Association of Relative Dysglycemia With Hospital Mortality in Critically Ill Patients: A Retrospective Study.

OBJECTIVES: Relative dysglycemia has been proposed as a clinical entity among critically ill patients in the ICU, but is not well studied. This study aimed to clarify associations of relative hyperglycemia and hypoglycemia during the first 24 hours after ICU admission with in-hospital mortality and the respective thresholds. DESIGN: A single-center retrospective study. SETTING: An urban tertiary hospital ICU. PATIENTS: Adult critically ill patients admitted urgently between January 2016 and March 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Maximum and minimum glycemic ratio (GR) was defined as maximum and minimum blood glucose values during the first 24 hours after ICU admission divided by hemoglobin A1c-derived average glucose, respectively. Of 1700 patients included, in-hospital mortality was 16.9%. Nonsurvivors had a higher maximum GR, with no significant difference in minimum GR. Maximum GR during the first 24 hours after ICU admission showed a J-shaped association with in-hospital mortality, and a mortality trough at a maximum GR of approximately 1.12; threshold for increased adjusted odds ratio for mortality was 1.25. Minimum GR during the first 24 hours after ICU admission showed a U-shaped relationship with in-hospital mortality and a mortality trough at a minimum GR of approximately 0.81 with a lower threshold for increased adjusted odds ratio for mortality at 0.69. CONCLUSIONS: Mortality significantly increased when GR during the first 24 hours after ICU admission deviated from between 0.69 and 1.25. Further evaluation will necessarily validate the superiority of personalized glycemic management over conventional management.

The Gap in Attitudes Toward Withholding and Withdrawing Life-Sustaining Treatment Between Japanese Physicians and Citizens.

BACKGROUND: According to some medical ethicists and professional guidelines, there is no ethical difference between withholding and withdrawing life-sustaining treatment. However, medical professionals do not always agree with this notion. Patients and their families may also not regard these decisions as equivalent. Perspectives on life-sustaining treatment potentially differ between cultures and countries. This study compares Japanese physicians' and citizens' attitudes toward hypothetical cases of withholding and withdrawing life-sustaining treatment. METHODS: Ten vignette cases were developed. A web-based questionnaire was administered to 457 citizens and 284 physicians to determine whether they supported withholding or withdrawing treatment. RESULTS: In a case where a patient had an advance directive refusing ventilation, 77% of the physicians and 68% of the citizens chose to withhold treatment. In a case where there was an advance directive but the patient's family requested treatment, 55% of the physicians and 45% of the citizens chose to withhold the ventilator. When a family requested withdrawal of the ventilator but patient wishes were unknown, 19% of the physicians and 48% of the citizens chose to withdraw the ventilator. However, when the patient had also indicated their wishes in writing, 49% of the physicians and 66% of the citizens chose to withdraw treatment. More physicians were prepared to withdraw dialysis (84%) and artificial nutrition (81%) at a patient's request than mechanical ventilation (49%). CONCLUSIONS: A significant proportion of Japanese physicians and citizens were reluctant to withhold or withdraw life-sustaining treatment, even in cases where the patient had indicated their wishes in writing. They were more likely to withhold than withdraw treatment, and more likely to withdraw artificial nutrition than mechanical ventilation. Japanese physicians gave significant weight to family views about treatment but were less likely to agree to withdraw treatment than citizens, indicating a potential source of conflict in clinical settings.

Feasibility of Nurse-Led Advance Care Planning Before Pre-cardiac Procedures: A Descriptive Study.

