Xinggang Liu

Pregnancy Among Women Surgeons: Trends Over Time

BACKGROUNDnWomen compose half of all medical students but are underrepresented in the field of general surgery. Concerns about childbirth and pregnancy during training and practice are factors that may dissuade women from electing a career in surgery.nnnOBJECTIVEnTo assess experiences related to childbirth and pregnancy among women general surgeons.nnnDESIGNnSurvey questionnaire.nnnSETTINGnSelf-administered survey sent individually to women surgeons in training and practice.nnnPARTICIPANTSnWomen members of the Association for Women Surgeons or the American College of Surgeons who graduated from medical school and practice general surgery or a general surgery subspecialty.nnnMAIN OUTCOME MEASURESnDescriptive data on the timing of pregnancy and perception of stigma attending childbirth and pregnancy as experienced by women surgeons, according to date of medical school graduation (0-9 years since graduation, 10-19 years, 20-29 years, and ≥ 30 years). The survey response rate was 49.6%. Trends over time were evaluated using comparisons of proportions and the Cochrane-Armitage trend tests across age cohorts.nnnRESULTSnThe perception of stigma associated with pregnancy during training remained large but decreased from 76% in the most remote cohort to 67% in the most recent graduation cohort (P<.001). External influences, even women resident colleagues, were perceived as evincing negative instead of encouraging attitudes toward childbearing during residency, though less so than men, both resident colleagues and faculty. Frequency of pregnancy and pregnancies earlier in training increased over the time cohorts.nnnCONCLUSIONSnThe number of women general surgeons becoming pregnant during training has increased in recent years; however, substantial negative bias persists. Although the overall magnitude of perceived negative attitudes is greater among male peers than female peers and among faculty than peers, even women residents hold negative views of pregnancy among their colleagues during training. More than half of all women surgeons delay childbearing until they are in independent practice, post-training. Surgical residents and faculty of both sexes exerted negative influences with regard to consideration of childbearing. There was also a trend toward increased childbearing in more recent graduates.

Learned helplessness among families and surrogate decision-makers of patients admitted to medical, surgical, and trauma ICUs

BACKGROUNDnWe sought to determine the prevalence of and clinical variables associated with learned helplessness, a psychologic state characterized by reduced motivation, difficulty in determining causality, and depression, in family members of patients admitted to ICUs.nnnMETHODSnWe conducted an observational survey study of a prospectively defined cohort of family members, spouses, and partners of patients admitted to surgical, medical, and trauma ICUs at a large academic medical center. Two validated instruments, the Learned Helplessness Scale and the Perceived Stress Scale, were used, and self-report of patient clinical characteristics and subject demographics were collected.nnnRESULTSnFour hundred ninety-nine family members were assessed. Of these, 238 of 460 (51.7%) had responses consistent with a significant degree of learned helplessness. Among surrogate decision-makers, this proportion was 50% (92 of 184). Characteristics associated with significant learned helplessness included grade or high school education (OR, 3.27; 95% CI, 1.29-8.27; P = .01) and Perceived Stress Scale score > 18 (OR, 4.15; 95% CI, 2.65-6.50; P < .001). The presence of a patient advance directive or do not resuscitate (DNR) order was associated with reduced odds of significant learned helplessness (OR, 0.56; 95% CI, 0.32-0.98; P = .05).nnnCONCLUSIONSnThe majority of family members of patients in the ICU experience significant learned helplessness. Risk factors for learned helplessness include lower educational levels, absence of an advance directive or DNR order, and higher stress levels among family members. Significant learned helplessness in family members may have negative implications in the collaborative decision-making process.

Decreased mortality resulting from a multicomponent intervention in a tertiary care medical intensive care unit.

