Pilot Study of a Digital Behavioral Therapy for Overactive Bladder in Women.

IMPORTANCE: The burden and high prevalence of overactive bladder (OAB) underline the urgent need for effective treatment. This study provides an initial look at an alternative approach to behavioral therapy for overactive bladder (OAB) that is delivered as an app on a smartphone. OBJECTIVE: This study aimed to investigate feasibility, acceptability, and preliminary efficacy of a digital therapeutic for OAB. STUDY DESIGN: This was a multicentered prospective pilot study. We used a convenience sample (N = 30) from waiting lists of women referred for incontinence, excluding urinary tract infections, urinary retention, bladder pain syndrome, pelvic cancer, current pregnancy, kidney disease, dementia, stroke, and prior neuromodulation. The intervention, a smartphone app, provided an 8-week program with weekly modules combining evidence-based knowledge videos and skill-building exercises that incorporated behavioral therapy, cognitive behavioral therapy, pelvic muscle training, and general health information. Combined scores on the International Consultation on Incontinence Questionnaire was the primary outcome measure. Secondary outcomes included improvement in quality of life, based on International Consultation on Incontinence Questionnaire, a 72-hour urinary diary, and Patient Global Impression of Improvement. We evaluated usability with the Mobile Application Rating Scale. Statistical tests included Shapiro-Wilk tests and paired-sample t tests. RESULTS: Overall, 100% of participants reported a reduction in their OAB symptoms and 82% reported an improvement in quality of life. There was a significant improvement in diary parameters, including frequency (10.19-6.71 a day: SD, 1.25; P = 0.017) and incontinence (10-3.57: SD, 4.58). Participants rated the app highly on functionality, and 70% would recommend it. Patient Global Impression of Improvement improved for 72% of participants. CONCLUSIONS: This study supports the application of a digital platform to over-come the real-world barriers for first-line treatment for OAB and offers information to inform further evaluation of the safety and efficacy of the NUIG OAB App.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient.

PURPOSE: Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE: Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS: Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

RéSUMé: OBJECTIF: Depuis la dernière publication des lignes directrices du Canadian Airway Focus Group (CAFG) en 2013, la littérature sur la prise en charge des voies aériennes s'est considérablement étoffée. Le CAFG s'est donc réuni à nouveau pour examiner la littérature et mettre à jour ses recommandations de pratique. Ce premier article de deux traite de la prise en charge des voies aériennes difficiles chez un patient inconscient. SOURCES: Des sujets de recherche ont été assignés aux membres du Canadian Airway Focus Group, qui compte des médecins anesthésistes, urgentologues et intensivistes. Les recherches ont été menées dans les bases de données Medline, EMBASE, Cochrane Central Register of Controlled Trials et CINAHL. Les résultats ont été présentés au groupe et discutés lors de vidéoconférences toutes les deux semaines entre avril 2018 et juillet 2020. Les recommandations du CAFG sont fondées sur les meilleures données probantes publiées. Si les données probantes de haute qualité manquaient, les énoncés se fondent alors sur le consensus du groupe. CONSTATATIONS ET RECOMMANDATIONS CLéS: La plupart des études comparant la vidéolaryngoscopie à la laryngoscopie directe indiquent un taux de réussite plus élevé à la première tentative et globalement avec la vidéolaryngoscopie, ainsi que des taux de complication inférieurs. Ainsi, les ressources le permettant, le CAFG recommande dorénavant l'utilisation de vidéolaryngoscopes avec le type de lame convenablement sélectionné pour faciliter toutes les intubations trachéales. En cas d'échec de la première tentative d'intubation trachéale ou d'échec de positionnement du dispositif supraglottique (DSG), d'autres tentatives peuvent être entreprises tant que la ventilation et l'oxygénation du patient le permettent. Néanmoins, le nombre total de tentatives devrait être limité, à trois ou moins, avant de déclarer un échec et de considérer les options de « stratégie de retrait ¼. En cas d'échec de l'intubation, les options de stratégie de retrait chez un patient toujours oxygéné comprennent l'éveil (si possible), la temporisation avec un DSG, une dernière tentative d'intubation trachéale à l'aide d'une technique différente, ou une cricothyroïdotomie. L'échec de l'intubation trachéale, de la ventilation au masque facial et de la ventilation via un DSG accompagné d'une hypoxémie présente ou imminente, définit une urgence « impossible de ventiler, impossible d'oxygéner ¼. Le bloc neuromusculaire doit alors être confirmé ou mis en place, et une tentative finale de ventilation au masque, de positionnement du DSG ou d'intubation trachéale avec une lame de vidéolaryngoscopie hyper-angulée peut être réalisée, si cette approche n'a pas encore été essayée. Si la ventilation demeure impossible, une cricothyroïdotomie d'urgence devrait être réalisée sans délai utilisant une technique de scalpel-bougie-tube (chez le patient adulte). Le CAFG recommande à toutes les institutions de désigner une personne comme « leader des voies aériennes ¼ afin d'assister à la mise en place de protocoles pour les voies aériennes difficiles, d'assurer une formation et un équipement adéquats et d'aider aux examens de la qualité en rapport avec les voies aériennes.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway.

