Association of Standard Electroencephalography Findings With Mortality and Command Following in Mechanically Ventilated Patients Remaining Unresponsive After Sedation Interruption.

CONTEXT: Delayed awakening after sedation interruption is frequent in critically ill patients receiving mechanical ventilation. OBJECTIVES: We aimed to investigate the association of standard electroencephalography with mortality and command following in this setting. DESIGN, SETTING, AND PATIENTS: In a single-center study, we retrospectively analyzed standard electroencephalography performed in consecutive mechanically ventilated patients remaining unresponsive (comatose/stuporous or unable to follow commands) after sedation interruption. Standard electroencephalography parameters (background activity, continuity, and reactivity) were reassessed by neurophysiologists, blinded to patients' outcome. Patients were categorized during follow-up into three groups based on their best examination as: 1) command following, 2) unresponsive, or 3) deceased. Cause-specific models were used to identify independent standard electroencephalography parameters associated with main outcomes, that is, mortality and command following. Follow-up was right-censored 30 days after standard electroencephalography. MEASUREMENTS AND MAIN RESULTS: Main standard electroencephalography parameters recorded in 121 unresponsive patients (median time between sedation interruption and standard electroencephalography: 2 d [interquartile range, 1-4 d]) consisted of a background frequency greater than 4 Hz in 71 (59%), a discontinuous background in 19 (16%), and a preserved reactivity in 98/120 (82%) patients. At 30 days, 66 patients (55%) were command following, nine (7%) were unresponsive, and 46 (38%) had died. In a multivariate analysis adjusted for nonneurologic organ failure, a reactive standard electroencephalography with a background frequency greater than 4 Hz was independently associated with a reduced risk of death (cause-specific hazard ratio, 0.38; CI 95%, 0.16-0.9). By contrast, none of the standard electroencephalography parameters were independently associated with command following. Sensitivity analyses conducted after exclusion of 29 patients with hypoxic brain injury revealed similar findings. CONCLUSIONS: In patients remaining unresponsive after sedation interruption, a pattern consisting of a reactive standard electroencephalography with a background frequency greater than 4 Hz was associated with decreased odds of death. None of the standard electroencephalography parameters were independently associated with command following.

Using the Knowledge to Action Framework to Describe a Nationwide Implementation of the WHO Surgical Safety Checklist in Cameroon.

BACKGROUND: Surgical safety has advanced rapidly with evidence of improved patient outcomes through structural and process interventions. However, knowledge of how to apply these interventions successfully and sustainably at scale is often lacking. The 2019 Global Ministerial Patient Safety Summit called for a focus on implementation strategies to maintain momentum in patient safety improvements, especially in low- and middle-income settings. This study uses an implementation framework, knowledge to action, to examine a model of nationwide World Health Organization (WHO) Surgical Safety Checklist implementation in Cameroon. Cameroon is a lower-middle-income country, and based on data from high- and low-income countries, we hypothesized that more than 50% of participants would be using the checklist (penetration) in the correct manner (fidelity) 4 months postintervention. METHODS: A collaboration of 3 stakeholders (Ministry of Health, academic institution, and nongovernmental organization) used a prospective observational design. Based on knowledge to action, there were 3 phases to the study implementation: problem identification (lack of routine checklist use in Cameroonian hospitals), multifaceted implementation strategy (3-day multidisciplinary training course, coaching, facilitated leadership engagement, and support networks), and outcome evaluation 4 months postintervention. Validated implementation outcomes were assessed. Primary outcomes were checklist use (penetration) and fidelity; secondary outcomes were perioperative teams' reactions, learning and behavior change; and tertiary outcomes were perioperative teams' acceptability of the checklist. RESULTS: Three hundred and fifty-one operating room staff members from 25 hospitals received training. Median time to evaluation was 4.5 months (interquartile range [IQR]: 4.5-5.5, range 3-7); checklist use (penetration) increased from 20% (95% confidence interval [CI], 16-25) to 56% (95% CI, 49-63); fidelity for adherence to 6 basic safety processes was high: verification of patient identification was 91% (95% CI, 87-95); risk assessment for difficult intubation was 79% (95% CI, 73-85): risk assessment for blood loss was 88% (95% CI, 83-93) use of pulse oximetry was 93% (95% CI, 90-97); antibiotic administration was 95% (95% CI, 91-98); surgical counting was 89% (95% CI, 84-93); and fidelity for nontechnical skills measured by the WHO Behaviorally Anchored Rating Scale was 4.5 of 7 (95% CI, 3.5-5.4). Median scores for all secondary outcomes were 10/10, and 7 acceptability measures were consistently more than 70%. CONCLUSIONS: This study shows that a multifaceted implementation strategy is associated with successful checklist implementation in a lower-middle-income country such as Cameroon, and suggests that a theoretical framework can be used to practically drive nationwide scale-up of checklist use.

