Impact of a Pharmacist-Driven Medication Diluent Volume Optimization Protocol on Fluid Balance and Outcomes in Critically Ill Patients.

Background: Volume overload (VO) is common in the intensive care unit (ICU) and associated with negative outcomes. Approaches have been investigated to curtail VO; however, none specifically focused on medication diluent volume optimization. Objective: Investigate the impact of a pharmacist-driven medication diluent volume optimization protocol on fluid balance in critically ill patients. Methods: A prospective, pilot study was conducted in a medical ICU during October 2021 to December 2021 (pre) and February 2022 to April 2022 (post). A pharmacist-driven medication diluent volume optimization protocol focusing on vasopressor and antimicrobial diluent volumes was implemented. Demographics and clinical data were collected during ICU admission up to 7 days. The primary outcome was net fluid balance on day 3. Secondary outcomes were medication volumes administered, net fluid balance, ICU length of stay, and mortality. Results: Supply chain shortages caused the study to stop at the end of February 2022. Overall, 152 patients were included (123 pre group, 29 post group). The most common admission diagnosis was acute respiratory failure (35%). Vasopressors and antimicrobials were utilized in 47% and 66% of patients, respectively. Net fluid balance on day 3 was greater but not significant in the post group (227.1 mL [-1840.3 to 3483.7] vs 2012.3 mL [-2686.0 to 4846.0]; P = .584). Antimicrobial diluent volumes were significantly less in the post group. No differences were seen in other secondary outcomes. Protocol group assignment was not associated with net fluid balance on day 3. Conclusion: Despite decreasing antimicrobial volume contributions, optimizing diluent volumes alone did not significantly impact overall volume status. Future studies should focus on comprehensive approaches to medication diluent optimization and fluid stewardship.

Three-dimensional virtual surgical planning (3D-VSP) in orthognathic surgery: Advantages, disadvantages and pitfalls.

In this article, the advantages, disadvantages and pitfalls of three-dimensional virtual surgical planning (3D-VSP) compared to traditional two-dimensional (2D) planning methods in orthognathic surgery are discussed, alongside a standardised protocol that can be utilised. A skeletal Class II, skeletal Class III and an anterior open bite clinical case along with their 3D-VSP management are presented, highlighting modifications that can be made to computer-aided design/computer-aided manufacture (CAD/CAM) cutting guide and plate designs.

3-D CT is the most reliable imaging modality when quantifying glenoid bone loss.

BACKGROUND: Posttraumatic anterior shoulder instability is associated with anterior glenoid bone loss, contributing to recurrence. Accurate preoperative quantification of bone loss is paramount to avoid failure of a soft tissue stabilization procedure as bone reconstruction is recommended for glenoid defects greater than 20% to 27%. QUESTIONS/PURPOSES: We determined whether radiography, MRI, or CT was most reliable to quantify glenoid bone loss in recurrent anterior shoulder instability. METHODS: Seven intact fresh-frozen human cadaveric shoulders were imaged with radiography, MRI, CT, and three-dimensional (3-D) CT. Three sequential anterior glenoid defects then were created, measured, and the shoulders reimaged after each defect. Defect sizes were less than 12%, 12% to 25%, and 25% to 40%. The gold standard measurement was determined by comparing measurements taken on the cadaver by two surgeons using digital calipers with the measurements determined by using electronic digital calipers on the 3-D CT. This measurement was used for comparison of all estimations by the evaluators. Twelve independent blinded evaluators reviewed the 112 image sets and estimated the percent of glenoid bone loss. Images were scrambled and rereviewed by the same observers 2 months later to determine intraobserver reliability. We determined reliability with kappa values. RESULTS: Kappa values between predicted bone loss versus true loss (determined by our gold standard measurements) across all 12 raters for each modality were: 3-D CT, 0.50; CT, 0.40; MRI, 0.27; and radiographs, 0.15. Interobserver agreement (kappa) values were: 3-D CT, 0.54; CT, 0.47; MRI, 0.31; and radiographs, 0.15. The intraobserver agreement (kappa) values were: 3-D CT, 0.59; CT, 0.64; MRI, 0.51; and radiographs, 0.45. CONCLUSIONS: Three-dimensional CT was the most reliable imaging modality for predicting glenoid bone loss. Regular CT was the second most reliable and reproducible modality.

Comparison of various imaging techniques to quantify glenoid bone loss in shoulder instability.

INTRODUCTION: The purpose of this study was to determine the most accurate imaging modality to quantify glenoid bone loss in recurrent anterior shoulder instability. This will allow the best preoperative prediction for patients needing a bone graft. MATERIALS AND METHODS: Seven fresh frozen shoulder cadavers were imaged with radiographs, magnetic resonance imaging (MRI), computed tomography (CT), and 3-dimensional CT (3-D CT). Native shoulders were imaged, and 3 sequential anterior-inferior glenoid defects were created, measured, and reimaged. Defect sizes were <12.5%, 12.5% to 27%, and >27%. Four blinded evaluators (2 musculoskeletal radiologists, 2 shoulder fellowship-trained surgeons) reviewed the 112 image sets and estimated the percentage of glenoid bone loss. Images were scrambled and re-reviewed by the same observers 2 months later to determine intraobserver reliability. RESULTS: Pearson correlation coefficients between predicted vs true bone loss across all 4 raters were 0.875 (3-D CT), 0.831 (CT), 0.693 (MRI), and 0.457 (x-ray imaging). Prediction errors (PE) were (mean ± SD in percentages) 3-D CT (-3.3 ± -6.6), CT (-3.7 ± -8.0), MRI (-2.75 ± -10.6), and x-ray images (-6.9 ± -13.1). Mean PE values were not significantly different among 3-D CT, CT, and MRI; however, the PE SDs were similar among the 4 evaluators for 3-D CT and lower than all other imaging techniques. Prediction based on x-ray images had the largest PE and SD. Covariance parameters revealed large variances for shoulders for MRI and x-ray imaging. The intraobserver intraclass correlation coefficients were 0.947 (3-D CT), 0.927 (CT), 0.837 (MRI), and 0.726 (x-ray image). CONCLUSIONS: The most accurate imaging modality in predicting glenoid bone loss among the 4 blinded independent evaluators was 3-D CT.

