Mattress Coil Spring Fatigue and Weight-Bearing Support: Comparison of Weight-Bearing and Non-Weight-Bearing Springs.

OBJECTIVE: The purpose of this study was to compare the firmness of used mattress coil springs from the areas bearing greatest body weight versus areas subjected to little compression. METHODS: Weight-bearing springs (WBS) extracted from the center of the mattresses (N = 32), and non-weight-bearing springs (NWBS) extracted from the head/foot were of the same mattresses. To determine spring weakness, a 1296-g ingot was placed on the coil, and the compression distance was measured (cm). In addition, a gauge was used to measure the amount of pressure required to compress the coil springs a distance of 2 cm. Comparison between WBS and NWBS data were statistically treated using independent t tests and a 1-way analysis of variance. RESULTS: There were no significant group differences in weight or height in unloaded coils. However, there were significant (P < .05) differences in coil spring compression distance under load (WBS = 2.78 ± 0.34 cm; NWBS = 1.52 ± 0.39 cm) and force gauge compression (WBS = 1090.51 ± 88.42 g; NWBS = 1213.12 ± 71.38 g) between groups. CONCLUSION: This study found that WBSs were weaker when compressed than the NWBS from used mattresses, and such characteristics may not be visually apparent in a mattress when not in use. Thus, coil springs in bedding systems may eventually fail to provide the initial structural support after use. Such sagging may compromise sleep posture with accompanying poor sleep quality and quantity.

Similar Anaerobic and Aerobic Adaptations After 2 High-Intensity Interval Training Configurations: 10:5 s vs. 20:10 s Work-to-Rest Ratio.

ABSTRACT: Moghaddam, M, Estrada, CA, Muddle, TWD, Magrini, MA, Jenkins, NDM, and Jacobson, BH. Similar anaerobic and aerobic adaptations after 2 high-intensity interval training configurations: 10:5 s vs. 20:10 s work-to-rest ratio. J Strength Cond Res 35(6): 1685-1692, 2021-This study compares the effects of 2 high-intensity interval training (HIIT) configurations, a 10-5 vs. a 20-10 second work-to-rest ratio, on anaerobic and aerobic performance. Thirty-four individuals were randomly assigned to 10-5-HIIT (n = 17) and 20-10-HIIT (n = 17) groups to complete 6 cycles of 6 exercises, 3 days a week for 4 weeks. The 10-5-HIIT was performed with 10 s:5 s work-to-rest ratio with 1-minute recovery between cycles, while the 20-10-HIIT was performed with 20 s:10 s work-to-rest ratio followed by a 2-minute recovery. Anaerobic (i.e., peak power [PP], anaerobic capacity [AC], anaerobic power [AP], and total work [TW]) and aerobic fitness (i.e., time to exhaustion [TE], absolute V̇o2max [A-V̇o2max], relative V̇o2max [R-V̇o2max]) were measured with pre-training and post-training intervention. A significant main effect time was observed for both 10-5-HIIT and 20-10-HIIT (p < 0.05) in PP (9.2%, 5.7%); AC (14.9%, 8.6%); AP (9.0%, 6.2%); TW (15.1%, 8.5%); TE (4.3%, 5.5%); A-V̇o2max (9.4%, 8.9%); R-V̇o2max (8.5%, 8.2%), respectively. In conclusion, individuals may be able to achieve similar health benefits as 20-10-HIIT by performing 10-5-HIIT, despite exercising for 50% less total time. High-intensity interval training has been suggested as a "time-efficient" mode of exercise that can mitigate the most significant barrier to physical activity, "lack of time." Both 10-5-HIIT and 20-10-HIIT can induce performance adaptations to a similar extent. However, because of shorter time commitment, performing 10-5-HIIT at 10 s:5 s work-to-rest ratio may offer a shorter and equally efficient interval. Functional fitness training during HIIT protocols seems to be as beneficial as ergometer-based HIIT to improve anaerobic and aerobic performance.

