bluuebunny/crossref_metadata_2025 huggingface dataset:
A General Population Utility Valuation Study for Metastatic Epidural Spinal Cord Compression Health States
Authors: Pahuta Markian A. , Wai Eugene K. , Werier Joel , van Walraven Carl , Coyle Doug
Published: January 2019

Study Design.

General population utility valuation study.

Objective.

This study obtained utility valuations from a Canadian general population perspective for 31 unique metastatic epidural spinal cord compression (MESCC) health states and determined the relative importance of MESCC-related consequences on quality-of-life.

Summary of Background Data.

Few prospective studies on the treatment of MESCC have collected quality-adjusted-life-year weights (termed “utilities”). Utilities are an important summative measure which distills health outcomes to a single number that can assist healthcare providers, patients, and policy makers in decision making.

Methods.

We recruited a sample of 1138 adult Canadians using a market research company. Quota sampling was used to ensure that the participants were representative of the Canadian population in terms of age, sex, and province of residence. Using the validated MESCC module for the “Self-administered Online Assessment of Preferences” (SOAP) tool, participants were asked to rate six of the 31 MESCC health states, each of which presented varying severities of five MESCC-related dysfunctions (dependent; non-ambulatory; incontinent; pain; other symptoms).

Results.

Participants equally valued all MESCC-related dysfunctions which followed a pattern of diminishing marginal disutility (each additional consequence resulted in a smaller incremental decrease in utility than the previous). These results demonstrate that the general population values physical function equal to other facets of quality-of-life.

Conclusion.

We provide a comprehensive set of ex ante utility estimates for MESCC health states that can be used to help inform decision making. This is the first study reporting direct utility valuation for a spinal disorder. Our methodology offers a feasible solution for obtaining quality-of-life data without collecting generic health status questionnaire responses from patients.

Level of Evidence: 4
Cross-cultural Adaptation and Validation of the Norwegian Short-form McGill Pain Questionnaire-2 in Low Back-related Leg Pain
Authors: Hasvik Eivind , Haugen Anne Julsrud , Haukeland-Parker Stacey , Rimehaug Stein Arne , Gjerstad Johannes , Grøvle Lars
Published: January 2019

Study Design.

A prospective observational study with translation and psychometric analyses of a questionnaire.

Objective.

Cross-cultural adaptation of the Short-Form McGill Pain Questionnaire-2 into Norwegian.

Summary of Background Data.

The different versions of the McGill Pain Questionnaire (MPQ) have been important and influential tools for pain assessment. To more reliably assess qualities of both neuropathic and non-neuropathic pain, the Short-Form MPQ was revised in 2009 (SF-MPQ-2), including seven additional descriptors. No Norwegian adaptation of the SF-MPQ-2 has been performed.

Methods.

A translation of the SF-MPQ-2 was performed based on established guidelines. Forward-translations were compared and discussed in an expert workgroup. A synthesis was achieved by consensus. A backward translation was reviewed and consolidated with the forward translations to confirm linguistic equivalence. A prefinal version was tested in eight patients, who were interviewed to evaluate acceptability and comprehension of the questionnaire. Minor changes were implemented. The questionnaire was externally proofread. The final Norwegian version (NSF-MPQ-2) was tested for content and construct validity and internal consistency reliability in a population with low back-related leg pain.

Results.

The backward translation was in good accordance with the original version. The prefinal version showed excellent acceptability and comprehension in initial patient-testing. The NSF-MPQ-2 showed satisfactory content and construct validity, including responsiveness to change, and acceptable internal consistency reliability as measured by Cronbach's alpha. A confirmatory factor analysis showed poor fit for the established four-factor structure, especially regarding the neuropathic subscale.

Conclusion.

The NSF-MPQ-2 showed excellent acceptability and comprehension, satisfactory content and construct validity, including responsiveness to change, and internal consistency reliability as measured by Cronbach's alpha. However, a confirmatory factor analysis raised concerns regarding the factor-structure in the present population. Until more evidence emerges for the four-factor solution we suggest the NSF-MPQ-2 should be used as a single measure.