Ascorbic Acid in the Acute Care Setting.

Ascorbic acid (AA) is an essential nutrient with many physiologic roles not limited to the prevention of scurvy. Beyond its role as a supplement, it has gained popularity in the acute care setting as an inexpensive medication for a variety of conditions. Because of limitations with absorption of oral formulations and reduced serum concentrations observed in acute illness, intravenous (IV) administration, and higher doses, may be needed to produce the desired serum concentrations for a particular indication. Following a PubMed search, we reviewed published studies relevant to AA in the acute care setting and summarized the results in a narrative review. In the acute care setting, AA may be used for improved wound healing, improved organ function in sepsis and acute respiratory distress syndrome, faster resolution of vasoplegic shock after cardiac surgery, reduction of resuscitative fluids in severe burn injury, and as an adjunctive analgesic, among other uses. Each indication differs in its level of evidence supporting exogenous administration of AA, but overall, AA was not commonly associated with adverse effects in the identified studies. Use of AA remains an active area of clinical investigation for various indications in the acute care patient population.

Platelet Function Testing with a VerifyNow-Directed Personalized Antiplatelet Strategy and Associated Rates of Thromboembolic Complications After Pipeline Embolization for Complex Cerebral Aneurysms.

BACKGROUND: VerifyNow-directed personalized antiplatelet therapy for aneurysm embolization with a Pipeline Embolization Device (PED) remains controversial. Evaluate thrombotic complications between patients who received VerifyNow-directed personalized antiplatelet therapy versus those who did not after PED flow diversion of complex cerebral aneurysms. METHODS: This was a retrospective cohort of consecutive patients undergoing flow diversion with PED at the Medical University of South Carolina between January 2012 and May 2018. Patients who received VerifyNow-directed personalized antiplatelet therapy were compared with those who received antiplatelet therapy without platelet function testing. Patients with a P2Y12 reaction unit (PRU) ≥194 were deemed to be clopidogrel hyporesponsive. The primary outcome is the rate of thrombotic complications, and the secondary outcomes are the rate of hemorrhagic and thrombotic complications stratified by PRU and high-risk clinical and procedure-related candidate predictors. RESULTS: Thrombotic complications were not different between patients managed with (n = 159) versus without (n = 110) VerifyNow (6.9% vs. 7.3%; P = 0.911). Hemorrhagic complications were also no different (3.1% vs. 4.5%; P = 0.550). PRU stratification revealed no difference in thrombotic or hemorrhagic complications (P = 0.488 and P = 0.136, respectively). The only significant predictors for thrombotic complications were the presence of diabetes (OR 2.9; P = 0.034), obesity (OR 5.1; P ≤ 0.001), fusiform aneurysm (OR 3.3; P = 0.023), posterior circulation implantation (OR 3.4; P = 0.016), and >1 PED implanted (OR 2.4; P = 0.046). CONCLUSIONS: The role of VerifyNow and personalized antiplatelet therapy in patients undergoing flow diversion with PED to treat complex aneurysms did not demonstrate a benefit in reducing thrombotic complications.

Oral cavity, pharyngeal and salivary gland cancer: disparities in ethnicity-specific incidence among the London population.

OBJECTIVES: We examined the association between ethnicity and the incidence of oral and pharyngeal cancers in the London population. METHODS: Data on London residents diagnosed with oral and pharyngeal cancer (ICD-10 codes C00-C14) between 1998 and 2007 were retrieved from the Thames Cancer Registry. Age-standardised incidence rate ratios (IRR) for cancers of the nasopharynx (C11), oropharynx (C09-C10), hypopharynx (C12-C13), oral cavity (C00.3-C06), salivary glands (C07-C08) and Waldeyer's ring (C02.4, C09, C11.1, C14.2) were calculated for different ethnic groups using White males and females as the baseline groups. RESULTS: Records on 5833 individuals were examined, and ethnicity information was available for 4679 (80%) of these patients. The incidence rate of oral and pharyngeal cancer combined was 9.0 and 3.9 per 100,000 for males and females, respectively. Compared with their White counterparts, the highest incidence rate ratios of nasopharyngeal cancer were seen in Chinese males (IRR: 23, 95% confidence interval (CI): 7-73) and females (IRR: 16, 95% CI: 2-107). Waldeyer's ring cancers were most common in Bangladeshi and White groups. Analysis of the oropharynx and oral cavity cancers gave rise to variable but less obvious patterns among the different ethnic groups, whereas less variation was observed between ethnic groups for cancers of the hypopharynx and salivary glands. CONCLUSION: The incidence rates of individual oral and pharyngeal cancer types are low, but seem to vary by ethnic group. The variation in incidence appears to be unique to the different cancer subtypes and may therefore reflect specific ethnicity-related risk factors.