Objective:To evaluate whether a multicomponent intervention, particularly increasing staff, can achieve reductions in patient mortality in an already high-intensity, Leapfrog-compliant medical intensive care unit. Design:Retrospective, observational study. Setting:Medical intensive care unit of a tertiary care, academic medical center. Patients:A total of 1,263 patients admitted between April 19, 2004 and April 18, 2006 (before the organizational change) were compared with 2,424 patients admitted between September 5, 2006 and September 4, 2008. Interventions:A multicomponent intervention including the physical move from a 10-bed to a 29-bed medical intensive care unit with larger patient rooms, the initiation of 24-hr critical care specialist coverage in the medical intensive care unit, an increase in the respiratory therapist:patient ratio, and the addition of a clinical pharmacist to the multidisciplinary team. Measurements and Main Results:Measurements were made based on mortality in the intensive care unit and in-hospital. Patient comorbidity as measured by the Charlson score did not change after the intervention (2.7 ± 2.7 vs. 2.8 ± 2.6, p = .62), nor did the acuity of illness as measured by the case mix index (3.0 ± 3.7 vs. 3.1 ± 3.8, p = .69). The unadjusted medical intensive care unit mortality decreased from 18.4% to 14.9% (p = .006), as did in-hospital mortality (from 25.8% to 21.7%, p = .005). The reduction in medical intensive care unit mortality was consistent in the multivariable regression with adjustment for multiple possible confounders (odds ratio = 0.74, 95% confidence interval: 0.61–0.91, p = .003), as was the reduction in hospital mortality (odds ratio = 0.74, 95% confidence interval: 0.62–0.88, p = .001). In mechanically ventilated patients, there was an increase in median 28-day ventilator-free days (21, interquartile range 0–25 vs. 22, interquartile range 0–26, p = .04). An increase in median medical intensive care unit (2.4, interquartile range 1.1–5.2 vs. 2.7, interquartile range 1.3–5.9), p = .009) but not hospital (8.3, interquartile range 4.1–17.0 vs. 8.2, interquartile range 4.0–16.8; p = .851) length of stay in days occurred with the intervention. The mean daily dosing of fentanyl and lorazepam decreased after the intervention. Conclusions:A multicomponent reorganization of medical intensive care unit services was associated with important reductions in mortality for medical intensive care unit patients, as well as an increased number of ventilator-free days. Substantial and sustained changes in clinically important outcomes may be obtained from organizational changes.

Transfusion practice in the intensive care unit: a 10-year analysis

BACKGROUND: Clinical guidelines recommend a restrictive transfusion strategy in nonhemorrhaging critically ill patients.

Non-invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA 3 CT): Design of a Phase IIb, placebo-controlled, double-blind, randomized clinical trial of doxycycline for the reduction of growth of small abdominal aortic aneurysm

OBJECTIVESnThe Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA(3)CT) is a Phase IIb randomized, placebo-controlled clinical trial, testing doxycycline (100mg bid) for inhibition of growth in the greatest transverse, orthogonal diameter of small abdominal aortic aneurysms (AAA).nnnMETHODSnWe will enroll 258 patients, ≥55years of age who have AAA, men: 3.5-5.0cm and women: 3.5-4.5cm on CT scans confirmed centrally. The primary outcome is growth in maximal transverse, orthogonal diameter from baseline to 24-month follow-up. Secondary analyses address doxycycline effects on clinical events, aneurysm volume, and biomarkers. Primary analysis will be performed according to the principle of intention-to-treat accounting for death and ruptures by use of normal scores in analysis of covariance. At the time of the data file reported, 200 subjects have been randomized. We started enrollment in mid-2013 and will complete enrollment by mid-2016.nnnRESULTSnParticipant average age=70.9years, (SD=7.6years) and maximum transverse diameter=4.3cm for men (SD=0.4) and 4.0cm for women (SD=0.3).nnnCONCLUSIONnN-TA(3)CT is a critical experiment to determine whether doxycycline reduces growth of small AAA and systemic markers of inflammation previously seen in bench experiments and observational human studies to be associated with AAA growth. Our patient population baseline measurements agree with the design assumptions supporting our expectation of 90% power or greater to reject a null hypothesis in favor of an alternative hypothesis when growth is reduced by at least 40%.nnnREGISTRATIONnclinicaltrials.gov #NCT01756833.

