3D Filaments Based on Polyhydroxy Butyrate-Micronized Bacterial Cellulose for Tissue Engineering Applications.

In this work, scaffolds based on poly(hydroxybutyrate) (PHB) and micronized bacterial cellulose (BC) were produced through 3D printing. Filaments for the printing were obtained by varying the percentage of micronized BC (0.25, 0.50, 1.00, and 2.00%) inserted in relation to the PHB matrix. Despite the varying concentrations of BC, the biocomposite filaments predominantly contained PHB functional groups, as Fourier transform infrared spectroscopy (FTIR) demonstrated. Thermogravimetric analyses (i.e., TG and DTG) of the filaments showed that the peak temperature (Tpeak) of PHB degradation decreased as the concentration of BC increased, with the lowest being 248 °C, referring to the biocomposite filament PHB/2.0% BC, which has the highest concentration of BC. Although there was a variation in the thermal behavior of the filaments, it was not significant enough to make printing impossible, considering that the PHB melting temperature was 170 °C. Biological assays indicated the non-cytotoxicity of scaffolds and the provision of cell anchorage sites. The results obtained in this research open up new paths for the application of this innovation in tissue engineering.

Effect of Ward-Based High-Flow Nasal Cannula (HFNC) Oxygen Therapy on Critical Care Utilization During the COVID-19 Pandemic: A Retrospective Cohort Analysis.

BACKGROUND: Hospitals expanded critical care capacity during the COVID-19 pandemic by treating COVID-19 patients with high-flow nasal cannula oxygen therapy (HFNC) in non-traditional settings, including general internal medicine (GIM) wards. The impact of this practice on intensive care unit (ICU) capacity is unknown. OBJECTIVE: To describe how our hospital operationalized the use of HFNC on GIM wards, assess its impact on ICU capacity, and examine the characteristics and outcomes of treated patients. DESIGN: Retrospective cohort study of all patients treated with HFNC on GIM wards at a Canadian tertiary care hospital. PARTICIPANTS: All patients admitted with COVID-19 and treated with HFNC on GIM wards from December 28, 2020, to June 13, 2021, were included. MAIN MEASURES: We combined administrative data on critical care occupancy daily with chart-abstracted data for included patients to establish the total number of patients receiving ICU-level care at our hospital per day. We also collected data on demographics, medical comorbidities, illness severity, COVID-19 treatments, HFNC care processes, and patient outcomes. KEY RESULTS: We treated 124 patients with HFNC on the GIM wards (median age 66 years; 48% female). Patients were treated with HFNC for a median of 5 days (IQR 3 to 8); collectively, they received HFNC for a total of 740 hospital days, 71% of which were on GIM wards. At peak ICU capacity strain (144%), delivering HFNC on GIM wards added 20% to overall ICU capacity by managing up to 14 patients per day. Patients required a median maximal fraction of inspired oxygen of 80% (IQR 60 to 95). There were 18 deaths (15%) and 85 patients (69%) required critical care admission; of those, 40 (47%) required mechanical ventilation. CONCLUSIONS: With appropriate training and resources, treatment of COVID-19 patients with HFNC on GIM wards appears to be a feasible strategy to increase critical care capacity.

Comparison of 2 Triage Scoring Guidelines for Allocation of Mechanical Ventilators.

