunately, an increasing number of deaths have been linked to kratom usage. Six states have made it illegal to possess or sell kratom. CONCLUSIONS: Kratom is an emerging drug of abuse in the United States. Its use is increasing in individuals who may seek to experience an opioidlike "high" as well as to help reduce withdrawal effects from other opioids.

Pharmacological interventions for prevention and treatment of upper gastrointestinal bleeding in newborn infants.

BACKGROUND: Upper gastrointestinal bleeding is typically a mild, self-limiting condition that can affect both preterm and term neonates, although it can be severe particularly when associated with co-morbidities. Pharmacological interventions with a proton pump inhibitor (PPI), H2 receptor antagonist (H2RA), antacid, bismuth and sucralfate may have effects on both the prevention and treatment of upper gastrointestinal bleeding in infants. OBJECTIVES: To assess how different pharmacological interventions (PPIs, H2RAs, antacids, sucralfate or bismuth salts) administered to preterm and term neonates for the prevention or treatment of upper gastrointestinal bleeding to reduce morbidity and mortality compare with placebo or no treatment, supportive care, or each other. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 6), MEDLINE via PubMed (1966 to 12 July 2018), Embase (1980 to 12 July 2018), and CINAHL (1982 to 12 July 2018). We also searched clinical trial databases, conference proceedings, the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials, and online for Chinese literature articles. SELECTION CRITERIA: We selected randomised, quasi-randomised and cluster-randomised trials involving preterm and term neonates. Trials were included if they used a proton pump inhibitor, H2 receptor antagonist, antacid, sucralfate or bismuth either for the prevention or treatment of upper gastrointestinal bleeding. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility of studies for inclusion, extracted data and assessed methodological quality. We conducted meta-analysis using a fixed-effect model. We used the GRADE approach to assess quality of evidence. MAIN RESULTS: Eleven studies with 818 infants met the criteria for inclusion in this review.Four trials with 329 infants assessed the use of an H2 receptor antagonist for prevention of upper gastrointestinal bleeding in high-risk newborn infants. Meta-analysis of these four trials identified a reduction in any upper gastrointestinal bleeding when using an H2 receptor antagonist (typical risk ratio (RR) 0.36, 95% confidence interval (CI) 0.22 to 0.58; typical risk difference (RD) -0.20, 95% CI -0.28 to -0.11; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 9). The quality of evidence was moderate. A single trial with 53 infants assessing prevention of upper gastrointestinal bleeding reported no difference in mortality in infants assigned H2 receptor antagonist versus no treatment; however the quality of evidence was very low.Seven trials with 489 infants assessed an inhibitor of gastric acid (H2 receptor antagonist or proton pump inhibitor) for treatment of gastrointestinal bleeding in newborn infants. Meta-analysis of two trials (131 infants) showed no difference in mortality from use of a H2 receptor antagonist compared to no treatment. The quality of evidence was low. Meta-analysis of two trials (104 infants) showed a reduction in duration of upper gastrointestinal bleeding from use of an inhibitor of gastric acid compared to no treatment (mean difference -1.06 days, 95% CI -1.28 to -0.84). The quality of evidence was very low. Meta-analysis of six trials (451 infants) showed a reduction in continued upper gastrointestinal bleeding from use of any inhibitor of gastric acid compared to no treatment (typical RR 0.36, 95% CI 0.26 to 0.49; typical RD -0.26, 95% CI -0.33, -0.19; NNTB 4, 95% CI 3 to 5). The quality of evidence was low. There were no significant subgroup differences in duration of upper gastrointestinal bleeding or of continued upper gastrointestinal bleeding according to type of inhibitor of gastric acid. A single trial (38 infants) reported no difference in anaemia requiring blood transfusion from use of a H2 receptor antagonist compared to no treatment.Although no serious adverse events were reported from the use of a H2 receptor antagonist or proton pump inhibitor, some neonatal morbidities - including necrotising enterocolitis, ventilator-associated pneumonia, duration of ventilation and respiratory support, and duration of hospital stay - were not reported. Long-term outcome was not reported. AUTHORS' CONCLUSIONS: There is moderate-quality evidence that use of an H2 receptor antagonist reduces the risk of gastrointestinal bleeding in newborn infants at high risk of gastrointestinal bleeding. There is low-quality evidence that use of an inhibitor of gastric acid (H2 receptor antagonist or proton pump inhibitor) reduces the duration of upper gastrointestinal bleeding and the incidence of continued gastric bleeding in newborn infants with gastrointestinal bleeding. However, there is no evidence that use of an inhibitor of gastric acid in newborn infants affects mortality or the need for blood transfusion. As no study reported the incidence of necrotising enterocolitis, ventilator- or hospital-associated pneumonia, sepsis, or long-term outcome, the safety of inhibitors of gastric acid secretion is unclear.