Level of Evidence: 3
Estimating Health Utility in Patients Presenting for Spine Surgery Using Patient-reported Outcomes Measurement Information System (PROMIS) Health Domains
Authors: Raad Micheal , Neuman Brian J. , Kebaish Khaled M. , Riley Lee H. , Skolasky Richard L.
Published: January 2019

Study Design.

Prospective cohort study.

Objective.

To evaluate whether Patient-Reported Outcomes Measurement Information System (PROMIS) health domains can effectively estimate health utility index values for patients presenting for spine surgery.

Summary of Background Data.

Stable estimates of health utility are required to determine cost-effectiveness of spine surgery. There are no established methods to estimate health utility using PROMIS.

Methods.

We enrolled 439 patients with spine disease (mean age, 54 ± 18 yrs) presenting for surgery and assessed their health using the Medical Outcomes Study Short Form-12, version 2 (SF-12v2) and PROMIS domains. Standard health utility values were estimated from the SF-12v2. Participants were randomly assigned to derivation or validation cohort. In the derivation cohort, health utility values were estimated as a function of PROMIS domains using regression models. Model fit statistics determined the most parsimonious health utility estimation equation (HEE). In the validation cohort, values were calculated using the HEE. Estimated health utility values were correlated with SF-12v2-derived health utility values.

Results.

Mean preoperative health utility was 0.492 ± 0.008 and was similar between the two cohorts. All PROMIS health domains were significantly associated with health utility except Anxiety (P = 0.830) and Sleep Disturbance (P = 0.818). The final HEE was:

Health Utility (est) = 0.70742 – 0.00471 × Pain + 0.00647 × Physical function – 0.00316 × Fatigue – 0.00214 × Depression + 0.00317 × Satisfaction with Participation in Social Roles.

The estimation model accounted for 74% of observed variation in health utility. In the validation sample, mean health utility was 0.5033 ± 0.1684 and estimated health utility was 0.4966 ± 0.1342 (P = 0.401). These measures were strongly correlated (rho = 0.834).

Conclusion.

Our results indicate that PROMIS provides a reasonable estimate of health utility in adults presenting for lumbar or cervical spine surgery.

Level of Evidence: 1
The Effect of Core Stabilization Exercises on Trunk–Pelvis Three-Dimensional Kinematics During Gait in Non-Specific Chronic Low Back Pain
Authors: Bagheri Rasool , Parhampour Behrouz , Pourahmadi Mohammadreza , Fazeli Sayyed Hamed , Takamjani Ismail Ebrahimi , Akbari Mahmood , Dadgoo Mahdi
Published: January 2019

Study Design.

Controlled clinical trial study.

Objective.

This study aimed to evaluate the effect of core stabilization exercise program (CSEP) on trunk–pelvis kinematics during gait in non-specific chronic low back pain (NCLBP).

Summary of Background Data.

NCLBP is a major public burden with variety of dysfunction including gait variability.

Methods.

Thirty participants (15 NCLBP and 15 healthy) were included in this study via the convenience sampling method. NCLBP group were intervened via the 16 sessions CSEP 3 days for 6 weeks and trunk–pelvis kinematics (angular displacement, waveform pattern [CVp], and offset variability [CVo]) during gait, pain, disability were evaluated before and after the intervention.

Results.

No significant differences in displacement and CVo in three planes were found between NCLBP and healthy groups. Independent t test was revealed that significant differences in CVp in the sagittal, frontal, and transverse planes were found between healthy and NCLBP in pre intervention. No significant changes in displacement and CVo were found as the result of intervention in NCLBP. Pain and disability decreased significantly after intervention. Paired t test revealed that the CSEP increased the frontal (P = 0.04) and transverse planes (P = 0.02) pattern variability significantly. However, there was a significant difference between groups in the sagittal plane CVp after intervention (sagittal plane CVp in healthy vs. NCLBP in post-CSE: mean difference = 14.1; P = 0.04).

Conclusion.

Considering the role of the deep trunk muscles in gait, and their common deconditioning in CLBP, a CSEP intervention may increase trunk–pelvis kinematic pattern variability. These results suggest CSEP may specifically increase transverse and frontal plane variability, indicating improved motor pattern replication through this movement planes.