Background Shared decision-making is important for deciding whether to perform surgery, especially high-risk surgery, or end-of-life care in cases of serious complications after the surgery. In shared decision-making, surgeons should be aware of patients' values. Therefore, advance care planning (ACP) before the surgery is important. In Japan, the feasibility of ACP, particularly preoperative nurse-led ACP, is yet to be evaluated. Methodology This retrospective, single-center, descriptive study included all adult candidates for open-heart or thoracic aortic surgery and transcutaneous aortic valve implantation (TAVI) referred by their surgeon for a nurse-led preoperative ACP between April 1, 2020 and December 31, 2021. The nurse conducted semi-structured interviews with patients regarding goals of care, unacceptable conditions, undesired procedures, advance directives, and their surrogates and documented them. The content of these interviews and their influence on decision-making were retrospectively investigated. Results Sixty-four patients (median age, 82 years; Society of Thoracic Surgeons (STS) score, 7.9; EuroSCORE II, 4.2; JapanSCORE, 7.0) were included (open-heart or thoracic aortic surgery 24, TAVI 40). Among them, 63 (98.4%), 56 (87.5%), and 13 (20.3%) patients articulated their goals of care, unacceptable conditions, and undesired procedures. Only one (1.6%) had a written advance directive. Although all of the patients could designated their surrogate, only 11 (17.2%) had shared their values disclosed in the pre-procedure ACP communication with their surrogates. Two patients who planned to undergo open-heart surgery disclosed their wish not to undergo the surgery only to the nurses but could not tell their surgeon; thereafter, the surgery was canceled. Three patients died after the procedure; however, the patients' value disclosed in ACP was not used for the end-of-life decision. Conclusion Nurse-led ACP can be implemented before high-risk cardiac procedures. It may have an impact on the decision-making of surgery although the ACP content may not be utilized for the end-of-life discussion after the procedures between surgeons and the family member.

Ethical Healthcare Attitudes of Japanese Citizens and Physicians: Patient-Centered or Family-Centered?

BACKGROUND: In current Western medical ethics, patient-centered medicine is considered the norm. However, the cultural background of collectivism in East Asia often leads to family-centered decision-making. In Japan, prior studies have reported that family-centered decision-making is more likely to be preferred in situations of disease notification and end-of-life decision-making. Nonetheless, there has been a recent shift from collectivism to individualism due to changes in the social structure. Various personal factors have also been reported to influence moral decision-making. Therefore, this study examined whether the current trend in attitudes of healthcare decision-making in Japan is family-centered or patient-centered among the general public and physicians. In addition, the personal factors that influence this tendency were examined. METHODS: Three vignettes on disease notification and two vignettes on decision-making during end-of-life care were created, and 457 members of the public and 284 physicians were asked about their attitudes (behavioral intentions) regarding these vignettes. RESULTS: Approximately, 95% of physicians were patient-centered in explaining the patient's severe medical condition. However, approximately 80% of physicians emphasized the wishes of the family over patient wishes when making life-sustaining decisions. Nearly half the general public emphasized the patient's wishes in the explanation of a severe medical condition and in life-sustaining decisions. In both the public and physician groups, personal factors, particularly the presence or absence of a disease under treatment and prior caregiving experience, influenced ethical attitudes toward medical treatment decisions. CONCLUSIONS: In relatively low-conflict situations, such as the announcement of a patient's medical condition, physicians tended to be patient-centered, while they tended to be family-centered in situations of strong conflict in withholding life-sustaining treatment. The fact that personal factors influenced the family-centered response in situations of strong conflict highlights the importance of not only acquiring knowledge of medical ethics but also learning to fairly apply this knowledge in practice.

Association of Diaphragm Movement During Cough, as Assessed by Ultrasonography, With Extubation Outcome.

BACKGROUND: A cough peak flow (CPF) of < 60 L/min was associated with increased risk of extubation failure after a successful spontaneous breathing trial (SBT). Passive cephalic excursion of the diaphragm (PCED), measured by ultrasonography during cough expiration, was reported to predict CPF in healthy adults. We hypothesized that PCED, diaphragm peak velocity, or both during cough, as measured by ultrasonography, might predict CPF and extubation outcomes in mechanically ventilated patients. This study attempted to identify associations of diaphragm movement during cough, as assessed by ultrasonography with simultaneously measured CPF, and to determine predictive values of ultrasonographic indices for extubation outcomes after a successful SBT. METHODS: In the study, 252 mechanically ventilated subjects with a successful SBT were enrolled in a prospective cohort study. Right hemidiaphragm passive cephalic excursion and peak velocity were measured by ultrasonography during voluntary cough expiration with maximum effort. CPF was measured simultaneously by ultrasonography. RESULTS: A multiple regression model adjusted for age and sex showed a significant association between PCED and CPF (P < .001, adjusted ß coefficient 11.4, 95% CI 8.88-14.0, adjusted R2 = 0.287) and between diaphragm peak velocity and CPF (P < .001, adjusted ß coefficient 1.71, 95% CI 1.91-2.24, adjusted R2 = 0.235). The areas under the curves of PCED, diaphragm peak velocity, and CPF for extubation failure were 0.791 (95% Cl 0.668-0.914), 0.587 (95% Cl 0.426-0.748), and 0.765 (95% Cl 0.609-0.922), respectively. CONCLUSIONS: PCED on ultrasonography was significantly associated with CPF and extubation failure after a successful SBT. Future studies should investigate if this method is applicable for determination of tracheostomy decannulation in stable patients in general wards.