PURPOSE: Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. SOURCE: Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS: Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient's tolerance for withdrawal of airway support and whether re-intubation might be difficult.

RéSUMé: OBJECTIF: Depuis la dernière publication des lignes directrices du Canadian Airway Focus Group (CAFG) en 2013, la littérature sur la prise en charge des voies aériennes s'est considérablement étoffée. Le CAFG s'est donc réuni à nouveau pour examiner la littérature et mettre à jour ses recommandations de pratique. Ce deuxième article traite de l'évaluation des voies aériennes, de la prise de décision et de la mise en œuvre sécuritaire d'une stratégie de prise en charge des voies aériennes lorsque des difficultés sont anticipées. SOURCES: Des sujets de recherche ont été assignés aux membres du Canadian Airway Focus Group, qui compte des médecins anesthésistes, urgentologues et intensivistes. Les recherches ont été réalisées dans les bases de données Medline, EMBASE, Cochrane Central Register of Controlled Trials et CINAHL. Les résultats ont été présentés au groupe et discutés lors de vidéoconférences toutes les deux semaines entre avril 2018 et juillet 2020. Les recommandations du CAFG sont fondées sur les meilleures données probantes publiées. Si les données probantes de haute qualité manquaient, les énoncés se fondent alors sur le consensus du groupe. CONSTATATIONS ET RECOMMANDATIONS CLéS: Avant d'amorcer la prise en charge des voies aériennes, une stratégie documentée devrait être formulée pour chaque patient, en fonction de l'évaluation de ses voies aériennes. L'examen au chevet devrait rechercher les prédicteurs de difficultés pour la ventilation au masque, l'intubation trachéale utilisant la vidéolaryngoscopie ou la laryngoscopie directe, l'utilisation d'un dispositif supraglottique, ainsi que pour la cricothyroïdotomie d'urgence. La physiologie du patient et ses problématiques contextuelles devraient également être évaluées. Les difficultés anticipées devraient inciter à prendre des décisions éclairées sur la façon la plus sécuritaire de procéder à la prise en charge des voies aériennes. L'intubation trachéale éveillée peut procurer une marge de sécurité supplémentaire lorsqu'on s'attend à ce que la vidéolaryngoscopie ou la laryngoscopie directe soient impossibles, lorsqu'on prévoit des difficultés pour plus d'un mode de prise en charge des voies aériennes (p. ex., intubation trachéale et ventilation au masque), ou lorsque la difficulté prévue coïncide avec des problèmes physiologiques ou contextuels importants. En cas de choix de prise en charge des voies respiratoires du patient après induction de l'anesthésie générale malgré les difficultés prévues, les directives à l'équipe devraient inclure les déclencheurs pour passer d'une technique à l'autre, l'aide d'experts disponibles et l'équipement requis disponible. Des difficultés imprévues lors de la prise en charge des voies aériennes peuvent toujours survenir, de sorte que la personne responsable de la prise en charge des voies aériennes devrait avoir une stratégie pour chaque patient, et l'établissement doit rendre facilement disponible le matériel pour la prise en charge des voies aériennes difficiles. L'extubation trachéale du patient à risque doit également être soigneusement planifiée, y compris l'évaluation de la tolérance du patient lors du retrait du dispositif de soutien des voies aériennes et d'une ré-intubation potentiellement difficile.

