Christianne A. van Nieuwenhoven

Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study.

Context:Reducing aspiration of gastric contents by placing mechanically ventilated patients in a semirecumbent position has been associated with lower incidences of ventilator-associated pneumonia (VAP). The feasibility and efficacy of this intervention in a larger patient population, however, are unknown. Objective:Assessment of the feasibility of the semirecumbent position for intensive care unit patients and its influence on development of VAP. Design:In a prospective multicentered trial, critically ill patients undergoing mechanical ventilation were randomly assigned to the semirecumbent position, with a target backrest elevation of 45°, or standard care (i.e., supine position) with a backrest elevation of 10°. Main Outcome Measures:Backrest elevation was measured continuously during the first week of ventilation with a monitor-linked device. A deviation of position was defined as a change of the randomized position >5°. Diagnosis of VAP was made by quantitative cultures of samples obtained by bronchoscopic techniques. Results:One hundred nine patients were assigned to the supine group and 112 to the semirecumbent group. Baseline characteristics were comparable for both groups. Average elevations were 9.8° and 16.1° at day 1 and day 7, respectively, for the supine group and 28.1° and 22.6° at day 1 and day 7, respectively, for the semirecumbent group (p < .001). The target semirecumbent position of 45° was not achieved for 85% of the study time, and these patients more frequently changed position than supine-positioned patients. VAP was diagnosed in eight patients (6.5%) in the supine group and in 13 (10.7%) in the semirecumbent group (NS), after a mean of 6 (range, 3–9) and 7 (range, 3–12) days, respectively. There were no differences in numbers of patients undergoing enteral feeding, receiving stress ulcer prophylaxis, or developing pressure sores or in mortality rates or duration of ventilation and intensive care unit stay between the groups. Conclusions:The targeted backrest elevation of 45° for semirecumbent positioning was not reached in the conditions of the present randomized study. The achieved difference in treatment position (28° vs. 10°) did not prevent the development of VAP.

Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies

BACKGROUND Estimating attributable mortality of ventilator-associated pneumonia has been hampered by confounding factors, small sample sizes, and the difficulty of doing relevant subgroup analyses. We estimated the attributable mortality using the individual original patient data of published randomised trials of ventilator-associated pneumonia prevention. METHODS We identified relevant studies through systematic review. We analysed individual patient data in a one-stage meta-analytical approach (in which we defined attributable mortality as the ratio between the relative risk reductions [RRR] of mortality and ventilator-associated pneumonia) and in competing risk analyses. Predefined subgroups included surgical, trauma, and medical patients, and patients with different categories of severity of illness scores. FINDINGS Individual patient data were available for 6284 patients from 24 trials. The overall attributable mortality was 13%, with higher mortality rates in surgical patients and patients with mid-range severity scores at admission (ie, acute physiology and chronic health evaluation score [APACHE] 20-29 and simplified acute physiology score [SAPS 2] 35-58). Attributable mortality was close to zero in trauma, medical patients, and patients with low or high severity of illness scores. Competing risk analyses could be done for 5162 patients from 19 studies, and the overall daily hazard for intensive care unit (ICU) mortality after ventilator-associated pneumonia was 1·13 (95% CI 0·98-1·31). The overall daily risk of discharge after ventilator-associated pneumonia was 0·74 (0·68-0·80), leading to an overall cumulative risk for dying in the ICU of 2·20 (1·91-2·54). Highest cumulative risks for dying from ventilator-associated pneumonia were noted for surgical patients (2·97, 95% CI 2·24-3·94) and patients with mid-range severity scores at admission (ie, cumulative risks of 2·49 [1·81-3·44] for patients with APACHE scores of 20-29 and 2·72 [1·95-3·78] for those with SAPS 2 scores of 35-58). INTERPRETATION The overall attributable mortality of ventilator-associated pneumonia is 13%, with higher rates for surgical patients and patients with a mid-range severity score at admission. Attributable mortality is mainly caused by prolonged exposure to the risk of dying due to increased length of ICU stay. FUNDING None.

Oral decontamination is cost-saving in the prevention of ventilator-associated pneumonia in intensive care units

ObjectiveAlthough the development of ventilator-associated pneumonia (VAP) is assumed to increase costs of intensive care unit stay, it is unknown whether prevention of VAP by means of oropharyngeal decontamination is cost-effective. Because of wide ranges of individual patient costs, crude cost comparisons did not show significant cost reductions. DesignBased on actual cost data of 181 individual patients included in a former randomized clinical trial, cost-effectiveness of prevention of VAP was determined using a decision model and univariate sensitivity analyses, and bootstrapping was used to assess the impact of variability in the various outcomes. Data SourcePublished data on prevention of VAP by oropharyngeal decontamination, which resulted in a relative risk for VAP of 0.45, with a baseline rate of VAP of 29% among control patients. The mean costs of the intervention were

Percutaneous Aponeurotomy and Lipofilling (PALF) versus Limited Fasciectomy in Patients with Primary Dupuytren's Contracture: A Prospective, Randomized, Controlled Trial.