Does strict validation criteria for individual motor units alter population-based regression models of the motor unit pool?

The purpose of this study was to determine if the implementation of a strict validation procedure, designed to limit the inclusion of inaccuracies from the decomposition of surface electromyographic (sEMG) signals, affects population-based motor unit (MU) analyses. Four sEMG signals were obtained from the vastus lateralis of 59 participants during isometric contractions at different relative intensities [30%, 70%, and 100% of maximal voluntary contraction (MVC)], and its individual motor unit potential trains (MUPTs) were extracted. The MUPTs were then excluded (ISIval) based on the coefficient of variation and histogram of the interspike intervals (ISI), the absence of additional clusters that reveals missed or additional firings, and more. MU population-based regression models (i.e., modeling the entire motor unit pool) were performed between motor unit potential size (MUPSIZE), mean firing rate (MFR), and recruitment threshold (RT%) separately for DSDCOnly (includes all MUPTs without the additional validation performed) and ISIval data at each contraction intensity. The only significant difference in regression coefficients between DSDCOnly and ISIval was for the intercepts of the MUPSIZE/MFR at 100% MVC. The validation had no other significant effect on any of the other regression coefficients for each of the contraction intensities. Our findings suggest that even though the decomposition of surface signals leads to some inaccuracies, these errors have limited effects on the regression models used to estimate the behavior of the whole pool. Therefore, we propose that motor unit population-based regression models may be robust enough to overcome decomposition-induced errors at the individual MU level.

Cross-education: effects of age on rapid and maximal voluntary contractile characteristics in males.

PURPOSE: The purpose of this study was to determine the effect of age on the cross-education of rapid and maximal contractile properties for the knee extensors. METHODS: Young (n = 10; age = 21.1 ± 1.7 years) and older (n = 10; age = 65.3 ± 8.3 years) males performed unilateral isokinetic resistance training (RT) of the knee extensors for 4 weeks. Maximal voluntary isokinetic (45° s-1 and 300° s-1) and isometric testing was conducted for the trained and untrained leg before and after RT. Peak torque (PT) and acceleration were obtained from isokinetic testing as well as torque at 30 ms (TQ30) and 100 ms (TQ100) from the 45° s-1 contraction. PT and rate of torque development were recorded from the isometric contractions. RESULTS: Independent of age, isometric PT (10.1%; p = 0.006) as well as PT and acceleration at 300° s-1 (6.7%; p = 0.008 and 4.0%; p = 0.016, respectively) increased in the untrained leg. At 45° s-1, acceleration was increased (3.6%; p = 0.021), but PT remained unchanged (p = 0.227). TQ100 increased similarly between groups (4.5%; p = 0.014), but TQ30 increased only in the older group (9.5%; p = 0.022). CONCLUSIONS: Cross-education of rapid and maximal contractile parameters can be achieved early during unilateral RT independent of age. These findings indicate the potential for particular unilateral RT protocols to be used for older adults in rehabilitative settings to offset disuse-related reductions in contractile function, which are most dramatic in this population.

Signed, Sealed, Delivered: Increasing Patient Notification of Test Results in an Internal Medicine Resident Continuity Clinic.

OBJECTIVES: Informing patients of their test results is an important patient safety issue, yet many physicians perform dismally in this regard. Residents often face additional barriers to communicating test results to patients. We wanted to determine whether streamlining the notification process, communicating expectations, and having residents audit their performance would increase result notification rates. METHODS: We used a quasi-experimental design, and a single-group before-and-after intervention. Our multifold intervention consisted of development and standardization of a notification process in the electronic medical record, an education component, and a self-audit component. During a 15-minute session, we educated residents on the use of the new process. We also restated expectations regarding notifying patients of their results. Residents audited their own charts for a period before the intervention and during a second, postintervention period. An independent review of notification rates took place simultaneously as well as during an additional period several months later. RESULTS: In total, 87 residents were eligible for participation. All 87 completed the project, giving a 100% participation rate. Resident-reported laboratory test notification rates increased from 16% to 91%; other test result rates increased from 33% to 84%. The three independent reviews showed laboratory test notification rates increased from 18.5% to 71.7% to 87.1%, and notification of other test results increased from 23.5% to 66.7% to 91.7%. CONCLUSIONS: Baseline rates of notification for diagnostic tests results were low, but streamlining the notification process, clearly stating expectations for using it, and using resident self-audit can improve notification rates.