Importance: In the current setting of the coronavirus disease 2019 pandemic, there is concern for the possible need for triage criteria for ventilator allocation; to our knowledge, the implications of using specific criteria have never been assessed. Objective: To determine which and how many admissions to intensive care units are identified as having the lowest priority for ventilator allocation using 2 distinct sets of proposed triage criteria. Design, Setting, and Participants: This retrospective cohort study conducted in spring 2020 used data collected from US hospitals and reported in the Philips eICU Collaborative Research Database. Adult admissions (N = 40 439) to 291 intensive care units from 2014 to 2015 who received mechanical ventilation and were not elective surgery patients were included. Exposures: New York State triage criteria and original triage criteria proposed by White and Lo. Main Outcomes and Measures: Sequential Organ Failure Assessment (SOFA) scores were calculated for admissions. The proportion of patients who met initial criteria for the lowest level of priority for mechanical ventilation using each set of criteria and their characteristics and outcomes were assessed. Agreement was compared between the 2 sets of triage criteria, recognizing differences in stated criteria aims. Results: Among 40 439 intensive care unit admissions of patients who received mechanical ventilation, the mean (SD) age was 62.6 (16.6) years, 54.9% were male, and the mean (SD) SOFA score was 4.5 (3.7). Using the New York State triage criteria, 8.9% (95% CI, 8.7%-9.2%) were in the lowest priority category; these lowest priority admissions had a mean (SD) age of 62.9 (16.6) years, used a median (interquartile range) of 57.3 (20.1-133.5) ventilator hours each, and had a hospital survival rate of 38.6% (95% CI, 37.0%-40.2%). Using the White and Lo triage criteria, 4.3% (95% CI, 4.1%-4.5%) were in the lowest priority category; these admissions had a mean (SD) age of 68.6 (13.2) years, used a median (interquartile range) of 61.7 (24.3-142.8) ventilator hours each, and had a hospital survival rate of 56.2% (95% CI, 53.8%-58.7%). Only 655 admissions (1.6%) were in the lowest priority category for both guidelines, with the κ statistic for agreement equal to 0.20 (95% CI, 0.18-0.21). Conclusions and Relevance: Use of 2 initially proposed ventilator triage guidelines identified approximately 1 in every 10 to 25 admissions as having the lowest priority for ventilator allocation, with little agreement. Clinical assessment of different potential criteria for triage decisions in critically ill populations is important to ensure valid and equitable allocation of resources.

Reducing redundant creatine kinase testing in cardiac injury.

BACKGROUND: Creatine kinase (CK) testing in the setting of suspected cardiac injury is commonly performed yet rarely provides clinical value beyond troponin testing. We sought to evaluate and reduce CK testing coupled with troponin testing by 50% or greater. METHODS: We performed root cause analysis to study prevailing processes and patterns of CK testing. We developed new institutional guidelines, removed CK from high-volume paper and electronic order bundles and conducted academic detailing for departments with highest ordering frequency. We evaluated consecutive patients at Sunnybrook Health Sciences Centre between 1 January 2018 and 31 March 2020 who had either a CK or troponin level measured. We prespecified successful implementation as a reduction of 50% in total CK orders and a decrease in the ratio of CK-to-troponin tests to one-third or less. We retained additional data beyond our study period to assess for sustained reductions in testing. RESULTS: Total CK tests decreased over the study period from 3963 to 2111 per month, amounting to a 46.7% reduction (95% CI 33.2 to 60.2; p<0.001) equalling 61 fewer tests per hospital day. Troponin testing did not significantly change during the intervention. Ratio of CK-to-troponin tests decreased from 0.91 to 0.49 (p<0.001). The reduction coincided with changes to order-sets, was observed across all clinical units and was sustained during additional months beyond the study period. These reductions in testing resulted in a projected annual cost savings of C$28 446. CONCLUSIONS: We demonstrate that a low-cost and feasible quality improvement initiative may lead to significant reduction in unnecessary CK testing and substantial savings in healthcare costs for patients with suspected cardiac injury.

Short-term effects of maximal dynamic exercise on flow-mediated dilation in professional female soccer players.