351 per patient (

Patients' Preferences for Treatment for Dupuytren's Disease: A Discrete Choice Experiment.

32 per patient per day). All other costs were derived from the hospital administrative database for all individual patients. Results of Base-Case AnalysisPrevention of VAP led to mean total costs of

Comparison of Functional Outcome Scores in Radial Polydactyly

16,119 and

Intrafamilial variability of the triphalangeal thumb phenotype in a Dutch population: Evidence for phenotypic progression over generations?

18,268 for patients without preventive measures administered. Thus, costs were saved and instances of VAP were prevented. Similar results were observed in terms of overall survival. Results of Sensitivity AnalysisPrevention of VAP remains cost-saving if the relative risk for VAP because of intervention is <0.923, the costs of the intervention are less than

Recurrence of Dupuytren's contracture: A consensus-based definition

2,500, and the prevalence of VAP without intervention is >4%. Bootstrapping confirmed that, with about 80% certainty, oropharyngeal decontamination results in prevention of VAP and simultaneously saves costs. In terms of a survival benefit, the results are less evident; the results indicate that with only about 60% certainty can we confirm that oropharyngeal decontamination would result in a survival benefit and simultaneously save costs. ConclusionsThis study provides strong evidence that prevention of VAP by means of oropharyngeal decontamination is cost-effective.

A matched comparative study of the Bilhaut procedure versus resection and reconstruction for treatment of radial polydactyly types II and IV

Background: As an alternative to needle aponeurotomy release and limited fasciectomy treatment of Dupuytren’s contracture, the authors introduced an extensive percutaneous aponeurotomy and lipofilling (PALF) procedure. In their previous study, the authors reported that contractures significantly improved and most patients returned to normal use of the hand within 2 to 4 weeks. To establish the safety and efficacy of PALF, the authors compared it to the standard limited fasciectomy in a single-blind, multicenter, prospective, randomized, controlled trial. Methods: Patients with a primary Dupuytren’s contracture were assigned randomly to the limited fasciectomy group or the PALF group. Patients were measured at baseline and at 2 weeks, 3 weeks, 6 months, and 1 year postoperatively. Primary outcome of the trial was contracture correction and convalescence time. Groups were compared using a mixed models approach. Results: Eighty patients were randomized to PALF or limited fasciectomy. In both groups, almost full metacarpophalangeal joint contracture correction was obtained, whereas for the proximal interphalangeal joint, some residual contracture remained. Patients in the PALF group returned significantly earlier to their normal daily activity. At 1 year after surgery, no significant differences in recurrence rate or hand function were present. However, limited fasciectomy seems to have a higher incidence of permanent complications. Conclusions: PALF demonstrates a significantly shorter convalescence, similar operative contracture correction, lower incidence of long-term complications, and no significant difference regarding 1-year postoperative results compared with limited fasciectomy. It is therefore a valuable, minimally invasive alternative to limited fasciectomy in the treatment of Dupuytren’s disease. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A multicenter comparative study of two classification systems for radial polydactyly.

Background: Although in modern medicine, patients’ preferences are important, these have never been defined for characteristics of Dupuytren treatment. This study determines these patients’ preferences using a discrete choice experiment. Methods: A multicenter discrete choice experiment study was conducted among patients with Dupuytren’s disease who had been treated previously. Patients were asked about their preferences for attributes of Dupuytren treatments using scenarios based on treatment method, major and minor complication rates, recurrence rates, convalescence, residual extension deficit after treatment, and aesthetic results. The relative importance of these attributes and the tradeoffs patients were willing to make between them were analyzed using a panel latent class logit model. Results: Five-hundred six patients completed the questionnaire. All above-mentioned attributes proved to influence patients’ preferences for Dupuytren treatment (p < 0.05). Preference heterogeneity was substantial. Men who stated they performed heavy labor made different tradeoffs than women or men who did not perform heavy labor. In general, recurrence rate (36 percent) and extension deficit (28 percent) were the most important attributes in making treatment choices, followed by minor complication rate (13 percent). Patients accepted an increase in recurrent disease of 11 percent if they could receive needle aponeurotomy treatment instead of limited fasciectomy. Conclusions: This study confirms the importance of low recurrence rates and complete contracture corrections, but also emphasizes the significance of low complication rates. Convalescence was not an attribute, which scored high. The preference heterogeneity shows that patient consultations need to be targeted differently, which may result in different treatment decisions, depending on patient characteristics and preferences.