Telemedicine Critical Care-Mediated Mortality Reductions in Lower-Performing Patient Diagnosis Groups: A Prospective, Before and After Study.

OBJECTIVES: Studies evaluating telemedicine critical care (TCC) have shown mixed results. We prospectively evaluated the impact of TCC implementation on risk-adjusted mortality among patients stratified by pre-TCC performance. DESIGN: Prospective, observational, before and after study. SETTING: Three adult ICUs at an academic medical center. PATIENTS: A total of 2,429 patients in the pre-TCC (January to June 2016) and 12,479 patients in the post-TCC (January 2017 to June 2019) periods. INTERVENTIONS: TCC implementation which included an acuity-driven workflow targeting an identified "lower-performing" patient group, defined by ICU admission in an Acute Physiology and Chronic Health Evaluation diagnoses category with a pre-TCC standardized mortality ratio (SMR) of greater than 1.5. MEASUREMENTS AND MAIN RESULTS: The primary outcome was risk-adjusted hospital mortality. Risk-adjusted hospital length of stay (HLOS) was also studied. The SMR for the overall ICU population was 0.83 pre-TCC and 0.75 post-TCC, with risk-adjusted mortalities of 10.7% and 9.5% (p = 0.09). In the identified lower-performing patient group, which accounted for 12.6% (n = 307) of pre-TCC and 13.3% (n = 1671) of post-TCC ICU patients, SMR decreased from 1.61 (95% CI, 1.21-2.01) pre-TCC to 1.03 (95% CI, 0.91-1.15) post-TCC, and risk-adjusted mortality decreased from 26.4% to 16.9% (p < 0.001). In the remaining ("higher-performing") patient group, there was no change in pre- versus post-TCC SMR (0.70 [0.59-0.81] vs 0.69 [0.64-0.73]) or risk-adjusted mortality (8.5% vs 8.4%, p = 0.86). There were no pre- to post-TCC differences in standardized HLOS ratio or risk-adjusted HLOS in the overall cohort or either performance group. CONCLUSIONS: In well-staffed and overall higher-performing ICUs in an academic medical center, Acute Physiology and Chronic Health Evaluation granularity allowed identification of a historically lower-performing patient group that experienced a striking TCC-associated reduction in SMR and risk-adjusted mortality. This study provides additional evidence for the relationship between pre-TCC performance and post-TCC improvement.

Mechanical Ventilation Practices and Low Tidal Volume Ventilation in Air Medical Transport Patients: The AIR-VENT Study.

BACKGROUND: The management of mechanical ventilation critically impacts outcome for patients with acute respiratory failure. Ventilator settings in the early post-intubation period may be especially influential on outcome. Low tidal volume ventilation in the prehospital setting has been shown to impact the provision of low tidal volume after admission and influence outcome. However, there is an overall paucity of data on mechanical ventilation for air medical transport patients. The objectives of this study were to characterize air medical transport ventilation practices and assess variables associated with nonprotective ventilation. METHODS: This was a multi-center, nationwide (approximately 130 bases) retrospective cohort study conducted on consecutive, adult mechanically ventilated air medical transport patients treated in the prehospital environment. Descriptive statistics were used to assess the cohort; the chi-square test compared categorical variables, and continuous variables were compared using independent samples t test or Mann-Whitney U test. To assess for predictors of nonprotective ventilation, a multivariable logistic regression model was constructed to adjust for potentially confounding variables. Low tidal volume ventilation was defined as a tidal volume of ≤ 8 mL/kg predicted body weight (PBW). RESULTS: A total of 68,365 subjects were studied. Height was documented in only 4,186 (6.1%) subjects. Significantly higher tidal volume/PBW (8.6 [8.3-9.2] mL vs 6.5 [6.1-7.0] mL) and plateau pressure (20.0 [16.5-25.0] cm H2O vs 18.0 [15.0-22.0] cm H2O) were seen in the nonpro-tective ventilation group (P < .001 for both). According to sex, females received higher tidal volume/PBW compared to males (7.4 [6.6-8.0] mL vs 6.4 [6.0-6.8] mL, P < .001) and composed 75% of those subjects with nonprotective ventilation compared to 25% male, P < .001. After multivariable logistic regression, female sex was an independent predictor of nonprotective ventilation (adjusted odds ratio 6.79 [95% CI 5.47-8.43], P < .001). CONCLUSIONS: The overwhelming majority of air medical transport subjects had tidal volume set empirically, which may be exposing patients to nonprotective ventilator settings. Given a lack of PBW assessments, the frequency of low tidal volume use remains unknown. Performance improvement initiatives aimed at indexing tidal volume to PBW are easy targets to improve the delivery of mechanical ventilation in the prehospital arena, especially for females.

Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact.

OBJECTIVES: Data suggest that low tidal volume ventilation (LTVV) initiated in the emergency department (ED) has a positive impact on outcome. This systematic review and meta-analysis quantify the impact of ED-based LTVV on outcomes and ventilator settings in the ED and ICU. DATA SOURCES: We systematically reviewed MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, references, conferences, and ClinicalTrials.gov. STUDY SELECTION: Randomized and nonrandomized studies of mechanically ventilated ED adults were eligible. DATA EXTRACTION: Two reviewers independently screened abstracts. The primary outcome was mortality. Secondary outcomes included ventilation duration, lengths of stay, and occurrence rate of acute respiratory distress syndrome (ARDS). We assessed impact of ED LTVV interventions on ED and ICU tidal volumes. DATA SYNTHESIS: The search identified 1,023 studies. Eleven studies (n = 12,912) provided outcome data and were meta-analyzed; 10 additional studies (n = 1,863) provided descriptive ED tidal volume data. Overall quality of evidence was low. Random effect meta-analytic models revealed that ED LTVV was associated with lower mortality (26.5%) versus non-LTVV (31.1%) (odds ratio, 0.80 [0.72-0.88]). ED LTVV was associated with shorter ICU (mean difference, -1.0; 95% CI, -1.7 to -0.3) and hospital (mean difference, -1.2; 95% CI, -2.3 to -0.1) lengths of stay, more ventilator-free days (mean difference, 1.4; 95% CI, 0.4-2.4), and lower occurrence rate (4.5% vs 8.3%) of ARDS (odds ratio, 0.57 [0.44-0.75]). ED LTVV interventions were associated with reductions in ED (-1.5-mL/kg predicted body weight [PBW] [-1.9 to -1.0]; p < 0.001) and ICU (-1.0-mL/kg PBW [-1.8 to -0.2]; p = 0.01) tidal volume. CONCLUSIONS: The use of LTVV in the ED is associated with improved clinical outcomes and increased use of lung protection, recognizing low quality of evidence in this domain. Interventions aimed at implementing and sustaining LTVV in the ED should be explored.

Case report: Ketogenic diet acutely improves cognitive function in patient with Down syndrome and Alzheimer's disease.

Ketogenic diets have a century-long history as a therapeutic tool to treat intractable epilepsy. Recently, a renewed interest in neuroketotherapeutics has arisen, with ketogenic diets being explored for the treatment of neurodegenerative diseases such as Alzheimer's disease and Parkinson's disease, as well as mental health conditions. Herein, we present a case report of a 47-year-old woman with Down syndrome diagnosed with Alzheimer's disease and absence seizures with accelerated cognitive decline over 6 years. A ketogenic diet restored her cognitive function over 6 weeks, with an increase in Activities of Daily Living Scale score from 34 to 58. A therapeutic ketogenic diet was associated with significant cognitive improvement in this patient with concurrent Down syndrome and dementia.

The AIR-SED Study: A Multicenter Cohort Study of SEDation Practices, Deep Sedation, and Coma Among Mechanically Ventilated AIR Transport Patients.

OBJECTIVES: To characterize prehospital air medical transport sedation practices and test the hypothesis that modifiable variables related to the monitoring and delivery of analgesia and sedation are associated with prehospital deep sedation. DESIGN: Multicenter, retrospective cohort study. SETTING: A nationwide, multicenter (approximately 130 bases) air medical transport provider. PATIENTS: Consecutive, adult mechanically ventilated air medical transport patients treated in the prehospital environment (January 2015 to December 2020). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as: 1) Richmond Agitation-Sedation Scale of -3 to -5; 2) Ramsay Sedation Scale of 5 or 6; or 3) Glasgow Coma Scale of less than or equal to 9. Coma was defined as being unresponsive and based on median sedation depth: 1) Richmond Agitation-Sedation Scale of -5; 2) Ramsay of 6; or 3) Glasgow Coma Scale of 3. A total of 72,148 patients were studied. Prehospital deep sedation was observed in 63,478 patients (88.0%), and coma occurred in 42,483 patients (58.9%). Deeply sedated patients received neuromuscular blockers more frequently and were less likely to have sedation depth documented with a validated sedation depth scale (i.e., Ramsay or Richmond Agitation-Sedation Scale). After adjusting for covariates, a multivariable logistic regression model demonstrated that the use of longer-acting neuromuscular blockers (i.e., rocuronium and vecuronium) was an independent predictor of deep sedation (adjusted odds ratio, 1.28; 95% CI, 1.22-1.35; p < 0.001), while use of a validated sedation scale was associated with a lower odds of deep sedation (adjusted odds ratio, 0.29; 95% CI, 0.27-0.30; p < 0.001). CONCLUSIONS: Deep sedation (and coma) is very common in mechanically ventilated air transport patients and associated with modifiable variables related to the monitoring and delivery of analgesia and sedation. Sedation practices in the prehospital arena and associated clinical outcomes are in need of further investigation.