Changes in Transfusion Practice Over Time in the Picu

Objectives: Recent randomized clinical trials have shown the efficacy of a restrictive transfusion strategy in critically ill children. The impact of these trials on pediatric transfusion practice is unknown. Additionally, long-term trends in pediatric transfusion practice in the ICU have not been described. We assessed transfusion practice over time, including the effect of clinical trial publication. Design: Single-center, retrospective observational study. Setting: A 10-bed PICU in an urban academic medical center. Patients: Critically ill, nonbleeding children between the ages of 3 days and 14 years old, admitted to the University of Maryland Medical Center PICU between January 1, 1998, and December 31, 2009, excluding those with congenital heart disease, hemolytic anemia, and hemoglobinopathies. Interventions: None. Measurements and Main Results: During the time period studied, 5,327 patients met inclusion criteria. Of these, 335 received at least one RBC transfusion while in the PICU. The overall proportion transfused declined from 10.5% in 1998 to 6.8% in 2009 (p = 0.007). Adjusted for acuity, the likelihood of transfusion decreased by calendar year of admission. In transfused patients, the pretransfusion hemoglobin level declined, from 10.5 g/dL to 9.3 g/dL, though these changes failed to meet statistical significance (p = 0.09). Neonatal age, respiratory failure, shock, multiple organ dysfunction syndrome, and acidosis were associated with an increased likelihood of transfusion in both univariate and multivariable models. Conclusions: The overall proportion of patients transfused between 1998 and 2009 decreased significantly. The magnitude of the decrease varied over time, and no additional change in transfusion practice occurred after the publication of a major pediatric clinical trial in 2007. Greater illness acuity and younger patient age were associated with an increased likelihood of transfusion.

Ambient light levels and critical care outcomes

PURPOSEnGuidelines for the construction of critical care units require windows in room design to ensure a contribution of natural sunlight to ambient lighting. However, few studies have been published with evidence assessing this recommendation. We investigated the association of ambient light levels with clinical outcomes and sedative/analgesic/neuroleptic use in a medical intensive care unit (MICU).nnnMETHODSnThis is a retrospective, observational study at a tertiary care facility with a 29-bed MICU. First/single MICU admissions between April 19, 2006, and June 30, 2009 (N = 3577), were analyzed with respect to clinical outcomes and sedation use according to MICU room orientation and corresponding light levels.nnnRESULTSnLight levels were low but varied among the 4 room orientations. There were no significant differences in MICU mortality (north, 14.0%; east, 13.5%; west, 16.2%; south, 15.6%; P = .451), hospital mortality (20.8%, 20.9%, 22.2%, 22.3%; P = .796), 28-day intensive care unit-free days (17.6 ± 10.2, 18.0 ± 10.1, 17.7 ± 10.5, 17.2 ± 10.4; P = .555), 28-day ventilator-free days (16.3 ± 11.1, 16.5 ± 11.1, 15.5 ± 11.5, 15.4 ± 11.4; P = .273). No clinically significant differences in intravenous sedative/analgesic use occurred across room orientations.nnnCONCLUSIONSnDespite differing ambient light, room orientation was not associated with critical care outcomes or differences in sedative/analgesic/neuroleptic use. Current guidelines positing that windows alone are necessary or sufficient for MICU room light management may require further investigation and consideration.

Determinants of intrathoracic adipose tissue volume and associations with cardiovascular disease risk factors in Amish