1-(2,3-Di-methyl-phen-yl)piperazine-1,4-diium tetra-chlorido-cuprate(II).

In the title salt, (C12H20N2)[CuCl4], the Cu(II) atom occupies a general position in a flattened tetra-hedral environment by Cl ligands, characterized by Cl-Cu-Cl angles of 134.04 (3) and 137.18 (4)°. The six-membered piperazinediium ring adopts a chair conformation. The organic cation and inorganic anion inter-act through N-H⋯Cl and C-H⋯Cl hydrogen bonds, forming a three-dimensional network.

Bis[1-(2,3-di-methyl-phen-yl)piperazine-1,4-diium] bis-(oxonium) cyclo-hexa-phosphate dihydrate.

In the title compound, 2C12H20N2 (2+)·2H3O(+)·P6O18 (6-)·2H2O, a protonated water mol-ecule bridges the centrosymmetrical anionic P6O18 ring via O-H⋯O hydrogen bonds. The centrosymmetric hydrogen-bonded rings formed by four oxonium cations and four phosphate anions can be described by an R 4 (8)(36) graph-set motif. The ring motifs are connected by hydrogen bonds into inorganic layers perpendicular to [100]. The 1-(2,3-di-methyl-phen-yl)piperazine-1,4-diium cations are located between the layers, compensating their negative charge and establishing N-H⋯O hydrogen bonds with the O atoms of the anionic framework.

Poly[bis-(piperazine-1,4-diium) [(µ4-cyclo-hexa-phosphato)dilithium] tetra-hydrate].

In the title compound, {(C4H12N2)2[Li2(P6O18)]·4H2O} n , the phosphate ring anion, located around an inversion center, adopts a chair conformation. Adjacent P6O18 rings are linked via corner-sharing by LiO4 tetra-hedra, generating anionic porous {[Li2(P6O18)](4-)} n layers parallel to (101). The piperazine-1,4-diium cations occupy the pores and develop hydrogen bonds with the inorganic framework. An extensive network of N-H⋯O and O-H⋯O hydrogen-bonding inter-actions link the components into a three-dimensional network and additional stabilization is provided by weak C-H⋯O hydrogen bonds.

Dilithium disodium nickel(II) cyclo-hexa-phosphate dodeca-hydrate, Li(2)Na(2)NiP(6)O(18)·12H(2)O.

The crystal structure of Li(2)Na(2)NiP(6)O(18)·12H(2)O is characterized by the presence of six-membered P(6)O(18) (6-) phosphate ring anions (inter-nal symmetry -1) having a chair conformation and three different cations, viz. Li(+), Na(+) and Ni(2+), to counterbalance the anionic charge. All atoms are in general positions except for nickel, which lies on a special position with site symmetry 2. Lithium has a tetra-hedral environment (LiO(4)), and sodium and nickel have octa-hedral environments [NaO(6) and Ni(H(2)O)(6), respectively]. The P(6)O(18) rings are linked via corner sharing by NaO(6) octa-hedra and LiO(4) tetra-hedra to form a three-dimensional framework presenting tunnels running along [010] in which the six-coordinated Ni(2+) cations are located. The structure is stabilized by a network of O-H⋯O hydrogen bonds.

A Simplified Electroencephalography Montage and Interpretation for Evaluation of Comatose Patients in the ICU.