BACKGROUND: Endothelial function assessment may provide important insights into the cardiovascular function and long-term effects of exercise training. Many studies have investigated the possible negative effects on cardiovascular function due to extreme athletic performance, leading to undesirable effects. The purposes of this study were to investigate the acute effects of maximal intensity exercise on endothelium-dependent vasodilation, and to understand the patterns of flow-mediated dilation (FMD) change following maximal exercise in elite female athletes with a high-volume training history. METHODS: Twenty-six elite female soccer players (mean age, 22±4 years; BMI, 21±2 kg/m2; VO2max, 41±4 mL/kg/min) were evaluated. Brachial artery FMD was determined using high-resolution ultrasound at rest, and after 15 and 60 min of maximal cardiopulmonary exercise (CPX) testing on a treadmill. Flow velocity was measured at baseline and during reactive hyperemia at the same periods. RESULTS: Rest FMD was 12.4±5.5%. Peak diameter in response to reactive hyperemia was augmented after 15 min of CPX (3.5±0.4 vs. 3.6±0.4 mm, P<0.05), returning to resting values after 60 min. However, %FMD did not change among time periods. There were two characteristic patterns of FMD response following CPX. Compared to FMD at rest, half of the subjects responded with an increased FMD following maximum exercise (10.5±6.1 vs. 17.8±7.5%, P<0.05). The other subjects demonstrated a reduced FMD response following maximum exercise (14.2±4.3 vs. 10.9±3.2%, P<0.01). CONCLUSIONS: These results indicate that elite female soccer players presented robust brachial artery FMD at rest, with a heterogeneous FMD response to acute exercise with a 50% FMD improvement rate.

An international perspective on the frequency, perception of utility, and quality of interprofessional rounds practices in intensive care units.

PURPOSE: To describe international variation in interprofessional rounds in intensive care units (ICUs). MATERIALS AND METHODS: Survey of ICU clinicians on their practices and perceptions of rounds using societal mailing lists and social media. RESULTS: Out of 2402 respondents, 1752 (72.8%) use rounds. Teams are mostly composed of intensivists, nurses and medical trainees. The majority of rounds (57.5%) last >2 h, and North Americans report the highest rates of rounds allowing family attendance (92.4%). Shorter rounds (1-2 h, OR 0.67, 0.52-0.86, p < 0.01; <1 h, OR 0.72, 0.53-0.97, p = 0.03), and strategies such as designating a person for writing (OR 0.73, 0.57-0.95, p = 0.01), and designating a person to assist other patients (OR 0.75, 0.57-0.98, p = 0.04) are associated with a lower perception of negative outcomes. Using daily goals during rounds is associated with a higher perception of positive outcomes (OR 1.85, 1.17-2.90, p < 0.01). CONCLUSIONS: Three-quarters of respondents perform rounds, and models of rounds are heterogeneous, creating challenges for future studies on improving rounds. Respondents reporting better outcomes also experience shorter rounds, and adopt strategies such as discussion of daily goals, and designation individuals for writing or assisting other patients during rounds.

Frequency of Screening for Weaning From Mechanical Ventilation: Two Contemporaneous Proof-of-Principle Randomized Controlled Trials.

OBJECTIVES: It is unknown whether more frequent screening of invasively ventilated patients, identifies patients earlier for a spontaneous breathing trial, and shortens the duration of ventilation. We assessed the feasibility of conducting a large trial to evaluate screening frequency in critically ill adults in the North American context. DESIGN: We conducted two contemporaneous, multicenter, pilot, randomized controlled trials (the LibeRation from MEchanicaL VEntilAtion and ScrEening Frequency [RELEASE] and Screening Elderly PatieNts For InclusiOn in a Weaning [SENIOR] trials) to address concerns regarding the potential for higher enrollment, fewer adverse events, and better outcomes in younger patients. SETTING: Ten and 11 ICUs in Canada, respectively. PATIENTS: Parallel trials of younger (RELEASE < 65 yr) and older (SENIOR ≥ 65 yr) critically ill adults invasively ventilated for at least 24 hours. INTERVENTIONS: Each trial compared once daily screening to "at least twice daily" screening led by respiratory therapists. MEASUREMENTS AND MAIN RESULTS: In both trials, we evaluated recruitment (aim: 1-2 patients/month/ICU) and consent rates, reasons for trial exclusion, protocol adherence (target: ≥ 80%), crossovers (aim: ≤ 10%), and the effect of the alternative screening frequencies on adverse events and clinical outcomes. We included 155 patients (53 patients [23 once daily, 30 at least twice daily] in RELEASE and 102 patients [54 once daily, 48 at least twice daily] in SENIOR). Between trials, we found similar recruitment rates (1.32 and 1.26 patients/month/ICU) and reasons for trial exclusion, high consent and protocol adherence rates (> 92%), infrequent crossovers, and few adverse events. Although underpowered, at least twice daily screening was associated with a nonsignificantly faster time to successful extubation and more successful extubations but significantly increased use of noninvasive ventilation in both trials combined. CONCLUSIONS: Similar recruitment and consent rates, few adverse events, and comparable outcomes in younger and older patients support conduct of a single large trial in North American ICUs assessing the net clinical benefits associated with more frequent screening.