What Defines an Honors Student? Survey of Pediatric and Internal Medicine Faculty Perspectives.

OBJECTIVE: Although considerable emphasis is placed on the attainment of honors in core medical school clerkships, little is known about what student characteristics are used by attending physicians to earn this designation. The purpose of this study was to evaluate what values and characteristics that attending physicians consider important in the evaluation of Pediatrics and Internal Medicine clerkship students for clinical honors designation. METHODS: This cross-sectional survey study was framed around Accreditation Council for Graduate Medical Education (ACGME) competencies. It was administered at three tertiary care hospitals associated with one large medical school in an urban setting. Teaching ward attendings in Pediatrics and Internal Medicine who evaluated third-year medical students between 2013 and 2016 were surveyed. RESULTS: Overall, Pediatric and Internal Medicine faculty demonstrated close agreement in which competencies were most important in designating clinical honors. Both groups believed that professionalism was the most important factor and that systems-based practice and patient care were among the least important factors. The only competency with a significant difference between the two groups was systems-based practice, with Internal Medicine placing more emphasis on the coordination of patient care and understanding social determinants of health. CONCLUSIONS: Professionalism, communication skills, and medical knowledge are the most important characteristics when determining clinical honors on Pediatrics and Internal Medicine clerkships.

What Attracts Medical Students to Primary Care? A Nominal Group Evaluation.

OBJECTIVE: To examine the perceptions of first-year medical students on their experiences in primary care. METHODS: Nominal group technique sessions were conducted with first-year medical students for 5 years. Questions were designed to evaluate primary care experiences and the role of primary care physicians. The questions explored what would make them consider primary care, what would detract from it, and what primary care has to offer that no other specialty can. Responses were weighted and ranked. The main outcome was the top five responses to three questions that were obtained at each session. RESULTS: Thirty-four students generated 280 responses to 3 questions. The top 5 responses for each year resulted in 29 experiences that strengthen enthusiasm: patient interactions (weighted sum, 43%), physician interactions/role modeling (22%), community interactions (20%), healthcare system/finances (8%), and other (6%). The top 5 responses resulted in 26 experiences that weaken enthusiasm, including hidden curriculum (45%), poor role models (29%), uncertainties about the healthcare system such as finances and documentation (20%), and patient interactions (6%). The top 5 responses regarding the uniqueness of primary care resulted in 37 experiences, including patient interactions (38%), continuity of care (20%), knowledge base (13%), community impact (10%), lifestyle benefits (10%), and education/prevention (9%). CONCLUSIONS: Medical students highlighted unique relationships with patients and continuity of care as experiences that increase their enthusiasm for primary care. Negative experiences that weakened enthusiasm for primary care included hidden curriculum and poor role models. Programs that provide experiences in primary care can increase student interest in primary care careers.

Age Does Not Attenuate Maximal Velocity Adaptations in the Ipsilateral and Contralateral Limbs During Unilateral Resistance Training.

This study examined the effects of unilateral resistance training (RT) on maximal velocity parameters in the ipsilateral and contralateral legs in young and older males. Young (n = 22; age = 21.55 ± 2.23 years) and older (n = 20; age = 65.10 ± 9.65 years) males were assigned to training or control groups. Unilateral isokinetic RT of the knee extensors was performed for 4 weeks. Peak velocity and acceleration were identified during a dynamic maximal voluntary contraction before (PRE), at Week 2 (MID), and after Week 4 (POST) of RT. Age-independent increases in peak velocity (1.5%) and acceleration (4.5%) were demonstrated at POST for the trained leg. For the untrained leg, acceleration increased (4.3%) at POST similarly between training groups. These findings provide evidence for the high degree of neuromuscular plasticity, regardless of age, during the early phase of RT, and the potential for cross education of acceleration.