Electroencephalography (EEG) is one of the main tools for diagnosis and prognostication of encephalopathy. Our two objectives were to assess: 1) the reliability of intensivists' interpretations (one trained intensivist and nonexpert intensivists) on specific EEG patterns and 2) the feasibility of performing simplified EEG by a trained intensivist in ICU. DESIGN: Prospective, single-center study. SETTING: One French tertiary-care center. PATIENTS: Thirty-six consecutive ICU patients with encephalopathy. INTERVENTION: A trained intensivist (1-year specific electrophysiologic course) recorded and interpreted EEGs using a 10 monopod montage at bedside. Then, 22 nonexpert intensivists underwent a 1-hour educational session on interpretation of EEG background (activity, continuity, and reactivity) and common patterns seen in ICU. Trained and nonexpert intensivists' interpretation of EEG recordings was evaluated and compared with an expert neurophysiologist's interpretation (gold standard). The agreement between the two interpretations was evaluated. Second, the duration of the entire EEG procedure (specifically EEG installation) at bedside was recorded. MEASUREMENTS AND MAIN RESULTS: Agreements and reliability between the trained intensivist and the neurophysiologist were acceptable for minimal (agreement, 94%; Pearson coefficient, 0.60) and maximal (89%, 0.89) background frequency, burst suppression (agreement, 100%; Kappa coefficient, 1), background continuity (83%, 0.59), and reactivity to auditory stimulus (78%, 0.44). Agreements between the 22 nonexpert intensivists and the neurophysiologist were heterogeneous. As a result, 87% of the 22 nonexpert intensivists obtained an acceptable reliability for the minimum background frequency, 95% for the maximum background frequency, and 73% and 95% for burst suppression and isoelectric background identification, respectively. The median duration of the entire EEG procedure was 47 minutes (43-53 min), including 22 minutes (20-28 min) of EEG installation. CONCLUSIONS: Intensivists can rapidly learn background activity and identify burst-suppression and isoelectric background. However, more educational sessions are required for interpretation of other EEG patterns frequently observed in the ICU setting.

Cerebrovascular complications and outcomes of critically ill adult patients with infective endocarditis.

BACKGROUND: Neurological complications are associated with poor outcome in patients with infective endocarditis (IE). Although guidelines recommend systematic brain imaging in the evaluation of IE patients, the association between early brain imaging findings and outcomes has never been evaluated in critically ill patients. We aimed to assess the association of CT-defined neurological complications with functional outcomes of critically ill IE patients. METHODS: This retrospective cohort study included consecutive patients with severe, left-sided IE hospitalized in the medical ICU of a tertiary care hospital. Patients with no baseline brain CT were excluded. Baseline CT-scans were classified in five mutually exclusive categories (normal, moderate-to-severe ischemic stroke, minor ischemic stroke, intracranial hemorrhage, other abnormal CT). The primary endpoint was 1-year favorable outcome, defined by a modified Rankin Scale score of 0-3. RESULTS: Between 06/01/2011 and 07/31/2018, 156 patients were included. Among them, 87/156 (56%) had a CT-defined neurological complication, including moderate-to-severe ischemic stroke (n = 33/156, 21%), intracranial hemorrhage (n = 24/156, 15%), minor ischemic stroke (n = 29/156, 19%), other (n = 3/156, 2%). At one year, 69 (45%) patients had a favorable outcome. Factors negatively associated with favorable outcome in multivariable analysis were moderate-to-severe ischemic stroke (OR 0.37, 95%CI 0.14 - 0.95) and age (OR 0.94, 95%CI 0.91-0.97). By contrast, the score on the Glasgow Coma Scale was positively associated with favorable outcome (per 1-point increment, OR 1.23, 95%CI 1.08-1.42). Sensitivity analyses conducted in operated patients revealed similar findings. Compared to normal CT, only moderate-to-severe ischemic stroke was associated with more frequent post-operative neurological complications (n = 8/23 (35%) vs n = 1/46 (2%), p < 0.01). CONCLUSION: Moderate-to-severe ischemic stroke had an independent negative impact on 1-year functional outcome in critically ill IE patients; whereas other complications, including intracranial hemorrhage, had no such impact.