Predicting Future Health Transitions Among Newly Admitted Nursing Home Residents With Heart Failure.

OBJECTIVES: To understand how a heart failure diagnosis and admission health instability predict health transitions and outcomes among newly admitted nursing home residents. DESIGN: Retrospective cohort study of linked administrative data, including the Continuing Care Report System MDS 2.0 for nursing homes, the Discharge Abstract Database for hospitalized patients, and National Ambulatory Care Reporting System to track emergency department visits. SETTING AND PARTICIPANTS: Older adults, aged 65 years and above, admitted to nursing homes in Ontario, Alberta, and British Columbia, Canada, from 2010 to 2016. MEASURES: Mortality and hospitalization were plotted over 1 year. Multistate Markov models were used to estimate adjusted odds ratios (ORs) for transitions to different states of health in stability, hospitalization, and death, stratified by heart failure diagnosis and by interRAI Changes in Health and End-stage disease Signs and Symptoms (CHESS) score, at 90 days following admission to a nursing home. RESULTS: The final sample included 143,067 residents. Adverse events were most common in the first 90 days. A diagnosis of heart failure predicted worsening health instability, hospitalizations, and mortality. The effect of heart failure on hospitalizations and death was strongest for low baseline health instability (CHESS = 0; OR 1.63, 95% confidence interval (CI) 1.58-1.68, and OR 1.71, 95% CI 1.57-1.86, respectively), versus moderate instability (CHESS = 1-2; OR 1.36, 95% CI 1.32-1.39, and OR 1.48, 95% CI 1.41-1.55), versus high instability (CHESS = 3; OR 1.12, 95% CI 1.03-1.23, and OR 1.21, 95% CI 1.11-1.32). The magnitude of the impact of a heart failure diagnosis was greatest for lower baseline health instability. Residents with the highest degree of health instability were also most likely to die in hospital. CONCLUSIONS AND IMPLICATIONS: A diagnosis of heart failure and health instability provide complementary information to predict transfers, deaths, and adverse outcomes. Clearly identifying these at-risk patients may be useful in targeting interventions in nursing homes.

In Vivo Vaginal Fungal Load Reduction After Treatment with Itraconazole-Loaded Polycaprolactone-Nanoparticles.

Itraconazole (ITZ) has a broad spectrum of action and is commonly used for the treatment of fungal infections. Topic administration of ITZ is a promising strategy to improve vulvovaginal candidiasis treatment, which can be further optimized by its encapsulation in nanoparticles to increase drug delivery and reduce ITZ toxicity. In this work, we designed polycaprolactone nanoparticles containing ITZ and evaluated in vivo the efficacy of this yet unexplored approach. Nanocapsules (ITZ-NC) and nanospheres (ITZ-NS) were obtained by nanoprecipitation. ITZ-NC presented encapsulation efficiency of 99%, mean diameter of 190 nm, PDI 0.1 and zeta potential of -15 mV. ITZ-NS showed encapsulation efficiency of 97%, mean diameter of 120 nm, PDI 0.1 and zeta potential of -10 mV. Both particles were efficiently freeze-dried using 10% trehalose + 10% sucrose. Nanoparticles were then incorporated in a viscous formulation for vaginal application in female Balb/C mice infected with Candida albicans. Fungal load was significantly reduced in infected animals after treatment with ITZ-NC but not with ITZ-NS, compared to animals treated with ITZ solution. Histological analysis showed a clear difference between vaginal tissues of ITZ-NC and ITZ-NS and ITZ solution-treated animals, which correlated with IL-1ß and TNF-α quantification. Animals treated with ITZ-NC showed reduced cytokine levels and healthy tissue characteristics, while animals treated with ITZ-NS and ITZ solution showed increased IL-1ß and TNF-α levels and typical tissue inflammation. Our results demonstrate the potential of ITZ-NC to improve the treatment of vulvovaginal candidiasis after topical application in the vagina, opening new perspectives for the treatment of this disease.