Are All Teaching Activities Valued the Same? Their Relative Worth Is in the Eye of the Beholder.

OBJECTIVES: The pressures for generating revenue from clinical activities dissuade clinician-educators from teaching; taking the steps to develop an educational value system is a way to recognize and perhaps support education. We compared the perceived educational value of diverse pedagogical activities during clinical training from students, residents, and faculty in medical and surgical specialties. METHODS: Between 2016 and 2017, a survey among medical students, residents, and faculty from medical (internal medicine, pediatrics) or surgical (general surgery, obstetrics and gynecology) departments was conducted at an academic medical center that sponsors 88 training programs. Participants ranked teaching activities relative to their perceived teaching importance. RESULTS: In total, 156 subjects participated (48 core teaching faculty, 68 residents, and 40 medical students). Teaching in the wards was the highest-ranked teaching activity for medical (mean 1.6) and surgical specialties (mean 1.9). For medicine and pediatrics, active teaching activities were ranked higher (mean 2.9, 95% confidence interval [CI] 2.8-3.0) than passive teaching activities (mean 5.3, 95% CI 5.1-5.5, P < 0.001). Similarly, for surgery and obstetrics and gynecology, active teaching activities were ranked higher (mean 3.6, 95% CI 3.3-3.9) than passive teaching activities (mean 5.2, 95% CI 4.8-5.5, P < 0.001). CONCLUSIONS: Medical students, residents, and faculty across specialties have a high degree of agreement regarding the ranking of diverse pedagogical activities; such correlation will facilitate the interpretation of educational value units across specialties.

Engagement in an Online Cultural Competency Training.

OBJECTIVES: Engagement with online cultural competency training has not been well studied. We examined knowledge, attitudes, and skills differences among medical students, physicians, and other professionals in an online cultural competency education program. METHODS: A total of 1745 participants completed up to four online modules aimed at exploring stereotype, bias, diet, and religion among African American patients with hypertension. We examined knowledge, attitudes, and self-reported skills with 17 multiple-choice questions embedded in the 4 modules. Participants received comparative responses with their peers. RESULTS: Between 75% and 84% of participants knew the definition of stereotype and <50% knew the definition of bias (47% students, 36% physicians, 33% others, P < 0.001). Most responded that minorities perceive bias (98%-100%) and believe that evidence exists showing that bias affects decision making (62%-69%). Although most perceive that religious and spiritual beliefs affect reaction to illness often (78% students, 68% physicians, 79% others, P < 0.001), few would ask about religious beliefs during a typical encounter (13% students, 16% physicians, 30% others, P < 0.001). CONCLUSIONS: All of the participants struggled to define bias; however, most agreed that minorities perceive bias in the care they receive. We examined usage and interaction with the online content as a dimension of engagement.

Sensitivity for Diagnosing Group A Streptococcal Pharyngitis from Manufacturers is 10% Higher than Reported in Peer-Reviewed Publications.

