Jarone Lee

Diaphragm muscle thinning in patients who are mechanically ventilated.

BACKGROUND Approximately 40% of patients in medical ICUs require mechanical ventilation (MV). Approximately 20% to 25% of these patients will encounter difficulties in discontinuing MV. Multiple studies have suggested that MV has an unloading effect on the respiratory muscles that leads to diaphragmatic atrophy and dysfunction, a process called ventilator-induced diaphragmatic dysfunction (VIDD). VIDD may be an important factor affecting when and if MV can be discontinued. A sensitive and specific diagnostic test for VIDD could provide the physician with valuable information that might influence decisions regarding extubation or tracheostomy. The purpose of this study was to quantify, using daily sonographic assessments, the rate and degree of diaphragm thinning during MV. METHODS Seven intubated patients receiving MV during acute care were included. Using sonography, diaphragm muscle thickness was measured daily from the day of intubation until the patient underwent extubation or tracheostomy or died. We analyzed our data using standard descriptive statistics, linear regression, and mixed-model effects. RESULTS The overall rate of decrease in the diaphragm thickness of all seven patients over time averaged 6% per day of MV, which differed significantly from zero. Similarly, the diaphragm thickness decreased for each patient over time. CONCLUSION Sonographic assessment of the diaphragm provides noninvasive measurement of diaphragmatic thickness and the degree of diaphragm thinning in patients receiving MV. Our data show that diaphragm muscle thinning starts within 48 h after initiation of MV. However, it is unclear if diaphragmatic thinning correlates with diaphragmatic atrophy or pulmonary function. The relationship between diaphragm thinning and diaphragm strength remains to be elucidated.

Computed Tomography Use in the Adult Emergency Department of an Academic Urban Hospital From 2001 to 2007

STUDY OBJECTIVE There is both increasing recognition and growing scrutiny of the increased utilization of computed tomography (CT) in medicine. For our primary objective, we determine and quantify the CT utilization rate in our emergency department (ED) during the last 7 years. As a secondary objective, we compare trends in utilization for various types of CT scans. METHODS We performed an electronic chart review at our inner-city, academic ED with an annual census of 110,000 patients. We identified all patients older than 21 years who had a CT scan performed during ED management from January 2001 to December 2007. Specific, predetermined data elements (eg, subject demographics, type of CT scan) were extracted on standardized data forms by trained abstractors. We analyzed our data with standard descriptive statistics and linear regression. RESULTS The rate of CT utilization increased steadily at approximately 10 CTs per 1,000 (95% confidence interval 7.5 to 13.6 CTs) patients annually during our study period, from 51 per 1,000 patient visits in 2001 to 106 per 1,000 in 2007. Among these CTs, chest CTs increased most, with a 6-fold increase from 1 [corrected] per 1,000 patient visits to 6 [corrected] per 1,000. Neck CTs increased by 5-fold, from 2 [corrected] per 1,000 patient visits to 10 [corrected] per 1,000 patients. Similarly, the utilization of abdomen-pelvis CTs, facial bone CTs, and head CTs increased from 13 per 1,000 to 33 per 1,000 patient visits (150%), 1 per 1,000 to 2 per 1,000 patient visits (100%), and 33 per 1,000 to 53 per 1,000 patient visits (60%), respectively. CONCLUSION Recent CT utilization in our ED increased in all anatomic categories assessed, with chest CTs and neck CTs increasing the most, followed by abdomen-pelvis CTs, facial bone CTs, and head CTs.

Global Muscle Strength But Not Grip Strength Predicts Mortality and Length of Stay in a General Population in a Surgical Intensive Care Unit

Background Paresis acquired in the intensive care unit (ICU) is common in patients who are critically ill and independently predicts mortality and morbidity. Manual muscle testing (MMT) and handgrip dynamometry assessments have been used to evaluate muscle weakness in patients in a medical ICU, but similar data for patients in a surgical ICU (SICU) are limited. Objective The purpose of this study was to evaluate the predictive value of strength measured by MMT and handgrip dynamometry at ICU admission for in-hospital mortality, SICU length of stay (LOS), hospital LOS, and duration of mechanical ventilation. Design This investigation was a prospective, observational study. Methods One hundred ten patients were screened for eligibility for testing in the SICU of a large, academic medical center. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, diagnoses, and laboratory data were collected. Measurements were obtained by MMT quantified with the sum (total) score on the Medical Research Council Scale and by handgrip dynamometry. Outcome data, including in-hospital mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation, were collected for all participants. Results One hundred seven participants were eligible for testing; 89% were tested successfully at a median of 3 days (25th–75th percentiles=3–6 days) after admission. Sedation was the most frequent barrier to testing (70.6%). Manual muscle testing was identified as an independent predictor of mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation. Grip strength was not independently associated with these outcomes. Limitations This study did not address whether muscle weakness translates to functional outcome impairment. Conclusions In contrast to handgrip strength, MMT reliably predicted in-hospital mortality, duration of mechanical ventilation, SICU LOS, and hospital LOS.