Is there still room to explore cyclodextrin glycosyltransferase-producers in Brazilian biodiversity?

In the present work, different Brazilian biomes aiming to identify and select cyclodextrin glycosyltransferase-producer bacteria are explored. This enzyme is responsible for converting starch to cyclodextrin, which are interesting molecules to carry other substances of economic interest applied by textile, pharmaceutical, food, and other industries. Based on the enzymatic index, 12 bacteria were selected and evaluated, considering their capacity to produce the enzyme in culture media containing different starch sources. It was observed that the highest yields were presented by the bacteria when grown in cornstarch. These bacteria were also characterized by sequencing of the 16S rRNA region and were classified as Bacillus, Paenibacillus, Gracilibacillus and Solibacillus.

Driving Pressure and Hospital Mortality in Patients Without ARDS: A Cohort Study.

BACKGROUND: Driving pressure (ΔP) is associated with mortality in patients with ARDS and with pulmonary complications in patients undergoing general anesthesia. Whether ΔP is associated with outcomes of patients without ARDS who undergo ventilation in the ICU is unknown. Our objective was to determine the independent association between ΔP and outcomes in mechanically ventilated patients without ARDS on day 1 of mechanical ventilation. METHODS: This was a retrospective analysis of a cohort of 622 mechanically ventilated adult patients without ARDS on day 1 of mechanical ventilation from five ICUs in a tertiary center in the United States. The primary outcome was hospital mortality. The presence of ARDS was determined using the minimum daily Pao2 to Fio2 (PF) ratio and an automated text search of chest radiography reports. The data set was validated by first testing the model in 543 patients with ARDS. RESULTS: In patients without ARDS on day 1 of mechanical ventilation, ΔP was not independently associated with hospital mortality (OR, 1.01; 95% CI, 0.97-1.05). The results of the primary analysis were confirmed in a series of preplanned sensitivity analyses. CONCLUSIONS: In this cohort of patients without ARDS on day 1 of mechanical ventilation and within the limits of ventilatory settings normally used by clinicians, ΔP was not associated with hospital mortality. This study also confirms the association between ΔP and mortality in patients with ARDS not enrolled in a trial and in hypoxemic patients without ARDS.

Fabrication of Biocompatible, Functional, and Transparent Hybrid Films Based on Silk Fibroin and Epoxy Silane for Biophotonics.

In this work we explored the fabrication of flexible and transparent hybrids of silk fibroin (SF) and epoxy-modified siloxane for photonic applications. It is well-known that regenerated SF solutions can form free-standing films with high transparency. Although SF has a restricted number of chemically reactive side groups, the main issues of as-cast pristine SF films regard the high solubility into aqueous media, brittleness, and low thermal stability. The design of SF films with enhanced functionality but high transparency triggers new opportunities on a broader range of applications in biophotonics. Here we present a simple, functional, yet remarkably versatile hybrid material derived from silica sol-gel process based on SF protein and (3-glycidyloxypropyl)trimethoxysilane (GPTMS), an organically modified silicon-alkoxide owning a reactive terminal epoxy group. Specifically, we investigated the effect of the addition of GPTMS into SF solutions on the processability, morphology, crystallinity, and mechanical and optical properties of the resulting hybrid films. Highly transparent (ca. 90%) and flexible free-standing hybrid films were achieved. Cell viability assays revealed that the hybrid films are noncytotoxic to rat osteoblast cells even at high GPTMS content (up to 70 wt %). The hybrid films showed enhanced thermal stability and were rich in organic (epoxy) and inorganic (silanol) functional groups according to the content of GPTMS. We also evaluated the successful preparation of high-quality optical red emissive SF hybrid films by loading YVO4:Eu3+ nanoparticles at low concentration (<5 wt %). A meaningful description of the hybrid film structure is reported from the combination of scanning electron and atomic force microscopies, vibrational spectroscopy, solid-state NMR, and X-ray diffraction analyses.