BACKGROUND AND AIMnHypothesizing that intrathoracic fat might exert local effects on the coronary vasculature, we assessed the association of intrathoracic fat volume and its two subcomponents with coronary artery calcification (CAC) in 909 relatively healthy Amish adults.nnnMETHODS AND RESULTSnIntrathoracic fat, which is comprised of fat between the surface of the heart and the visceral epicardium (epicardial fat) and fat around the heart but outside of the fibrous pericardium (pericardial fat), was measured from electron beam CT scans. We examined the association between intrathoracic fat volume and cardiovascular disease risk factors in multivariate regression model. Fat volume in the epicardial and pericardial compartments were highly correlated with each other and with body mass index. Neither CAC extent nor CAC presence (Agatston score > 0) was associated with increased intrathoracic fat volume in sex-stratified models adjusting for age (p > 0.10). Intrathoracic fat volume was significantly correlated with higher systolic/diastolic blood pressure, pulse pressure, fasting glucose, insulin, triglyceride and lower high-density lipoprotein cholesterol in sex-stratified models adjusting for age (p < 0.05). However, associations were attenuated after further adjustment for body mass index.nnnCONCLUSIONSnThese data do not provide support for a significant role for intrathoracic fat in the development of CAC.

Respiratory Therapy Organizational Changes Are Associated With Increased Respiratory Care Utilization

BACKGROUND: The effect of the respiratory therapist (RT)/patient ratio and RT organizational factors on respiratory resource utilization is unknown. We describe the impact of a multi-component intervention that called for an increase in RT/patient ratio (1:14 to 1:10), improved RT orientation, and formation of a core staffing model on best practice, including spontaneous breathing trials (SBTs) and catheter and bronchoscopically directed lower respiratory tract cultures, or bronchoalveolar lavage (BAL), in both ventilated and non-ventilated patients in the ICU. METHODS: We conducted a single center, quasi-experimental study comparing 651 patients with single and first admissions between April 19, 2005 and April 18, 2006 before the RT services reorganization with 1,073 patients with single and first admissions between September 16, 2007 and September 4, 2008. Baseline characteristics were compared, along with SBTs, BAL use, lower respiratory tract cultures, and chest physiotherapy. RESULTS: Patients in the 2 groups were similar in terms of age (52.9 ± 15.8 y vs 53.9 ± 16.4 y, P = .23), comorbidity as measured by Charlson score (2.8 ± 2.6 vs 2.8 ± 2.7, P = .56), and acuity of illness as measured by the Case Mix Index (3.2 ± 3.9 vs 3.3 ± 4.1, P = .47). Mechanically ventilated patients had similar prevalences of respiratory diseases (24.2% vs 25.1%, P = .61). There was an increase in SBTs (0.5% vs 73.1%, P < .001), chest physiotherapy (7.4% vs 21.6%, P < .001), BALs (24.0% vs 41.4%, P < .001), and lower respiratory tract cultures (21.5% vs 38.0%, P < .001) in mechanically ventilated patients post-intervention. CONCLUSIONS: A multi-component intervention, including an increase in RT/patient ratio, improved RT orientation, and establishment of a core staffing model, was associated with increased respiratory resource utilization and evidence-based practice, specifically BALs and SBTs.

Cardiologist perceptions of family-centred rounds in cardiovascular clinical care

Objective Few data exist regarding physician attitudes and implementation of family-centred rounds (FCR) in cardiovascular care. This study aimed to assess knowledge and attitudes among cardiologists and cardiology fellows regarding barriers and benefits of FCRs. Methods An electronic, web-based questionnaire was nationally distributed to cardiology fellows and attending cardiologists. Results In total, 118 subjects were surveyed, comprising cardiologists (n=64, 54%) and cardiology fellows (n=54, 46%). Overall, 61% of providers reported participating in FCRs and 64% felt family participation on rounds benefits the patient. Both fellows and cardiologists agreed that family rounds eased family anxiety (fellows, 63%; cardiologists, 56%; p=0.53), improved communication between the medical team and the patient and family (fellows, 78%; cardiologists, 61%; p=0.18) and improved patient safety (fellows, 59%; cardiologists, 47%; p=0.43). Attitudes regarding enhancement of trainee education were similar (fellows, 69%; cardiologists, 55%; p=0.19). Fellows and cardiologists felt that family increased the duration of rounds (fellows, 78%; cardiologists, 80%; p=0.18) and led to less efficient rounds (fellows, 54%; cardiologists, 58%; p=0.27). Conclusion The majority of cardiologists and fellows believed that FCRs benefited families, communication and patient safety, but led to reduced efficiency and longer duration of rounds.