OBJECTIVES: Meta-analyses based on peer-reviewed publications report a sensitivity of approximately 85% for rapid antigen streptococcus tests to diagnose group A streptococcal (GAS) pharyngitis. Because these meta-analyses excluded package inserts, we examined the test characteristics of rapid antigen streptococcal tests and molecular methods that manufacturers report in their package inserts. METHODS: We included tests available in the US market (Food and Drug Administration, period searched 1993-2015) and used package insert data to calculate pooled sensitivity and specificity. To examine quality, we used the Quality Assessment of Diagnostic Accuracy Studies-2. We excluded 26 tests having different trade names but identical methods and data. RESULTS: The study design was prospective in 41.7% (10 of 24). The pooled sensitivity of the most commonly used method, lateral flow/immunochromatographic, was 95% (95% confidence interval [CI] 94-96) and the pooled specificity was 98% (96-98); 7108 patients. The pooled sensitivity of the polymerase chain reaction or molecular methods was 98% (95% CI 96-98) and the pooled specificity was 96% (95% CI 95-97); 5685 patients. CONCLUSIONS: Package inserts include sponsored studies that overestimate the sensitivity of rapid tests to diagnose GAS pharyngitis by approximately 10%. Physicians should understand that package inserts overestimate diagnostic test utility; a negative test cannot be used to exclude GAS pharyngitis.

Physician Order Entry Clerical Support Improves Physician Satisfaction and Productivity.

OBJECTIVES: To examine the impact of clerical support personnel for physician order entry on physician satisfaction, productivity, timeliness with electronic health record (EHR) documentation, and physician attitudes. METHODS: All seven part-time physicians at an academic general internal medicine practice were included in this quasi-experimental (single group, pre- and postintervention) mixed-methods study. One full-time clerical support staff member was trained and hired to enter physician orders in the EHR and conduct previsit planning. Physician satisfaction, productivity, timeliness with EHR documentation, and physician attitudes toward the intervention were measured. RESULTS: Four months after the intervention, physicians reported improvements in overall quality of life (good quality, 71%-100%), personal balance (43%-71%), and burnout (weekly, 43%-14%; callousness, 14%-0%). Matched for quarter, productivity increased: work relative value unit (wRVU) per session increased by 20.5% (before, April-June 2014; after, April-June 2015; range -9.2% to 27.5%). Physicians reported feeling more supported, more focused on patient care, and less stressed and fatigued after the intervention. CONCLUSIONS: This study supports the use of physician order entry clerical personnel as a simple, cost-effective intervention to improve the work lives of primary care physicians.

Effects of Energy Beverage Consumption on Pistol Aiming Steadiness in Law Enforcement Officers.

Monaghan, TP, Jacobson, BH, Sellers, JH, and Estrada, CA. Effects of energy beverage consumption on pistol aiming steadiness in law enforcement officers. J Strength Cond Res 31(9): 2557-2561, 2017-The popularity of energy drinks (EDs)/shots (ESs) has grown steadily over the years resulting in billions of dollars of sales annually. Energy drink marketing focuses on the improved performance and alertness and a reduction in fatigue. Although caffeine comprises one of the ingredients, it is not fully known how the combination of the many remaining active ingredients affects physical performance. The purpose of this study was to investigate the effect of a commercially available ES on pistol aiming steadiness. Subjects (N = 10) consisted of accredited police officers in the Midwest. A randomized, blinded, crossover design was used to evaluate the pistol aiming steadiness after the consumption of an ES or placebo. Pistol aiming steadiness was measured using a hole/stylus steadiness tester and laser attached to a training pistol before and 30 minutes after ES or placebo consumption. Analysis revealed that the ES significantly (p ≤ 0.05) impaired pistol steadiness, whereas the placebo yielded no significant difference in aiming steadiness. Based on these results, it was concluded that the consumption of an ES could compromise aiming accuracy and shot placement, thereby jeopardizing the health and welfare of law enforcement personnel.

The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study.