DNAhsp65 Vaccine as Therapy against Paracoccidioidomycosis.

The conventional treatment for fungal diseases usually shows long periods of therapy and the high frequency of relapses and sequels. New strategies of the treatment are necessary. We have shown that the Mycobacterium leprae HSP65 gene can be successfully used as therapy against murine Paracoccidioidomycosis (PCM). Here, we described the methodology of DNAhsp65 immunotherapy in mice infected with the dimorphic fungus Paracoccidioides brasiliensis, one of PCM agent, evaluating cytokines levels, fungal burden, and lung injury. Our results provide a new prospective on the immunotherapy of mycosis.

Transparent nanostructured cellulose acetate films based on the self assembly of PEO-b-PPO-b-PEO block copolymer.

In this study fabrication and characterization of transparent nanostructured composite films based on cellulose triacetate (CTA) and poly(ethylene oxide)-b-poly(propylene oxide)-b-poly(ethylene oxide) (EPE) triblock copolymer were presented. The effect of the addition of EPE triblock copolymer on the thermal stability, morphology, and mechanical properties of cellulose triacetate films was investigated. The triblock EPE was chosen since PEO blocks interact favorably with CTA, whereas, PPO blocks remain immiscible which provokes a microphase separation. This allows to obtain EPE/CTA composite films with ordered microphase-separated structures where PPO spherical microdomains are well-dispersed in PEO/CTA matrix by simple solvent-evaporation process. During this process, PEO block chains selectively interact with CTA by strong interpolymer hydrogen-bonding while PPO block microseparated. The addition even 40wt% of EPE leads to nanostructured EPE/CTA composite. The cytotoxicity assay of CTA and EPE/CTA composite films confirm non-toxic character of designed transparent nanostructured composites based on sustainable matrices.

Antifungal Therapy for Systemic Mycosis and the Nanobiotechnology Era: Improving Efficacy, Biodistribution and Toxicity.

Fungal diseases have been emerging as an important public health problem worldwide with the increase in host predisposition factors due to immunological dysregulations, immunosuppressive and/or anticancer therapy. Antifungal therapy for systemic mycosis is limited, most of times expensive and causes important toxic effects. Nanotechnology has become an interesting strategy to improve efficacy of traditional antifungal drugs, which allows lower toxicity, better biodistribution, and drug targeting, with promising results in vitro and in vivo. In this review, we provide a discussion about conventional antifungal and nanoantifungal therapies for systemic mycosis.

The Postcardiac Arrest Consult Team: Impact on Hospital Care Processes for Out-of-Hospital Cardiac Arrest Patients.

OBJECTIVE: To evaluate whether a Post-Arrest Consult Team improved care and outcomes for patients with out-of-hospital cardiac arrest. DESIGN: Prospective cohort study of Post-Arrest Consult Team implementation at two hospitals, with concurrent controls from 27 others. SETTING: Twenty-nine hospitals within the Strategies for Post-Arrest Care Network of Southern Ontario, Canada. PATIENTS: We included comatose adult nontraumatic out-of-hospital cardiac arrest patients surviving more than or equal to 6 hours after emergency department arrival who had no contraindications to targeted temperature management. INTERVENTION: The Post-Arrest Consult Team was an advisory consult service to improve 1) targeted temperature management, 2) assessment for percutaneous coronary intervention, 3) electrophysiology assessment, and 4) appropriately delayed neuroprognostication. MEASUREMENTS AND MAIN RESULTS: We used generalized linear mixed models to explore the association between Post-Arrest Consult Team implementation and performance of targeted processes. We included 1,006 patients. The Post-Arrest Consult Team was associated with a significant reduction over time in rates of withdrawal of life-sustaining therapy within 72 hours of emergency department arrival on the basis of predictions of poor neurologic prognosis (ratio of odds ratios, 0.13; 95% CI, 0.02-0.98). Post-Arrest Consult Team was not associated with improved successful targeted temperature management (ratio of odds ratios, 0.91; 95% CI, 0.31-2.65), undergoing angiography (ratio of odds ratios, 1.91; 95% CI, 0.17-21.04), receiving electrophysiology consultation (ratio of odds ratios, 0.93; 95% CI, 0.11-8.16), or functional survival (ratio of odds ratios, 0.75; 95% CI, 0.19-2.94). CONCLUSIONS: Implementation of a Post-Arrest Consult Team reduced premature withdrawal of life-sustaining therapy but did not improve rates of successful targeted temperature management, coronary angiography, formal electrophysiology assessments, or functional survival for comatose patients after out-of-hospital cardiac arrest.