Allocation of Mechanical Ventilators During a Pandemic: A Mixed-Methods Study of Perceptions Among Japanese Health Care Workers and the General Public.

BACKGROUND: In Japan, public dialogue on allocation of life-saving medical resources remains taboo, and discussion largely has been avoided. RESEARCH QUESTION: Do Japanese health care workers and the general public agree with principles of ventilator allocation developed internationally? STUDY DESIGN AND METHODS: A four-point Likert scale questionnaire was used to assess the extent of agreement or disagreement with internationally developed triage principles for rationing mechanical ventilators during pandemics. Questionnaires were distributed in person or online, and generalized linear models were used to analyze quantitative data. Free-text descriptions were analyzed qualitatively, both deductively and inductively, to compare respondent opinions with those described in previous US studies. RESULTS: Of 3,191 surveys distributed, 1,520 were returned. Allocation of resources to maximize survival from current illness ("save the most lives") was the most popular triage principle, with 95.8% of respondents in agreement. Allocation to ensure a minimum duration of benefit, as determined by predicted prognosis after illness ("ensure minimum duration of benefit"), and allocation to persons who have experienced fewer life stages ("life cycle") obtained agreement of 82.2% and 80.1%, respectively. Withdrawal and reallocation of mechanical ventilators to more appropriate patients was supported by 64.4% of respondents. Only 28.4% of respondents supported the principle of first-come, first-served access to ventilators. INTERPRETATION: Most respondents supported allocation principles developed internationally and disagreed with the idea of first-come, first-served allocation during resource shortages. The Japanese public seems largely to be prepared to discuss the ethical dilemmas and possible solutions regarding fair and transparent allocation of critical care resources as a necessary step in confronting present and future pandemics and disasters.

Ultrasonographic Assessment of Passive Cephalic Excursion of Diaphragm During Cough Expiration Predicts Cough Peak Flow in Healthy Adults.

BACKGROUND: Evaluation of cough strength is clinically important, especially for patients with neuromuscular disorders and before extubation of mechanically ventilated patients. The pressure gradient between the airway and thoracoabdominal cavities during the cough expiratory phase generates cough flow and passive cephalic movement of the diaphragm. We hypothesized that passive diaphragmatic cephalic excursion, peak velocity, or both during cough expiration might predict cough peak flow (CPF). This physiologic study investigated associations of CPF with simultaneously measured ultrasonographic indices in healthy adults during the cough expiratory phase. METHODS: 56 healthy adults participated in this study. Right hemidiaphragm excursion and peak velocity were measured with ultrasonography during voluntary cough expiration with maximum effort. CPF was simultaneously measured for all coughs along with the ultrasonographic measurements. A linear regression model was used to determine whether ultrasonographic indices predicted CPF. RESULTS: Simple regression analysis showed significant associations between excursion and CPF in men and women (P < .001, beta coefficient 37.8, 95% CI 10.9-64.7, adjusted R2 = 0.195 for men; P < .001, beta coefficient 46.1, 95% CI 22.3-69.9, adjusted R2 = 0.386 for women). A multiple regression model adjusted for age, height, and sex showed a significant association between CPF and excursion (P < .001, adjusted beta coefficient 38.32, 95% CI 21.20-55.44, adjusted R2 = 0.643). Simple regression analysis showed a significant association between diaphragmatic peak velocity and CPF only in women (P = .004, beta coefficient 5.07, 95% CI 1.81-8.33, adjusted R2 = 0.280 for women). CONCLUSIONS: Passive cephalic excursion of the diaphragm during the cough expiratory phase significantly predicted CPF with maximum cough effort in healthy adults. Future studies should investigate the relationship between CPF and excursion in persons with respiratory and neuromuscular disorders.