The economic cost of firearm-related injuries in the United States from 2006 to 2010

BACKGROUND Estimates of the number of firearm-related injuries widely vary. Although focus has been primarily on deaths, the societal cost of caring for victims of these injuries is largely unknown. Our goal was to estimate the economic impact of nonfatal, firearm-related injuries in the United States based on recent, publically available data. METHODS We queried several national registries for hospital and emergency department (ED) discharges from 2006 to 2010 to estimate the annual incidence of firearm-related injuries. The cost of direct medical services and lost productivity from firearm-related injuries were extrapolated from recently published estimates. To identify potentially important trends, we compared the economic impact and payor mix for firearm-related injuries in 2006 with those in 2010. RESULTS During the 5-year analytic period, we identified 385,769 (SE = 29,328) firearm-related ED visits resulting in 141,914 (SE = 14,243) hospital admissions, costing more than

Adequate Nutrition May Get You Home Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients

88 billion (SE =

Can sarcopenia quantified by ultrasound of the rectus femoris muscle predict adverse outcome of surgical intensive care unit patients as well as frailty? a prospective, observational cohort study

8.0 billion). Between 2006 and 2010, there was a decrease in the rate of hospital visits from 6.65 per 10,000 visits in 2006 to 5.76 per 10,000 visits in 2010 (P < .001). Similarly, the rate of hospital admissions and ED visits without admission decreased from 2.58 per 10,000 to 1.96 per 10,000 (P < .001) and 4.08 per 10,000 to 3.79 per 10,000 (P < .001). Regression of the economic costs from 2006 to 2010, adjusted for Consumer Price Index, showed no change (P = .15). There was a decrease in the proportion of Uninsured between 2006 and 2010 from 51.6% to 46.78% (P < .001). CONCLUSION Firearm-related injuries are a major economic burden to not only the American health care system but also to American society. The incidence of these injuries has decreased slightly from 2006 to 2010, with no change in the economic burden. Research aimed at understanding the associated financial, social, health, and disability-related issues related to firearm injuries is necessary and would likely enhance our knowledge of the causes of these events, and may accelerate development of interventions and policies to decrease the staggering medical and societal cost of gun violence.

The Deyo-Charlson and Elixhauser-van Walraven Comorbidity Indices as predictors of mortality in critically ill patients

BACKGROUND Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in-hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility. MATERIALS AND METHODS Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72-hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥ 6000 kcal) and protein deficit (<300 vs ≥ 300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ(2) tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders. RESULTS In total, 213 individuals were included. Nineteen percent in the low-caloric deficit group were discharged home compared with 6% in the high-caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high-caloric and protein-deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08-0.96; P = .04 and OR, 0.29; 95% CI, 0.0-0.89, P = .03, respectively). CONCLUSIONS In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness.

Noise Levels in Surgical ICUs Are Consistently Above Recommended Standards.

Objective: To compare sarcopenia and frailty for outcome prediction in surgical intensive care unit (SICU) patients. Background: Frailty has been associated with adverse outcomes and describes a status of muscle weakness and decreased physiological reserve leading to increased vulnerability to stressors. However, frailty assessment depends on patient cooperation. Sarcopenia can be quantified by ultrasound and the predictive value of sarcopenia at SICU admission for adverse outcome has not been defined. Methods: We conducted a prospective, observational study of SICU patients. Sarcopenia was diagnosed by ultrasound measurement of rectus femoris cross-sectional area. Frailty was diagnosed by the Frailty Index Questionnaire based on 50 variables. Relationship between variables and outcomes was assessed by multivariable regression analysis NCT02270502. Results: Sarcopenia and frailty were quantified in 102 patients and observed in 43.1% and 38.2%, respectively. Sarcopenia predicted adverse discharge disposition (discharge to nursing facility or in-hospital mortality, odds ratio 7.49; 95% confidence interval 1.47–38.24; P = 0.015) independent of important clinical covariates, as did frailty (odds ratio 8.01; 95% confidence interval 1.82–35.27; P = 0.006); predictive ability did not differ between sarcopenia and frailty prediction model, reflected by &khgr;2 values of 21.74 versus 23.44, respectively, and a net reclassification improvement (NRI) of −0.02 (P = 0.87). Sarcopenia and frailty predicted hospital length of stay and the frailty model had a moderately better predictive accuracy for this outcome. Conclusions: Bedside diagnosis of sarcopenia by ultrasound predicts adverse discharge disposition in SICU patients equally well as frailty. Sarcopenia assessed by ultrasound may be utilized as rapid beside modality for risk stratification of critically ill patients.