Usefulness of lactate albumin ratio at admission to predict 28-day mortality in critically ill severely burned patients: A retrospective cohort study.

INTRODUCTION: Lactate albumin ratio (LAR) has been used as a prognostic marker associated with organ failure in critically ill septic patients. LAR and its association with outcomes has never been studied in burned patients. The aim of this study was to evaluate the ability of LAR to predict 28-day mortality. METHODS: A retrospective cohort study including all burn patients hospitalized in intensive care unit. The primary endpoint was the 28-day mortality. RESULTS: One thousand three hundred thirty four patients were screened, and 471 were included between June 2012 and December 2018. Briefly, the population study was mainly composed by men (249, 59.1%), the median age, TBSA burned, full thickness, ABSI and IGS2 were 52 [34-68], 20 [10-40], 8 [1-23], 7 [5-9] and 25 [15-40] respectively. Fifty-two patients (12.4%) died at day 28 after admission. At admission, the LAR level was lower in 28-day survivors compared non-survivors (0.05 [0.04, 0.08] vs 0.12 [0.07, 0.26], p < 0.001 respectively). In multivariate analysis accounting for ABSI, LAR levels at admission> 0.13 was independently associated with 28-day mortality (adjusted OR = 3.98 (IC95 1.88-8.35)). The ability of LAR at admission to discriminate 28-day mortality showed an AUC identical when compared to SOFA and ABSI scores (0.81 (IC95 0.74-0.88), 0.80 (IC95 0.72-0.85) and (0.85 (IC95 0.80-0.90), p < 0.05, respectively). Patients with LAR levels ≥ 0.13 at admission had higher 28-day mortality (40.6% vs 6.8%, p < 0.001, HR 7.39 (IC95 4.28-12.76)). CONCLUSION: At admission, LAR is an easy and reliable marker independently associated to 28-day mortality in patients with severe burn injury, but prediction by LAR does not perform better than lactate level alone.

The one-dimensional coordination polymer poly[tetra-kis-[(4-chloro-phen-yl)methanaminium] [cadmate-µ-cyclo-hexa-phospho-rato]].

Cyclo-hexa-phospho-ric acid (P(6)O(18)H(6)) reacts with cadmium carbonate and 4-chloro-benzyl-amine (CBA) to give the mononuclear title complex, (C(7)H(9)ClN)(4)[Cd(P(6)O(18))](n), in which the Cd(II) atom, lying on an inversion centre, has an octa-hedral coordination built of six O atoms of two centrosymmetric P(6)O(18) rings. Each P(6)O(18) ligand acts as a bridge, linking two Cd(II) atoms and forming an anionic coordination polymer [Cd(P(6)O(18))(4-)](n) extending along [010]. Adjacent polymeric chains are connected through N-H⋯O and C-H⋯O hydrogen bonds, generating a three-dimensional supra-molecular network.

Crystal structure and Hirshfeld surface analysis of trans-2,5-di-methyl-piperazine-1,4-diium tetra-chlorido-cobaltate(II).

In the title mol-ecular salt, (C6H16N2)[CoCl4], the complete dication is generated by crystallographic inversion symmetry and the piperazine ring adopts a chair conformation with the pendant methyl groups in equatorial orientations. The complete dianion is generated by crystallographic twofold symmetry. In the crystal, the (C6H16N2)2+ and [CoCl4]2- ions are linked by N-H⋯Cl and C-H⋯Cl hydrogen bonds, thereby forming a two-dimensional supra-molecular network. The Hirshfeld surface analysis and fingerprint plots reveal that the largest contributions to the crystal stability come from H⋯Cl/Cl⋯H (68.4%) and H⋯H (27.4%) contacts.

Sepsis and septic shock in France: incidences, outcomes and costs of care.

