Implementation of an Early Extubation Protocol in Cardiac Surgical Patients Decreased Ventilator Time But Not Intensive Care Unit or Hospital Length of Stay.

OBJECTIVE: The optimal timing of extubation following cardiac surgery is currently unknown. Protocols implemented in order to achieve a rapid extubation may achieve this goal, but not prove beneficial in terms of outcomes. DESIGN: A prospective clinical trial. SETTING: Tertiary care cardiac surgical intensive care unit. PARTICIPANTS: Adult cardiac surgical patients. INTERVENTIONS: Implementation of an 8-tier multidisciplinary rapid weaning protocol. MEASUREMENTS AND MAIN RESULTS: Ventilator times 6 months prior to and 6 months after implementation of the protocol were measured. Outcomes associated with ventilator times were measured by dividing the patients into tertiles (<6 hours, 6-12 hours, >12 hours). Primary outcomes were intensive care unit (ICU) and hospital length of stay. Secondary outcomes included mortality at 30 days and other major morbidities. In all, 459 patients were included in the study. With implementation of the protocol, median ventilation times decreased from 7.4 hours (interquartile range, IQR = 3rd quartile - 1st quartil e= 6.72 hours) to 5.73 hours (IQR = 5.51 hours) (p < 0.0001). However, median ICU length of stay in patients who achieved extubation within 6 hours increased to 49.45 hours (IQR = 44.4) from 40.3 (IQR = 25.6) (p = 0.0017). Median hospital length of stay was not significantly changed due to the protocol in any ventilation tertile (p = 0.650). CONCLUSIONS: Decreasing intubation times to <6 hours in postsurgical cardiac patients is obtainable with implementation of a multidisciplinary rapid weaning protocol. However, patients extubated within 6 hours had increased ICU length of stay and no difference in hospital length of stay with this intervention.

Eagle Syndrome Presenting after Blunt Trauma.

As classically described, Eagle syndrome is an entity where patients develop pain or neurologic manifestations arising from an elongated styloid process and/or an ossified stylohyoid ligament irritating or compressing adjacent cranial nerves or the carotid arteries. Over the past few years, there have been reports of actual injury to the internal carotid artery with dissection, occlusion, and strokes. We present 3 cases identified after blunt trauma: 1 due to carotid compression and 2 due to actual injury to the internal carotid artery. Eagle syndrome should be a consideration in any patient with a carotid injury due to blunt trauma or suffering a syncopal episode which led to blunt trauma. Carotid stenting is an effective treatment modality for injury to the carotid artery when anticoagulation is contraindicated. Styloidectomy is performed for symptoms due to carotid artery compression or if there is concern for future carotid injury from the styloid process.

Acute respiratory distress syndrome.

Acute Respiratory Distress Syndrome (ARDS) is defined by bilateral diffuse infiltrates on chest radiography, a PO2/FiO2 ratio < 200, and noncardiogenic pulmonary edema. Pathophysiologically it is characterized by disruption of the alveolar lining and capillary endothelium, alveolar edema, protein exudation coupled with a marked inflammatory response and subsequent fibrosis and a resultant ventilation-perfusion mismatch. Effective treatment strategies include low tidal volume ventilation with positive end expiratory pressure, careful fluid management and good supportive care.

Comparison of methods to identify incident cataract in eyes of patients with neovascular maculopathy: Submacular Surgery Trials Report No. 18.

PURPOSE: To describe and compare methods used to monitor development and progression of presumed vision-limiting lens opacity in study eyes of Submacular Surgery Trials (SST) patients. DESIGN: Prospective study of patients enrolled in a set of randomized clinical trials. PARTICIPANTS: Patients enrolled in the SST who were phakic in the study eye at the time of enrollment (n = 690). In a subset of 114 patients, lens photographs were obtained at baseline and 2 years after enrollment. METHODS: Data collection at baseline and annual follow-up examinations included ocular history, ophthalmologic examination including the SST ophthalmologist's assessment of presence or absence of vision-limiting opacity, fundus photography, and lens photography (13 of 27 clinics only). All photographs were assessed by masked graders centrally using the Lens Opacities Classification System III (LOCS III). kappa statistics were calculated to compare LOCS III cataract classifications with fundus photograph quality and with the ophthalmologist's assessment of lens opacity, with the LOCS III classification considered the gold standard. MAIN OUTCOME MEASURE: Incidence of cataract in study eyes. RESULTS: Baseline lens photographs were available and graded for 312 (45%) of 690 patients with phakic study eyes; 2-year lens photographs were available for 156 (23%) of 690 initially phakic eyes. Both baseline and 2-year lens photographs were available for 114 eyes that remained phakic. Submacular surgery was associated with significant progression of nuclear color and nuclear opalescence characteristics within 2 years of enrollment. The reliability of fundus photograph quality versus cataract classification using a 4.5 LOCS III score threshold for cataract was poor to good at each time point and for all groups (kappa, 0-0.51), but sensitivity of the photograph quality score as a surrogate was low, and both positive and negative predictive values were low. Agreement between the ophthalmologists' assessments of lens opacity and the 4.5 LOCS III score threshold for cataract was good (kappa, 0.42-0.78). CONCLUSIONS: In the SST, clinical identification of severe cataract (LOCS III scores of 4.5 or worse for nuclear opacity or nuclear color) by the examining ophthalmologist was valid based on comparison with LOCS III scores and may be an adequate method to use in similar trials.