Engineered RNase P Ribozymes Are Efficient in Cleaving a Human Cytomegalovirus mRNA in Vitro and Are Effective in Inhibiting Viral Gene Expression and Growth in Human Cells

Objectives Our primary objective was to compare the utility of the Deyo-Charlson Comorbidity Index (DCCI) and Elixhauser-van Walraven Comorbidity Index (EVCI) to predict mortality in intensive care unit (ICU) patients. Setting Observational study of 2 tertiary academic centres located in Boston, Massachusetts. Participants The study cohort consisted of 59 816 patients from admitted to 12 ICUs between January 2007 and December 2012. Primary and secondary outcome For the primary analysis, receiver operator characteristic curves were constructed for mortality at 30, 90, 180, and 365 days using the DCCI as well as EVCI, and the areas under the curve (AUCs) were compared. Subgroup analyses were performed within different types of ICUs. Logistic regression was used to add age, race and sex into the model to determine if there was any improvement in discrimination. Results At 30 days, the AUC for DCCI versus EVCI was 0.65 (95% CI 0.65 to 0.67) vs 0.66 (95% CI 0.65 to 0.66), p=0.02. Discrimination improved at 365 days for both indices (AUC for DCCI 0.72 (95% CI 0.71 to 0.72) vs AUC for EVCI 0.72 (95% CI 0.72 to 0.72), p=0.46). The DCCI and EVCI performed similarly across ICUs at all time points, with the exception of the neurosciences ICU, where the DCCI was superior to EVCI at all time points (1-year mortality: AUC 0.73 (95% CI 0.72 to 0.74) vs 0.68 (95% CI 0.67 to 0.70), p=0.005). The addition of basic demographic information did not change the results at any of the assessed time points. Conclusions The DCCI and EVCI were comparable at predicting mortality in critically ill patients. The predictive ability of both indices increased when assessing long-term outcomes. Addition of demographic data to both indices did not affect the predictive utility of these indices. Further studies are needed to validate our findings and to determine the utility of these indices in clinical practice.

Microscale arrays for the profiling of start and stop signals coordinating human-neutrophil swarming

Objective:The equipment, monitor alarms, and acuity of patients in ICUs make it one of the loudest patient care areas in a hospital. Increased sound levels may contribute to worsened outcomes in these particularly vulnerable patients. Our objective was to determine whether ambient sound levels in surgical ICUs comply with recommendations established by the World Health Organization and Environmental Protection Agency, and whether implementation of an overnight “quiet time” intervention is associated with lower ambient sound levels. Design:Prospective, observational cohort study. Setting:Two comparable 18-bed, surgical ICUs in a large, teaching hospital. Only one ICU had a formal overnight quiet time policy at the start of the study period. Measurements and Main Results:Sound levels were measured in 30-second blocks at preselected locations during the day and night over a period of 6 weeks using a simple, hand-held sound meter. All sound measurements in both units at all times exceeded recommended standards. Median minimum sound levels were lower at night in both units (50.8 and 50.3 vs 53.1 and 51.0 dB, p = 0.0003 and p = 0.009) and were similar between the two units (p = 0.52). The maximum overnight sound levels were statistically lower in the unit with the quiet time intervention implemented (62.5 vs 59.6 dB; p = 0.0040) and decreased overnight immediately after implementation of quiet time in the other unit (62.5 vs 56.1 dB; p < 0.0001). Maximum sound levels were lower inside patient rooms (52.2 vs 55.3 dB; p = 0.004), but minimum sound levels were similar (49.1 vs 49.2 dB; p = 0.23). Linear regression analysis showed that ICU census did not significantly influence sound levels. Conclusions:Ambient sound levels in the surgical ICUs were consistently above levels recommended by the World Health Organization and Environmental Protection Agency at all times. The use of a formal quiet time intervention was associated with a significant, but clinically irrelevant reduction in the median maximum sound level at night. Our results suggest that excessive ambient noise in the ICU is largely attributable to environmental factors, and behavior modifications are unlikely to have a meaningful impact. Future investigations, as well as hospital designs, should target interventions toward ubiquitous noise sources such as ventilation systems, which may not traditionally be associated with patient care.