BACKGROUND: Sepsis is one of the leading causes of death worldwide. The associated incidence, mortality and trends do not differ greatly between documented reports. The purpose of this study was to provide an in-depth description of patients with sepsis and septic shock hospitalized in France from 2010 to 2015 and to explore the temporal trends of their clinical characteristics, costs and outcomes. METHODS: Retrospective cohort study of the French hospital administrative database in which organ failure therapies and severity scores are systematically registered. All patients admitted between 2010 and 2015 for sepsis and septic shock as defined by an ICD-10 code for infection, and for organ failure or the use of organ failure supplementation were included. Incidence, outcomes and trends were analyzed. Subgroup analyses based on several coding strategies and adjusted for severity scores were performed. RESULTS: A total of 737,147 patients with sepsis and 492,902 patients with septic shock were included. From 2010 to 2015, the incidence of sepsis and septic shock increased, respectively, from 206 to 243 and from 135 to 171 cases per 100,000 population. Case fatality remained at 34% for sepsis, but decreased from 46 to 44% for septic shock. Median hospital stay costs amounted to €11,400 (IQR: 5036; 24,364) for patients with sepsis and €16,439 (IQR: 7339; 29,360) for patients with septic shock. After adjustment for case-mix and illness severity, the risk of death was stable for sepsis (0.08% [- 0.04; 0.20] per year), but decreased for sepsis patients admitted to the intensive care unit and for cases of septic shock (- 0.33%[ - 0.40; - 0.27] per year). CONCLUSIONS: Sepsis is common, frequently fatal and expensive to treat. Its incidence has increased. Case fatality has decreased in most severely affected patients, owing partly to general improvements in care.

Bis(4-chloro-benzyl-ammonium) tetra-kis(2,6-diethyl-anilinium) cyclo-hexa-phosphate tetra-hydrate.

In the crystal of the title hydrated mol-ecular salt, 2C(7)H(9)ClN(+)·4C(10)H(16)N(+)·P(6)O(18) (6-)·4H(2)O, the packing consists of a three-dimensional O-H⋯O and N-H⋯O hydrogen-bonded network resulting from the association of anionic layers built up from centrosymmetric cyclohexaphosphate ions and water mol-ecules and the two types of organic cations.

5-Chloro-2-methoxy-anilinium nitrate.

The title salt, C(7)H(9)ClNO(+)·NO(3) (-), exhibits extensive hydrogen bonding between the ammonium functional group and the nitrate anion. A two-dimensional network of bifurcated N-H⋯O hydrogen bonds generates corrugated layers in the bc plane. The organic mol-ecules are stacked in a parallel orientation as a result of π-π inter-actions, with an inter-ring distance of 3.837 Å.

Synthesis, crystal structure and Hirshfeld surface analysis of a polymeric bis-muthate(III) halide complex, (C6H6N3)2[BiCl5]·2H2O.

The synthesis and the crystal structure of a new halide-bridged polymer, namely catena-poly[bis-(1,2,3-benzotriazolium) [[tetra-chlorido-bis-muth(III)]-µ-chlorido] dihydrate], {(C6H6N3)2[BiCl5]·2H2O} n are reported. The structure comprises polyanionic zigzag chains of formula [(BiCl5)2-] n running along the c-axis direction. The 1,2,3-benzotriazolium cations are linked between these polymer chains, via the water mol-ecules, giving rise to left- and right-handed helical chains. Hirshfeld surface analysis and fingerprint plots were used to decode the inter-molecular inter-actions in the crystal network and determine the contribution of the component units for the construction of the three-dimensional architecture.

The use and practice of body substance precautions in sports physiotherapy.

This study examined the use of Universal Precautions in the management of bleeding sports injuries. A survey was used which asked questions on: demographics, hepatitis B vaccination, first aid practices and frequency of blood contact. The national sample consisted of 1800 Australian Physiotherapy Association National Sports Physiotherapy Group members. The response rate was 29.2 per cent. Eighty-five per cent of physiotherapists were exposed to bleeding injuries. The use of rubber gloves in the treatment of bleeding injuries was low (47 per cent using them always/frequently). Only 60 per cent disposed of sharp instruments appropriately. Eighty per cent reported being immunised against hepatitis B. Experience was strongly associated with appropriate first aid practices. The study suggests that physiotherapists in sport are not consistently adhering to Universal Precautions.