Stimulus-Elicited Connectivity Influences Resting-State Connectivity Years Later in Human Development: A Prospective Study.

UNLABELLED: Although the functional architecture of the brain is indexed by resting-state connectivity networks, little is currently known about the mechanisms through which these networks assemble into stable mature patterns. The current study posits and tests the long-term phasic molding hypothesis that resting-state networks are gradually shaped by recurring stimulus-elicited connectivity across development by examining how both stimulus-elicited and resting-state functional connections of the human brain emerge over development at the systems level. Using a sequential design following 4- to 18-year-olds over a 2 year period, we examined the predictive associations between stimulus-elicited and resting-state connectivity in amygdala-cortical circuitry as an exemplar case (given this network's protracted development across these ages). Age-related changes in amygdala functional connectivity converged on the same regions of medial prefrontal cortex (mPFC) and inferior frontal gyrus when elicited by emotional stimuli and when measured at rest. Consistent with the long-term phasic molding hypothesis, prospective analyses for both connections showed that the magnitude of an individual's stimulus-elicited connectivity unidirectionally predicted resting-state functional connectivity 2 years later. For the amygdala-mPFC connection, only stimulus-elicited connectivity during childhood and the transition to adolescence shaped future resting-state connectivity, consistent with a sensitive period ending with adolescence for the amygdala-mPFC circuit. Together, these findings suggest that resting-state functional architecture may arise from phasic patterns of functional connectivity elicited by environmental stimuli over the course of development on the order of years. SIGNIFICANCE STATEMENT: A fundamental issue in understanding the ontogeny of brain function is how resting-state (intrinsic) functional networks emerge and relate to stimulus-elicited functional connectivity. Here, we posit and test the long-term phasic molding hypothesis that resting-state network development is influenced by recurring stimulus-elicited connectivity through prospective examination of the developing human amygdala-cortical functional connections. Our results provide critical insight into how early environmental events sculpt functional network architecture across development and highlight childhood as a potential developmental period of heightened malleability for the amygdala-medial prefrontal cortex circuit. These findings have implications for how both positive and adverse experiences influence the developing brain and motivate future investigations of whether this molding mechanism reflects a general phenomenon of brain development.

The Regional Autopsy Center: The University of Alabama at Birmingham Experience.

Rates of autopsied deaths have decreased significantly for the last several decades. It may not be practical for some institutions to maintain the facilities and staffing required to perform autopsies. In recent years, the University of Alabama at Birmingham (UAB) has established contracts to perform autopsies for several regional institutions including the Alabama Department of Forensic Sciences (ADFS), the United States Veterans Affairs, the local prison system, local community hospitals, and with families for private autopsy services. Contracts and autopsy data from 2004 to 2015 were obtained and reviewed. Since 2004, the number of UAB hospital autopsies trended slightly downward. On average, UAB hospital cases comprised most yearly cases, and the ADFS was the second largest contributor of cases. Income generated from outside autopsies performed from 2006 to 2015 totaled just more than 2 million dollars, and most of the income was generated from referred ADFS cases. This study provides evidence that a centralized institution (regional autopsy center [RAC]) can provide regional autopsy service in a practical, feasible, and economically viable manner, and a RAC can benefit both the referring institutions as well as the RAC itself.