A systematic review of meta-analyses comparing direct laryngoscopy with videolaryngoscopy.

PURPOSE: In the preceding 20 years, many randomized-controlled trials and meta-analyses have compared direct Macintosh laryngoscopy with videolaryngoscopy. The videolaryngoscope blades have included both traditional Macintosh blades and hyperangulated blades. Macintosh and hyperangulated blades differ in their geometry and technique for tracheal intubation; certain patient populations may benefit from one blade type over another. The primary objective of this systematic review was to assess whether published meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy have accounted for the videolaryngoscope blade type. Secondary objectives evaluated heterogeneity among practitioner experience and specialty, clinical context, patient population, and original primary study outcomes. SOURCE: A search was performed across Ovid Medline, Ovid Embase, ClinicalKey, PubMed, TRIP, AccessAnesthesiology, Google Scholar, and ANZCA discovery. A systematic review identified meta-analyses which compared direct Macintosh laryngoscopy to videolaryngoscopy. There were no patient age or clinical specialty restrictions. Exclusion criteria included non-English language, studies comparing non-Macintosh blade to videolaryngoscopy, and studies in awake patients. PRINCIPAL FINDINGS: Twenty-one meta-analyses were identified that were published between 1 January 2000 and 7 May 2020. Macintosh and hyperangulated videolaryngoscope blades were combined in most studies (16/21; 76%). Heterogeneity was also present among practitioner experience (20/21; 95%), clinician specialty (15/21; 71%), and clinical locations (10/21; 48%). Adult and pediatric patients were combined or not defined in 5/21 studies (24%). The primary outcomes of the meta-analyses varied, with the most common (7/21; 33%) being first-pass tracheal intubation success. CONCLUSIONS: Heterogeneity across important clinical variables is common in meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy. To better inform patient care, future videolaryngoscopy research should differentiate blade type, clinical context, and patient-related primary outcomes.

RéSUMé: OBJECTIF: Au cours des 20 dernières années, de nombreuses études randomisées contrôlées et méta-analyses ont comparé la laryngoscopie avec lame Macintosh à la vidéolaryngoscopie. Les lames de vidéolaryngoscope ont inclus à la fois des lames Macintosh traditionnelles et des lames hyperangulées. Les lames Macintosh et les lames hyperangulées diffèrent de par leur géométrie et leur technique pour l'intubation endotrachéale; certaines populations de patients pourraient bénéficier davantage d'un type de lame par rapport à une autre. L'objectif principal de cette revue systématique était d'examiner si les méta-analyses publiées comparant la laryngoscopie directe avec lame Macintosh à la vidéolaryngoscopie avaient tenu compte du type de lame du vidéolaryngoscope. Les objectifs secondaires évaluaient l'hétérogénéité entre l'expérience et la spécialité des praticiens, le contexte clinique, la population de patients et les critères d'évaluation principaux originaux. SOURCE: Une recherche a été effectuée dans les bases de données Ovid Medline, Ovid Embase, ClinicalKey, PubMed, TRIP, AccessAnesthesiology, Google Scholar et ANZCA discovery. Une revue systématique a identifié les méta-analyses comparant la laryngoscopie directe avec lame Macintosh à la vidéolaryngoscopie. Aucune restriction n'a été établie en matière d'âge des patients ou de spécialité clinique. Les critères d'exclusion comprenaient la langue non anglaise, les études comparant les lames autres que Macintosh à la vidéolaryngoscopie, et les études chez les patients éveillés. CONSTATATIONS PRINCIPALES: Vingt et une méta-analyses publiées entre le 1er janvier 2000 et le 7 mai 2020 ont été identifiées. Les lames de vidéolaryngoscope Macintosh et hyperangulées ont été combinées dans la plupart des études (16/21; 76 %). L'hétérogénéité était également présente en ce qui touchait à l'expérience des praticiens (20/21; 95 %), à la spécialité des cliniciens (15/21; 71 %) et aux départements cliniques (10/21; 48 %). Les patients adultes et pédiatriques étaient combinés ou non définis dans 5/21 études (24 %). Les critères d'évaluation principaux des méta-analyses étaient variés, les plus fréquents (7/21; 33 %) étant le succès de l'intubation trachéale à la première tentative. CONCLUSION: L'hétérogénéité de plusieurs variables cliniques importantes est fréquente dans les méta-analyses comparant la laryngoscopie directe avec lame Macintosh à la vidéolaryngoscopie. Pour mieux guider les soins aux patients, la recherche future sur la vidéolaryngoscopie devrait différencier le type de lame, le contexte clinique et les critères d'évaluation principaux liés au patient.

