Beyond the bundle: Clinical controversies in the management of sepsis in emergency medicine patients.

Sepsis is a condition characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. The emergency department (ED) serves as a crucial entry point for patients presenting with sepsis. Given the heterogeneous presentation and high mortality rate associated with sepsis and septic shock, several clinical controversies have emerged in the management of sepsis. These include the use of novel therapeutic agents like angiotensin II, hydrocortisone, ascorbic acid, thiamine ("HAT") therapy, and levosimendan, Additionally, controversies with current treatments in vasopressor dosing, and the use of and balanced or unbalanced crystalloid are crucial to consider. The purpose of this review is to discuss clinical controversies in the management of septic patients, including the use of novel medications and dosing strategies, to assist providers in appropriately determining what treatment strategy is best suited for patients.

A clinical pathway for heart failure reduces admissions from the ED without increasing congestion in the ED.

BACKGROUND: A multidisciplinary team at a major academic medical center established an Acutely Decompensated Heart Failure Clinical Pathway (ADHFCP) program to reduce inpatient readmission rates among patients with heart failure which, among several interventions, included an immediate consultation from a cardiologist familiar with an ADHFCP patient when the patient presented at the Emergency Department (ED). This study analyzed how that program impacted utilization of services in the ED and its subsequent effect on rates of admission from the ED and on disposition times. METHODS: ADHFCP inpatient visits were retrospectively risk stratified and matched with non-program inpatient visits to create a control group. A Cox survival model analyzed the ADHFCP's impact on patients' likelihood to visit the ED. Multivariable ANOVA evaluated the impact of the program on the patients' likelihood of being admitted when presenting at the ED. The ADHFCP's impact on bed-to-disposition time in the ED was evaluated by Wilcoxon's rank-sum test, as were doses of diuretics administered in the ED. RESULTS: The survival analysis showed no impact of the ADHFCP on patients' likelihood of visiting the ED, but ADHFCP patients presenting to the ED were 13.1 (95% CI: 3.6-22.6) percentage points less likely to be admitted. There was no difference in bed-to-disposition times, but ADHFCP patients received diuretics more frequently and at higher doses. CONCLUSIONS: Improved communication between cardiologists and ED physicians through the establishment of an explicit pathway to coordinate the care of heart failure patients may decrease that population's likelihood of admission without increasing ED disposition times.

Probing the role of multicellular organization in three-dimensional microenvironments.

Successful application of living cells in regenerative medicine requires an understanding of how tissue structure relates to organ function. There is growing evidence that presentation of extracellular cues in a three-dimensional (3D) context can fundamentally alter cellular responses. Thus, microenvironment studies that previously were limited to adherent two-dimensional (2D) cultures may not be appropriate for many cell types. Here we present a method for the rapid formation of reproducible, high-resolution 3D cellular structures within a photopolymerizable hydrogel using dielectrophoretic forces. We demonstrate the parallel formation of >20,000 cell clusters of precise size and shape within a thin 2-cm(2) hydrogel and the maintenance of high cell viability and differentiated cell markers over 2 weeks. By modulating cell-cell interactions in 3D clusters, we present the first evidence that microscale tissue organization regulates bovine articular chondrocyte biosynthesis. This platform permits investigation of tissue architecture in other multicellular processes, from embryogenesis to regeneration to tumorigenesis.