An interactive web application for processing, correcting, and visualizing genome-wide pooled CRISPR-Cas9 screens.

A limitation of pooled CRISPR-Cas9 screens is the high false-positive rate in detecting essential genes arising from copy-number-amplified genomics regions. To solve this issue, we previously developed CRISPRcleanR: a computational method implemented as R/python package and in a dockerized version. CRISPRcleanR detects and corrects biased responses to CRISPR-Cas9 targeting in an unsupervised fashion, accurately reducing false-positive signals while maintaining sensitivity in identifying relevant genetic dependencies. Here, we present CRISPRcleanR WebApp , a web application enabling access to CRISPRcleanR through an intuitive interface. CRISPRcleanR WebApp removes the complexity of R/python language user interactions; provides user-friendly access to a complete analytical pipeline, not requiring any data pre-processing and generating gene-level summaries of essentiality with associated statistical scores; and offers a range of interactively explorable plots while supporting a more comprehensive range of CRISPR guide RNAs' libraries than the original package. CRISPRcleanR WebApp is available at https://crisprcleanr-webapp.fht.org/.

Occurrence and complications of tracheal reintubation in critically ill adults.

BACKGROUND: Timing and preparation for tracheal extubation are as critical as the initial intubation. There are limited data on specific strategies for a planned extubation. The extent to which the difficult airway at reintubation contributes to patient morbidity is unknown. The aim of the present study was to describe the occurrence and complications of failed extubation and associated risk factors, and to estimate the mortality and morbidity associated with reintubation attempts. METHODS: Cohort study of 2,007 critically ill adult patients admitted to the ICU with an ETT. Patients were classified in 2 groups, based on the requirement for reintubation: "never reintubated" versus "≥ 1 reintubations." Baseline characteristics, ICU and hospital stay, hospital mortality, and in-patient costs were compared between patients successfully extubated and those with reintubation outside the operating room, using regression techniques. Reasons, airway management techniques, and complications of intubation and reintubation were summarized descriptively. RESULTS: 376 patients (19%) required reintubation, and 230 (11%) were reintubated within 48 hours, primarily due to respiratory failure. Patients requiring reintubation were older, more likely to be male, and had higher admission severity score. Difficult intubation and complications were similar for initial and subsequent intubation. Reintubation was associated with a 5-fold increase in the relative odds of death (adjusted odds ratio 5.86, 95% CI 3.87-8.89, P < .01), and a 2-fold increase in median ICU and hospital stay, and institutional costs. Difficult airway at reintubation was associated with higher mortality (adjusted odds ratio 2.23, 95% CI 1.01-4.93, P = .05). CONCLUSIONS: Nearly 20% of critically ill patients required out of operating room reintubation. Reintubation was associated with higher mortality, stay, and cost. Moreover, a difficult airway at reintubation was associated with higher mortality.

The association between fluid balance and outcomes after subarachnoid hemorrhage.

BACKGROUND: We sought to determine the association between early fluid balance and neurological/vital outcome of patients with subarachnoid hemorrhage. METHODS: Hospital admission, imaging, ICU and outcome data were retrospectively collected from the medical records of adult patients with aneurysmal SAH admitted to a level-1 trauma and stroke referral center during a 5-year period. Two groups were identified based on cumulative fluid balance by ICU day 3: (i) patients with a positive fluid balance (n = 221) and (ii) patients with even or negative fluid balance (n = 135). Multivariable logistic regression was used to adjust for age, Hunt-Hess and Fisher scores, mechanical ventilation and troponin elevation (>0.40 ng/ml) at ICU admission. The primary outcome was a composite of hospital mortality or new stroke. RESULTS: Patients with positive fluid balance had worse admission GCS and Hunt-Hess score, and by ICU day 3 had cumulatively received more IV fluids, but had less urine output when compared with the negative fluid balance group. There was no difference in the odds of hospital death or new stroke (adjusted OR: 1.47, 95%CI: 0.85, 2.54) between patients with positive and negative fluid balance. However, positive fluid balance was associated with increased odds of TCD vasospasm (adjusted OR 2.25, 95%CI: 1.37, 3.71) and prolonged hospital length of stay. CONCLUSIONS: Although handling of IV fluid administration was not an independent predictor of mortality or new stroke, patients with early positive fluid balance had worse clinical presentation and had greater resource use during the hospital course.