Patient and Organizational Factors Associated With Delays in Antimicrobial Therapy for Septic Shock.

OBJECTIVES: To identify clinical and organizational factors associated with delays in antimicrobial therapy for septic shock. DESIGN: In a retrospective cohort of critically ill patients with septic shock. SETTING: Twenty-four ICUs. PATIENTS: A total of 6,720 patients with septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Higher Acute Physiology Score (+24 min per 5 Acute Physiology Score points; p < 0.0001); older age (+16 min per 10 yr; p < 0.0001); presence of comorbidities (+35 min; p < 0.0001); hospital length of stay before hypotension: less than 3 days (+50 min; p < 0.0001), between 3 and 7 days (+121 min; p < 0.0001), and longer than 7 days (+130 min; p < 0.0001); and a diagnosis of pneumonia (+45 min; p < 0.01) were associated with longer times to antimicrobial therapy. Two variables were associated with shorter times to antimicrobial therapy: community-acquired infections (-53 min; p < 0.001) and higher temperature (-15 min per 1°C; p < 0.0001). After adjusting for confounders, admissions to academic hospitals (+52 min; p< 0.05), and transfers from medical wards (medical vs surgical ward admission; +39 min; p < 0.05) had longer times to antimicrobial therapy. Admissions from the emergency department (emergency department vs surgical ward admission, -47 min; p< 0.001) had shorter times to antimicrobial therapy. CONCLUSIONS: We identified clinical and organizational factors that can serve as evidence-based targets for future quality-improvement initiatives on antimicrobial timing. The observation that academic hospitals are more likely to delay antimicrobials should be further explored in future trials.

Exclusion of Residents From Surgery-Intensive Care Team Communication: A Qualitative Study.

OBJECTIVE: Communication competency is an important aspect of postgraduate training and patient care delivery in all specialties and clinical domains. This study explored staff surgeon and intensivist perceptions of and experiences with residents' communication with a view toward fostering high quality interspecialty team communication in the surgical intensive care unit. DESIGN: A qualitative study using semistructured interviews. Data were analyzed iteratively and inductively as per standard qualitative thematic approach. SETTING: University of Toronto, Toronto, Canada. PARTICIPANTS: A total of 15 staff surgeons and intensivists who collaborate in patient care in the surgical intensive care unit. RESULTS: The phenomenon of "resident bypass" emerged, resulting from staff surgeon and intensivist perceptions that residents threaten the quality of interspecialty team communication. Clear patterns and preferences for resident exclusion from this communication were present. A total of 5 interrelated drivers of resident bypass were discovered: lack of trust, lack of specialized knowledge, poor system design, need for timely communication, and residents' inadequate contribution to decision-making. Surgical and intensive care staff were dissatisfied with the structure of residents' roles in interspecialty team communication. Concerns about communication gaps, patient care continuity, and patient safety were expressed. CONCLUSIONS: Surgical and intensive care staff exclude residents from interspecialty team communication for the benefit of patient safety and care continuity, but this limits opportunities for residents to develop communication skill and competence. Efforts are needed to effectively integrate surgery and intensive care residents in interspecialty attending-resident communication in ways that are meaningful for both patient care and postgraduate training. The implications for medical education are discussed.