Ketogenic diet as a metabolic treatment for mental illness.

PURPOSE OF REVIEW: Ketogenic diets, which have been used to treat drug-refractory paediatric epilepsy for over 100 years, are becoming increasingly popular for the treatment of other neurological conditions, including mental illnesses. We aim to explain how ketogenic diets can improve mental illness biopathology and review the recent clinical literature. RECENT FINDINGS: Psychiatric conditions, such as schizophrenia, depression, bipolar disorder and binge eating disorder, are neurometabolic diseases that share several common mechanistic biopathologies. These include glucose hypometabolism, neurotransmitter imbalances, oxidative stress and inflammation. There is strong evidence that ketogenic diets can address these four fundamental diseases, and now complementary clinical evidence that ketogenic diets can improve the patients' symptoms. SUMMARY: It is important that researchers and clinicians are made aware of the trajectory of the evidence for the implementation of ketogenic diets in mental illnesses, as such a metabolic intervention provides not only a novel form of symptomatic treatment, but one that may be able to directly address the underlying disease mechanisms and, in so doing, also treat burdensome comorbidities (see Video, Supplementary Digital Content 1, http://links.lww.com/COE/A16, which summarizes the contents of this review).

Ketogenic diet for schizophrenia: clinical implication.

PURPOSE OF REVIEW: The aim of this article is to review recent findings on the efficacy of ketogenic diet in preclinical models and in patients with schizophrenia. This review will also highlight emerging evidence for compromised glucose and energy metabolism in schizophrenia, which provides a strong rationale and a potential mechanism of action for ketogenic diet. RECENT FINDINGS: Recent transcriptomic, proteomic and metabolomic evidence from postmortem prefrontal cortical samples and in-vivo NMR spectroscopy results support the hypothesis that there is a bioenergetics dysfunction characterized by abnormal glucose handling and mitochondrial dysfunctions resulting in impaired synaptic communication in the brain of people with schizophrenia. Ketogenic diet, which provides alternative fuel to glucose for bioenergetic processes in the brain, normalizes schizophrenia-like behaviours in translationally relevant pharmacological and genetic mouse models. Furthermore, recent case studies demonstrate that ketogenic diet produces improvement in psychiatric symptoms as well as metabolic dysfunctions and body composition in patients with schizophrenia. SUMMARY: These results support that ketogenic diet may present a novel therapeutic approach through restoring brain energy metabolism in schizophrenia. Randomized controlled clinical trials are needed to further show the efficacy of ketogenic diet as a co-treatment to manage both clinical symptoms and metabolic abnormalities inherent to the disease and resulted by antipsychotic treatment.

Chronological changes in terrestrial insect assemblages in the arid zone of Australia.

Arid and semiarid environments are characterized by highly unpredictable and 'pulsed' availability of essential biological resources. The 'boom and bust' response of many vertebrates is commonly invoked for invertebrates and especially insects. This perception of the Australian arid zone is exacerbated by the lack of long-term surveys of insects identified at high levels of taxonomic resolution. From an 18 mo continuous survey of insects in central Australia I determine the phenology of many insect taxa, and clarify which climatic variables most influenced the activity of these taxa. Total abundance and taxon richness were higher in the warmer months and lower in the cooler months. Minimum temperature, rainfall during the survey month, and rainfall during the previous month had significant effects on phenology, demonstrating that there is pronounced and predictable activity of many species in the absence of rain, although rainfall has a marked effect on the activity of some species. Other species were more active or only active in the coolest months. These findings have implications for the most productive time for surveys in the Australian arid zone, the availability of insects as prey or pollinators, and for the potential effects of climate change.

Cold hardiness of Apteropanorpa tasmanica Carpenter (Mecoptera: Apteropanorpidae).