BACKGROUND: Pharyngitis guidelines focus solely on group A ß-hemolytic streptococcal infection. European data suggest that in patients aged 15 to 30 years, Fusobacterium necrophorum causes at least 10% of cases of pharyngitis; however, few U.S. data exist. OBJECTIVE: To estimate the prevalence of F. necrophorum; Mycoplasma pneumoniae; and group A and C/G ß-hemolytic streptococcal pharyngitis and to determine whether F. necrophorum pharyngitis clinically resembles group A ß-hemolytic streptococcal pharyngitis. DESIGN: Cross-sectional. SETTING: University student health clinic. PATIENTS: 312 students aged 15 to 30 years presenting to a student health clinic with an acute sore throat and 180 asymptomatic students. MEASUREMENTS: Polymerase chain reaction testing from throat swabs to detect 4 species of bacteria and signs and symptoms used to calculate the Centor score. RESULTS: Fusobacterium necrophorum was detected in 20.5% of patients and 9.4% of asymptomatic students. Group A ß-hemolytic streptococcus was detected in 10.3% of patients and 1.1% of asymptomatic students. Group C/G ß-hemolytic streptococcus was detected in 9.0% of patients and 3.9% of asymptomatic students. Mycoplasma pneumoniae was detected in 1.9% of patients and 0 asymptomatic students. Infection rates with F. necrophorum, group A streptococcus, and group C/G streptococcus increased with higher Centor scores (P < 0.001). LIMITATIONS: The study focused on a limited age group and took place at a single institution. Asymptomatic students-rather than seasonal control participants-and a convenience sample were used. CONCLUSION: Fusobacterium necrophorum-positive pharyngitis occurs more frequently than group A ß-hemolytic streptococcal-positive pharyngitis in a student population, and F. necrophorum-positive pharyngitis clinically resembles streptococcal pharyngitis. PRIMARY FUNDING SOURCE: University of Alabama at Birmingham and the Justin E. Rodgers Foundation.

Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the academic hospitalist taskforce.

Physicians increasingly investigate, work, and teach to improve the quality of care and safety of care delivery. The Society of General Internal Medicine Academic Hospitalist Task Force sought to develop a practical tool, the quality portfolio, to systematically document quality and safety achievements. The quality portfolio was vetted with internal and external stakeholders including national leaders in academic medicine. The portfolio was refined for implementation to include an outlined framework, detailed instructions for use and an example to guide users. The portfolio has eight categories including: (1) a faculty narrative, (2) leadership and administrative activities, (3) project activities, (4) education and curricula, (5) research and scholarship, (6) honors, awards, and recognition, (7) training and certification, and (8) an appendix. The authors offer this comprehensive, yet practical tool as a method to document quality and safety activities. It is relevant for physicians across disciplines and institutions and may be useful as a standalone document or as an adjunct to traditional promotion documents. As the Next Accreditation System is implemented, academic medical centers will require faculty who can teach and implement the systems-based practice requirements. The quality portfolio is a method to document quality improvement and safety activities.

Teaching behaviors that define highest rated attending physicians: a study of the resident perspective.

BACKGROUND: Better understanding teaching behaviors of highly rated clinical teachers could improve training for teaching. We examined teaching behaviors demonstrated by higher rated attending physicians. METHODS: Qualitative and quantitative group consensus using the nominal group technique (NGT) among internal medicine residents and students on hospital services (2004-2005); participants voted on the three most important teaching behaviors (weight of 3 = top rated, 1 = lowest rated). Teaching behaviors were organized into domains of successful rounding characteristics. We used teaching evaluations to sort attending physicians into tertiles of overall teaching effectiveness. RESULTS: Participants evaluated 23 faculty in 17 NGT sessions. Participants identified 66 distinct teaching behaviors (total sum of weights [sw] = 502). Nineteen items had sw ≥ 10, and these were categorized into the following domains: Teaching Process (n = 8; sw = 215, 42.8%), Learning Atmosphere (n = 5; sw = 145, 28.9%), Role Modeling (n = 3; sw = 74, 14.7%) and Team Management (n = 3; sw = 65, 12.9%). Attendings in the highest tertile received a larger number of votes for characteristics within the Teaching Process domain (56% compared to 39% in lowest tertile). CONCLUSIONS: The most effective teaching behaviors fell into two broad domains: Teaching Process and Learning Atmosphere. Highest rated attending physicians are most recognized for characteristics in the Teaching Process domain.

Learning by doing: observing an interprofessional process as an interprofessional team.