Characterization of urge to cough and cough symptoms associated with the common cold: results of a US internet survey.

OBJECTIVES: Our knowledge of cough physiology is limited despite years of study. Even less is known about the sensation of urge to cough. Given that limited clinical data are available about urge to cough and cough attributes during a common cold, we sought to gain insights into experiences and perceptions related to these symptoms. METHODS: An internet survey consisting of 51 questions was fielded in the United States. Eligible survey participants included men and women aged 18 years and older who had suffered from a cold with cough within the three months preceding the survey. Participants who confirmed suffering from recurrent cough, asthma, chronic bronchitis, chronic obstructive pulmonary disease, cystic fibrosis, or gastrointestinal reflux were excluded. RESULTS: Of 19,530 initial respondents, 8011 had a cold in the past three months. Of these, 6484 (81%) had experienced cough symptoms; 2708 respondents with cough due to cold and no exclusionary condition made up the analysis sample. Most respondents (62%) reported that cough developed one to two days after the onset of cold symptoms, and 45% felt that cough worsened their other cold symptoms. In 69% of respondents, cough outlasted other cold symptoms. Urge to cough was reported by 98% of respondents, and among these respondents, 64% described it as uncontrollable and 65% rated severity as moderate. More than half of respondents (57%) considered the sensation of urge to cough and the act of coughing as equally bothersome. Although urge to cough and inability to control cough were the most bothersome aspects of cough due to cold, few (<20%) respondents asked healthcare providers for treatment recommendations. CONCLUSION: Symptoms of urge to cough and cough are common and have a significant impact on cold sufferers. Understanding attributes of these symptoms may provide insights for effective management and the development of novel treatment strategies.

Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child.

AIMS: To assess the safety of buprenorphine compared with methadone to treat pregnant women with opioid use disorder. METHODS: We searched PubMed, Embase and the Cochrane Library from inception to February 2015 for randomized controlled trials (RCT) and observational cohort studies (OBS) that compared buprenorphine with methadone for treating opioid-dependent pregnant women. Two reviewers assessed independently the titles and abstracts of all search results and full texts of potentially eligible studies reporting original data for maternal/fetal/infant death, preterm birth, fetal growth outcomes, fetal/congenital anomalies, fetal/child neurodevelopment and/or maternal adverse events. We ascertained each study's risk of bias using validated instruments and assessed the strength of evidence for each outcome using established methods. We computed effect sizes using random-effects models for each outcome with two or more studies. RESULTS: Three RCTs (n = 223) and 15 cohort OBSs (n = 1923) met inclusion criteria. In meta-analyses using unadjusted data and methadone as comparator, buprenorphine was associated with lower risk of preterm birth [RCT risk ratio (RR) = 0.40, 95% confidence interval (CI) = 0.18, 0.91; OBS RR = 0.67, 95% CI = 0.50, 0.90], greater birth weight [RCT weighted mean difference (WMD) = 277 g, 95% CI = 104, 450; OBS WMD = 265 g, 95% CI = 196, 335] and larger head circumference [RCT WMD = 0.90 cm, 95% CI = 0.14, 1.66; OBS WMD = 0.68 cm, 95% CI = 0.41, 0.94]. No treatment differences were observed for spontaneous fetal death, fetal/congenital anomalies and other fetal growth measures, although the power to detect such differences may be inadequate due to small sample sizes. CONCLUSIONS: Moderately strong evidence indicates lower risk of preterm birth, greater birth weight and larger head circumference with buprenorphine treatment of maternal opioid use disorder during pregnancy compared with methadone treatment, and no greater harms.

Surgical removal vs observation for idiopathic or ocular histoplasmosis syndrome-associated subfoveal choroidal neovascularization: Vision Preference Value Scale findings from the randomized SST Group H Trial: SST Report No. 17.

OBJECTIVE: To determine whether patients receiving observation vs surgery for subfoveal choroidal neovascularization that was idiopathic or associated with histoplasmosis differed in preference values assigned to their health and vision status. METHODS: Before and after enrollment, patients rated their current vision on a scale from 0 (blind) to 100 (perfect vision) and rated blindness and perfect vision on a scale from 0 (dead) to 100 (perfect health and vision). Scores for current vision were converted to a preference value scale (0 represents death; 100, perfect health and vision). RESULTS: In 170 patients, no significant difference existed between the observation and surgery arms in median vision preference values at baseline (74 vs 70) or at the 12- (74 vs 78) or 24-month follow-up (77 vs 73) (P > .05). Preference values did not differ between arms for subgroups defined by age, unilateral vs bilateral choroidal neovascularization, or good vs poor baseline visual acuity. CONCLUSIONS: Submacular surgery was no better than observation in the preference values patients assigned to their health status, despite previously reported improvements in vision-specific quality of life. TRIAL REGISTRATION: (clinicaltrials.gov) Identifier: NCT00000150. CLINICAL RELEVANCE: Ophthalmologists should consider the effects on different measures of quality of life when determining treatment for patients similar to those in the Submacular Surgery Trials Group H Trial.