Evaluation of the systemic inflammatory response syndrome criteria for the diagnosis of sepsis due to maternal bacteremia.

OBJECTIVE: To examine, in the setting of maternal bacteremia, the implications for the diagnosis of maternal sepsis of customizing the systemic inflammatory response syndrome (SIRS) criteria for physiologic changes of pregnancy. METHODS: Women with maternal bacteremia in a tertiary maternity hospital during 2009-2014 were identified. Records were retrospectively reviewed to determine whether they fulfilled the criteria for diagnosis of sepsis based on either the standard SIRS parameters derived from the Surviving Sepsis Campaign or SIRS parameters customized for pregnancy. Diagnosis of sepsis was based on the presence of two or more SIRS criteria, in conjunction with infection, during the hour before and the 6 hours after phlebotomy for blood culture. RESULTS: Of 93 women with bacteremia, 61 (66%) would have been diagnosed with sepsis based on standard criteria compared with 52 (56%) based on customized criteria (P=0.18). Seventeen women had a diagnosis of sepsis based on the standard but not the customized criteria, while eight women had sepsis based on the customized but not the standard criteria. CONCLUSION: In maternal bacteremia, customized SIRS criteria do not increase the rate of diagnosis of sepsis. Prospective studies should investigate whether the introduction of customized SIRS criteria can improve clinical outcomes.

Umbilical cord shortening: quantification postdelivery and postfixation.

The length of the umbilical cord is an important data item, and little is known about the effects of time and fixation on measurement. Such a change has implications for the diagnosis of a long and short cord. This study was conducted to examine the effects of time and formalin fixation on cord length in a routine practice setting. We measured 90 cords from singleton term pregnancies within 5 minutes of delivery, again in the fresh state at 1 to 2 hours, and again after 24 to 48 hours of formalin fixation. The mean cord length was 536.7 mm at delivery. Mean cord shortening was 17.6 mm (3% reduction in length) between delivery and measurement at 1 to 2 hours, and 62.2 mm (12% reduction) between delivery and measurement after 24 to 48 hours fixation. Both values were statistically significant (P < 0.001). Studies on cord length should include data on time of measurement and fixation status.

Toxic epidermal necrolysis: review of pathogenesis and management.

Toxic epidermal necrolysis (TEN) is a severe cutaneous drug reaction with a mortality rate of approximately 30%. The hallmark of TEN is widespread epidermal sloughing due to keratinocyte apoptosis. Multiple genetic associations between TEN and specific ethnic populations have been determined. The pathophysiology of TEN has yet to be fully elucidated; however, current pathogenic models implicate Fas ligand, granulysin, and reactive oxygen species. The value of current therapies, such as intravenous immunoglobulin and corticosteroids, remains under evaluation.

The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes--a follow-up study.