Inhaled hypertonic saline in infants and children younger than 6 years with cystic fibrosis: the ISIS randomized controlled trial.

CONTEXT: Inhaled hypertonic saline is recommended as therapy for patients 6 years or older with cystic fibrosis (CF), but its efficacy has never been evaluated in patients younger than 6 years with CF. OBJECTIVE: To determine if hypertonic saline reduces the rate of protocol-defined pulmonary exacerbations in patients younger than 6 years with CF. DESIGN, SETTING, AND PARTICIPANTS: The Infant Study of Inhaled Saline in Cystic Fibrosis (ISIS), a multicenter, randomized, double-blind, placebo-controlled trial conducted from April 2009 to October 2011 at 30 CF care centers in the United States and Canada. Participants were aged 4 to 60 months and had an established diagnosis of CF. A total of 344 patients were assessed for eligibility; 321 participants were randomized; 29 (9%) withdrew prematurely. INTERVENTION: The active treatment group (n = 158) received 7% hypertonic saline and the control group (n = 163) received 0.9% isotonic saline, nebulized twice daily for 48 weeks. Both groups received albuterol or levalbuterol prior to each study drug dose. MAIN OUTCOME MEASURES: Rate during the 48-week treatment period of protocol-defined pulmonary exacerbations treated with oral, inhaled, or intravenous antibiotics. RESULTS: The mean pulmonary exacerbation rate (events per person-year) was 2.3 (95% CI, 2.0-2.5) in the active treatment group and 2.3 (95% CI, 2.1-2.6) in the control group; the adjusted rate ratio was 0.98 (95% CI, 0.84-1.15). Among participants with pulmonary exacerbations, the mean number of total antibiotic treatment days for a pulmonary exacerbation was 60 (95% CI, 49-70) in the active treatment group and 52 (95% CI, 43-61) in the control group. There was no significant difference in secondary end points including height, weight, respiratory rate, oxygen saturation, cough, or respiratory symptom scores. Infant pulmonary function testing performed as an exploratory outcome in a subgroup (n = 73, with acceptable measurements at 2 visits in 45 participants) did not demonstrate significant differences between groups except for the mean change in forced expiratory volume in 0.5 seconds, which was 38 mL (95% CI, 1-76) greater in the active treatment group. Adherence determined by returned study drug ampoules was at least 75% in each group. Adverse event profiles were also similar, with the most common adverse event of moderate or severe severity in each group being cough (39% of active treatment group, 38% of control group). CONCLUSION: Among infants and children younger than 6 years with cystic fibrosis, the use of inhaled hypertonic saline compared with isotonic saline did not reduce the rate of pulmonary exacerbations over the course of 48 weeks of treatment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00709280.

Initial acuity of firearm injuries in the United States: are civilian injuries similar to combat casualty statistics.

Military studies have identified significant trends in combat related preventable death, particularly with respect to limb hemorrhage. Little is known, however regarding preventable death due to firearms in the civilian patient population, or the anatomic distribution of these injuries. An understanding of this information and the applicability of military studies to the civilian patient population is critical to developing strategies for treating these injuries. A retrospective database review of The National Emergency Medical Services Information Systems (NEMESIS) national database based on ICD 10 codes for firearm injuries logged in 2019 in the pre-hospital environment. Twenty three thousand three hundred and thirty-three firearm injuries were logged in NEMESIS in 2019, of which 15,148 were ultimately included as the other cases had incomplete information. Of these injuries there were 1438 (9.49%) to the chest, 913 (6.03%) to the abdomen, 221 (1.46%) to the neck, 468 (3.09%) to the back. These four anatomic locations were the most likely to be classified as Critical-Red by prehospital providers: 62.66% of chest injuries, 54.22% of abdomen injuries, 48.42% of neck injuries, and 42.31% of back injuries. The NEMESIS data on patient acuity indicates that the number of firearm related preventable deaths due to torso injury may be significantly greater than those due to limb exsanguination. In addition to the focus on tourniquet use, research focused on improved prehospital care of firearm injuries to the torso may provide additional strategies for reducing preventable death.