There are very few investigations of cold hardiness in native Australian insects, and no such studies on insects from Tasmania. The Apteropanorpidae is a family of wingless Mecoptera endemic to Tasmania, comprising four described species that can be active in winter. In this study, we used infrared video thermography to investigate the physiological and behavioural responses of Apteropanorpa tasmanica to fast (0.3 degrees Cmin(-1)) and slow (0.03 degrees Cmin(-1)) rates of temperature reduction down to -10 degrees C. No adults survived cooling to -10 degrees C at either cooling rate. Mean supercooling points (SCPs) from fast cooling were -7.0 and -4.6 degrees C in 2002 and 2003, respectively. Ice nucleation always began in the abdomen, however, the position of nucleation within the abdomen varied between individuals. There was no relationship between SCP and body length, and no significant difference in SCPs between males and females. Stress-induced fast walking began when insects reached approximately -1.5 degrees C. Cooling rate did not affect the SCP or the temperature at which the behavioural stress response began. Adults survived for only short periods of time in the supercooled state; however they survived in the laboratory for up to 60 days at 4 degrees C, indicating their longevity at more favourable temperatures. Members of the Apteropanorpidae are adapted to the relatively warm, maritime climate currently influencing Tasmania.

Incidence and patterns of polydrug use and craving for ecstasy in regular ecstasy users: an ecological momentary assessment study.

BACKGROUND: Previous studies employing retrospective assessments methods found that regular ecstasy users frequently use alcohol, marihuana and other drugs in combination with ecstasy. METHODS: Twenty-two participants (13 males, 9 females) wore a wrist actigraph/data recorder to record real-time drug use and ecstasy craving for 6 weeks. Rates of alcohol and drug use on ecstasy use versus non-use nights, and before, during, and after ecstasy use were analyzed with generalized estimation equations (GEE). Craving was modeled with GEE and linear mixed models. RESULTS: Approximately 70% of ecstasy uses occurred on Friday or Saturday nights. No drug was significantly more likely to be used on ecstasy use nights than comparison Friday and Saturday nights. On nights ecstasy was used, in general across all drugs assessed, use was more likely before and during than after ecstasy intoxication, while alcohol use was also more likely before than during ecstasy intoxication. Though low overall, craving for ecstasy increased over 24 h before use and was higher on Friday nights of weeks ecstasy was used on weekends than weeks it was not used. CONCLUSIONS: Use of ecstasy on a particular night may not be associated with any greater likelihood of using any other intoxicating drug, and use of other drugs on nights involving ecstasy use may simply reflect a "natural history" of drug-use nights that begins with alcohol, progresses to more intoxicating drugs, and ends with little drug use. Confirmation of these findings awaits further advances in the application of ecological momentary assessment methodologies.

Infrared video thermography: a technique for assessing cold adaptation in insects.

Insects can survive subzero temperatures by two main strategies: freeze tolerance and freeze avoidance. An array of techniques have been used to investigate the physiological limits of insects to low temperatures, such as differential scanning calorimetry, temperature-controlled cooling apparatus, thermocouples, and computer-controlled chart recording equipment. However, these techniques require animals to be stationary, precluding behavioral data. We used infrared video thermography to investigate cold adaptation in an alpine insect, expanding such investigations to include behavioral response as an indicator of physiological stress. This technique is noninvasive and provides a large amount of physiological information, such as supercooling points, lower lethal temperatures, and hemolymph melting points. Insect supercooling points in response to a constant cooling rate were variable; however, temperatures at the initiation of behavioral stress response were less variable. Assessments of supercooling points and lower lethal temperatures obtained in this way are more biologically meaningful because allowing unhindered movement of insects more closely resembles natural environments.

Application of quantitative analytical electron microscopy to the mineral content of insect cuticle.

Quantification of calcium in the cuticle of the fly larva Exeretonevra angustifrons was undertaken at the micron scale using wavelength dispersive X-ray microanalysis, analytical standards, and a full matrix correction. Calcium and phosphorus were found to be present in the exoskeleton in a ratio that indicates amorphous calcium phosphate. This was confirmed through electron diffraction of the calcium-containing tissue. Due to the pragmatic difficulties of measuring light elements, it is not uncommon in the field of entomology to neglect the use of matrix corrections when performing microanalysis of bulk insect specimens. To determine, firstly, whether such a strategy affects the outcome and secondly, which matrix correction is preferable, phi-rho (z) and ZAF matrix corrections were contrasted with each other and without matrix correction. The best estimate of the mineral phase was found to be given by using the phi-rho (z) correction. When no correction was made, the ratio of Ca to P fell outside the range for amorphous calcium phosphate, possibly leading to flawed interpretation of the mineral form when used on its own.