OBJECTIVE: To evaluate the impact of Rapid Response System (RRS) maturation on delayed Medical Emergency Team (MET) activation and patient characteristics and outcomes. DESIGN: Observational study. SETTING: Tertiary hospital. PATIENTS: Recent cohort of 200 patients receiving a MET review and early control cohort of 400 patients receiving a MET review five years earlier at the start of RRS implementation. MEASUREMENTS AND RESULTS: We obtained information including demographics, clinical triggers for and timing of MET activation in relation to the first documented MET review criterion (activation delay) and patient outcomes. We found that patients in the recent cohort were older, more likely to be surgical and to have Not For Resuscitation (NFR) orders before MET review. Furthermore, fewer patients (22.0% vs. 40.3%, p<0.001) had delayed MET activation. When delayed activation occurred, there was a non-significant difference in its duration (early cohort: 12.0 [IQR 23.0]h vs. recent cohort: 9.0 [IQR 20.5]h, p=0.554). Similarly, unplanned ICU admissions decreased from 31.3% to 17.3% (p<0.001). Delayed MET activation was independently associated with greater risk of unplanned ICU admission and hospital mortality (O.R. 1.79, 95% C.I. 1.33.-2.93, p=0.003 and O.R. 2.18, 95% C.I. 1.42-3.33, p<0.001, respectively). Being part of the recent cohort was independently associated with a decreased risk of delayed activation (O.R. 0.45, 95% C.I. 0.30-0.67, p<0.001) and unplanned ICU admission (O.R. 0.5, 95% C.I. 0.32-0.78, p=0.003). CONCLUSIONS: Maturation of a RRS is associated with a decrease in the incidence of unplanned ICU admissions and MET activation delay. Assessment of a RRS early in the course of its implementation may underestimate its efficacy.

Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension.

PURPOSE: To describe the characteristics and outcomes of patients receiving a medical emergency team (MET) review for the MET syndromes of respiratory distress or hypotension and to assess the effect of delayed MET activation on their outcomes. MATERIALS AND METHODS: We retrospectively analyzed the medical records of 2 cohorts of 100 patients for each of the MET syndromes of respiratory distress and hypotension. We collected information on patient demographics, comorbidities, presence of sepsis, and patient outcome. We documented the presence and duration of delayed MET activation. RESULTS: Patients with respiratory distress were more likely to be postoperative (40% vs 28%, P = .07), but less likely to have a history of congestive cardiac failure (12% vs 22%, P = .06). Sepsis was present in 58% of cases. The hospital mortality for MET calls due to respiratory distress and hypotension was 38% and 35%, respectively (P = .77). Delayed MET calls occurred in 50% of patients with the MET syndrome of respiratory distress and in 39% of those with hypotension (P = .11). The median duration of delay was 12 hours in patients with respiratory distress compared to 5 hours for patients with hypotension (P = .016). A delay in making a MET call was associated with an increase in mortality (odds ratio, 2.10; 95% confidence interval, 1.01-4.34; P = .045). CONCLUSIONS: Patients receiving MET calls for respiratory distress or hypotension were elderly and had a mortality greater than 35%. In many cases, MET activation was delayed. This delay was associated with increased mortality.

Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias.

OBJECTIVE: To describe the characteristics and outcomes of patients receiving a medical emergency team (MET) review for the MET syndromes of acute change in conscious state or arrhythmia and to assess the effect of delayed MET activation on their outcomes. DESIGN: Retrospective analysis of medical records. SETTING: University teaching hospital. PATIENTS: Two cohorts of 100 patients for each of the MET syndromes of acute change in conscious state or arrhythmia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We collected information on patient demographics, comorbidities, and presence of sepsis, hypovolemia, cardiogenic shock, and patient outcome. We also documented the presence and duration of delayed MET activation. The median age for both syndromes was >70 yrs, and major comorbidities were present in >10% of patients. A history of ischemic heart disease (p < .001) and congestive cardiac failure (p = .007) was more common in patients with arrhythmias. Cardiogenic shock and sepsis were common underlying causes of the MET calls for the two groups. However, cardiogenic shock was more common in patients with arrhythmias (p < .001). Hospital mortality was 35% for patients with an acute change in conscious state, compared with 18% for patients with arrhythmias (p = .01). Delayed MET activation occurred in 35% of acute change in conscious state patients and in 24% of arrhythmia patients (p = .09) with a median duration of delay of 16 and 13 hrs, respectively. Delayed MET activation was associated with increased mortality (odds ratio 3.1, 95% confidence interval 1.4-6.6, p = .005). CONCLUSIONS: An acute change in conscious state leading to a MET call carried a greater risk of death than activation due to arrhythmias. Delayed activation was common for both syndromes and was independently associated with an increased risk of death.