New competencies exist for interprofessional education, which are centered on the goal of improving quality of care and patient safety through improved interprofessional collaboration. Interprofessional education and effective interprofessional collaboration are cornerstones of the Veterans Affairs Quality Scholars fellowship program. The purpose of this project was to evaluate an innovative interprofessional education strategy in which teams of physicians and nurses were "learning by doing" as they observed and analyzed the functioning of an interprofessional process, specifically, inpatient discharge. Fellows completed voluntary, anonymous surveys seeking their perspectives about the project. Fellows' feedback revealed several themes, with both positive and negative characteristics related to team functioning, interprofessional understanding, microsystem knowledge, pooled knowledge and assignment challenges. The strength of this strategy is exemplified by the fact that fellows not only learned from each other's separate professional observations, but also observed the emergence of a shared interprofessional perspective through working together.

Clinical reasoning for the infectious disease specialist: a primer to recognize cognitive biases.

Infectious disease specialists are frequently consulted for diagnostic and therapeutic advice on challenging cases. When evaluating patients, the infectious disease specialist is well positioned to offer an appropriate diagnostic approach but is also at risk of not recognizing the correct diagnosis for a variety of reasons. We believe it is important to provide infectious disease specialists and trainees with a fundamental understanding of diagnostic errors, clinical reasoning, and cognitive biases. We present 2 cases demonstrating common cognitive biases leading to diagnostic errors, and we reflect on strategies that may aid in their prevention. We hope to provide knowledge and tools that may help prevent diagnostic errors in the future.

Hydroxyethyl starch in severe sepsis: end of starch era?

CITATION: Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, Madsen KR, Møller MH, Elkjær JM, Poulsen LM, Bendtsen A, Winding R, Steensen M, Berezowicz P, Søe-Jensen P, Bestle M, Strand K, Wiis J, White JO, Thornberg KJ, Quist L, Nielsen J, Andersen LH, Holst LB, Thormar K, Kjældgaard AL, Fabritius ML, Mondrup F, Pott FC, Møller TP, Winkel P, Wetterslev J; 6S Trial Group; Scandinavian Critical Care Trials Group: Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med 2012, 367:124-34. BACKGROUND: Hydroxyethyl starch (HES) is widely used for fluid resuscitation in ICUs, but its safety and efficacy have not been established in patients with severe sepsis. OBJECTIVE: To assess the effects of HES 130/0.4 compared with a balanced crystalloid solution on mortality and end-stage kidney failure in patients with severe sepsis. DESIGN: Multicenter, parallel-group, blinded, randomized clinical trial, in patients with severe sepsis. INTERVENTIONS: Patients with severe sepsis admitted to the ICU received fluid resuscitation with either 6% HES 130/0.42 (Tetraspan) or Ringer's acetate at a dose of up to 33 ml per kilogram of ideal body weight per day. RESULTS: Of the 804 patients who underwent randomization, 798 were included in the modified intention-to-treat population. The two intervention groups had similar baseline characteristics. At 90 days after randomization, 201 of 398 patients (51%) assigned to HES 130/0.42 had died, as compared with 172 of 400 patients (43%) assigned to Ringer's acetate (relative risk, 1.17; 95% confidence interval (CI), 1.01 to 1.36; P=0.03); 1 patient in each group had end-stage kidney failure. In the 90-day period, 87 patients (22%) assigned to HES 130/0.42 were treated with renal replacement therapy versus 65 patients (16%) assigned to Ringer's acetate (relative risk, 1.35; 95% CI, 1.01 to 1.80; P=0.04), and 38 patients (10%) and 25 patients (6%), respectively, had severe bleeding (relative risk, 1.52; 95% CI, 0.94 to 2.48; P=0.09). The results were supported by multivariate analyses, with adjustment for known risk factors for death or acute kidney injury at baseline. CONCLUSIONS: Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90 and were more likely to require renal replacement therapy compared with those receiving Ringer's acetate.