Spatial tomography of light resolved in time, spectrum, and polarisation.

Measuring polarisation, spectrum, temporal dynamics, and spatial complex amplitude of optical beams is essential to studying phenomena in laser dynamics, telecommunications and nonlinear optics. Current characterisation techniques apply in limited contexts. Non-interferometric methods struggle to distinguish spatial phase, while phase-sensitive approaches necessitate either an auxiliary reference source or a self-reference, neither of which is universally available. Deciphering complex wavefronts of multiple co-propagating incoherent fields remains particularly challenging. We harness principles of spatial state tomography to circumvent these limitations and measure a complete description of an unknown beam as a set of spectrally, temporally, and polarisation resolved spatial state density matrices. Each density matrix slice resolves the spatial complex amplitude of multiple mutually incoherent fields, which over several slices reveals the spectral or temporal evolution of these fields even when fields spectrally or temporally overlap. We demonstrate these features by characterising the spatiotemporal and spatiospectral output of a vertical-cavity surface-emitting laser.

Ebola Virus Disease in Uganda: A global emergency call.

The Ministry of Health of the Republic of Uganda declared the Ebola virus disease (EVD) outbreak on 20th September 2022 after a patient infected with the rare Sudan strain of Ebola virus (EBV) died in the Mubende district. Since the year 2000, several outbreaks of the EVD from the Sudan strain have been reported in Uganda and it has been more than a decade since the last case of EVD (Sudan strain) was reported in the country. EVD is a severe, often fatal illness that affects humans and other primates and presents with varied neurological and gastrointestinal symptoms. This article has explored various efforts by the World Health Organization and the Ministry of Health of the Republic of Uganda to coordinate outbreak preparedness and response. Certain recommendations have been made to individuals and the government for early management and prevention of the EVD. Further emphasis has been also laid on effective isolation, triage, and screening of symptomatic patients.

Leptospirosis outbreak in Tanzania: An alarming situation.

On July 5, 2022, the Tanzanian Ministry of Health (MoH) announced the re-emergence of leptospirosis after reporting 20 confirmed symptomatic cases and 3 mortalities. Leptospirosis is caused by a spirochete bacterium that lives in an animal's renal tubule and spreads to individuals through contact with contaminated animal urine. Unsupervised agricultural practices, urban development, wildlife infiltration, and a lack of sanitation have all been proposed as potential environmental causes of the present outbreak. The MoH is taking the necessary steps to halt the spread of said outbreak with assistance from the World Health Organization (WHO). This article examines the risk factors, etiology, number of confirmed cases, and subsequent case index to analyse the epidemiology of the current leptospirosis outbreak in Tanzania's southern Linda region. In light of these findings, this research further details recent recommendations made by the WHO, Centers for Disease Control and Prevention, and MoH to mitigate such an alarming situation. These recommendations include early detection and isolation, contact tracing, and chemoprophylaxis using doxycycline. The article concludes by outlining suggestions for individuals and governments, including the launch of public awareness campaigns, immunisation, increased surveillance, rapid detection testing, and the installation of suitable purification systems, to help contain future leptospirosis outbreaks.

Commonly Used Outcome Measurement Tools in Pediatric Physical Therapy Telerehabilitation in the Philippines: A Quantitative Cross-Sectional Descriptive Study.

With the COVID-19 pandemic, the adoption of telerehabilitation has rapidly increased to improve access and minimize cross-infection risk to patients. Nevertheless, Filipino pediatric physical therapists (PTs) must ensure that they conduct evidence-based procedures for specific tests and measures to determine patient outcomes. This investigation reported the most common pediatric outcome measurement tools (OMTs) used in telerehabilitation by Filipino pediatric PTs treating 0 to 21-year-olds in the Philippines. Validation and pilot testing of an adapted questionnaire on OMT usage was undertaken before dissemination via email and social media. Pediatric PTs reported that the commonly used OMTs in telerehabilitation are Gross Motor Function Measure (GMFM) (100%)-including both versions of GMFM-88 and GMFM-66 followed by Pediatric Balance Scale (PBS) (30%). These findings support the use of feasible OMTs in pediatric telerehabilitation due to their applicability in the online setting.

Attitudes and perceptions of UK medical students towards artificial intelligence and radiology: a multicentre survey.

OBJECTIVES: To explore the attitudes of United Kingdom (UK) medical students regarding artificial intelligence (AI), their understanding, and career intention towards radiology. We also examine the state of education relating to AI amongst this cohort. METHODS: UK medical students were invited to complete an anonymous electronic survey consisting of Likert and dichotomous questions. RESULTS: Four hundred eighty-four responses were received from 19 UK medical schools. Eighty-eight percent of students believed that AI will play an important role in healthcare, and 49% reported they were less likely to consider a career in radiology due to AI. Eighty-nine percent of students believed that teaching in AI would be beneficial for their careers, and 78% agreed that students should receive training in AI as part of their medical degree. Only 45 students received any teaching on AI; none of the students received such teaching as part of their compulsory curriculum. Statistically, students that did receive teaching in AI were more likely to consider radiology (p = 0.01) and rated more positively to the questions relating to the perceived competence in the post-graduation use of AI (p = 0.01-0.04); despite this, a large proportion of students in the taught group reported a lack of confidence and understanding required for the critical use of healthcare AI tools. CONCLUSIONS: UK medical students understand the importance of AI and are keen to engage. Medical school training on AI should be expanded and improved. Realistic use cases and limitations of AI must be presented to students so they will not feel discouraged from pursuing radiology.

Intensive insulin therapy and mortality in critically ill patients.

INTRODUCTION: Intensive insulin therapy (IIT) with tight glycemic control may reduce mortality and morbidity in critically ill patients and has been widely adopted in practice throughout the world. However, there is only one randomized controlled trial showing unequivocal benefit to this approach and that study population was dominated by post-cardiac surgery patients. We aimed to determine the association between IIT and mortality in a mixed population of critically ill patients. METHODS: We conducted a cohort study comparing three consecutive time periods before and after IIT protocol implementation in a Level 1 trauma center: period I (no protocol); period II, target glucose 80 to 130 mg/dL; and period III, target glucose 80 to 110 mg/dL. Subjects were 10,456 patients admitted to intensive care units (ICUs) between 1 March 2001 and 28 February 2005. The main study endpoints were ICU and hospital mortality, Sequential Organ Failure Assessment score, and occurrence of hypoglycemia. Multivariable regression analysis was used to evaluate mortality and organ dysfunction during periods II and III relative to period I. RESULTS: Insulin administration increased over time (9% period I, 25% period II, and 42% period III). Nonetheless, patients in period III had a tendency toward higher adjusted hospital mortality (odds ratio [OR] 1.15, 95% confidence interval [CI] 0.98, 1.35) than patients in period I. Excess hospital mortality in period III was present primarily in patients with an ICU length of stay of 3 days or less (OR 1.47, 95% CI 1.11, 1.93 There was an approximately fourfold increase in the incidence of hypoglycemia from periods I to III. CONCLUSION: A policy of IIT in a group of ICUs from a single institution was not associated with a decrease in hospital mortality. These results, combined with the findings from several recent randomized trials, suggest that further study is needed prior to widespread implementation of IIT in critically ill patients.