Level of Evidence: 2
What Are the Costs of Cervical Radiculopathy Prior to Surgical Treatment?
Authors: Barton Cameron , Kalakoti Piyush , Bedard Nicholas A. , Hendrickson Nathan R. , Saifi Comron , Pugely Andrew J.
Published: January 2019

Study Design.

Retrospective, observational study.

Objective.

To examine the costs associated with nonoperative management (diagnosis and treatment) of cervical radiculopathy in the year prior to anterior cervical discectomy and fusion (ACDF).

Summary of Background Data.

While the costs of operative treatment have been previously described, less is known about nonoperative management costs of cervical radiculopathy leading up to surgery.

Methods.

The Humana claims dataset (2007–2015) was queried to identify adult patients with cervical radiculopathy that underwent ACDF. Outcome endpoint was assessment of cumulative and per-capita costs for nonoperative diagnostic (x-rays, computed tomographic [CT], magnetic resonance imaging [MRI], electromyogram/nerve conduction studies [EMG/NCS]) and treatment modalities (injections, physical therapy [PT], braces, medications, chiropractic services) in the year preceding surgical intervention.

Results.

Overall 12,514 patients (52% female) with cervical radiculopathy underwent ACDF. Cumulative costs and per-capita costs for nonoperative management, during the year prior to ACDF was $14.3 million and $1143, respectively. All patients underwent at least one diagnostic test (MRI: 86.7%; x-ray: 57.5%; CT: 35.2%) while 73.3% patients received a nonoperative treatment. Diagnostic testing comprised of over 62% of total nonoperative costs ($8.9 million) with MRI constituting the highest total relative spend ($5.3 million; per-capita: $489) followed by CT ($2.6 million; per-capita: $606), x-rays ($0.54 million; per-capita: $76), and EMG/NCS ($0.39 million; per-capita: $467). Conservative treatments comprised of 37.7% of the total nonoperative costs ($5.4 million) with injections costs constituting the highest relative spend ($3.01 million; per-capita: $988) followed by PT ($1.13 million; per-capita: $510) and medications (narcotics: $0.51 million, per-capita $101; gabapentin: $0.21 million, per-capita $93; NSAIDs: 0.107 million, per-capita $47), bracing ($0.25 million; per-capita: $193), and chiropractic services ($0.137 million; per-capita: $193).

Conclusion.

The study quantifies the cumulative and per-capital costs incurred 1-year prior to ACDF in patients with cervical radiculopathy for nonoperative diagnostic and treatment modalities. Approximately two-thirds of the costs associated with cervical radiculopathy are from diagnostic modalities. As institutions begin entering into bundled payments for cervical spine disease, understanding condition specific costs is a critical first step.

Level of Evidence: 3
Surgical Outcomes of Anterior Versus Posterior Fusion in Lenke Type 1 Adolescent Idiopathic Scoliosis
Authors: Vavruch Ludvig , Brink Rob C. , Malmqvist Marcus , Schlösser Tom P.C. , van Stralen Marijn , Abul-Kasim Kasim , Ohlin Acke , Castelein René M. , Tropp Hans
Published: January 2019

Study Design.

Retrospective study.

Objective.

To describe surgical results in two and three dimensions and patient-reported outcomes of scoliosis treatment for Lenke type 1 idiopathic curves with an open anterior or posterior approach.

Summary of Background Data.

Different surgical techniques have been described to prevent curve progression and to restore spinal alignment in idiopathic scoliosis. The spine can be accessed via an anterior or a posterior approach. However, the surgical outcomes, especially in three dimensions, for different surgical approaches remain unclear.

Methods.

Cohorts of Lenke curve type 1 idiopathic scoliosis patients, after anterior or posterior spinal fusion were recruited, to measure curve characteristics on conventional radiographs, before and after surgery and after 2 years follow-up, whereas the vertebral axial rotation, true mid-sagittal anterior–posterior height ratio of individual structures, and spinal height differences were measured on 3D reconstructions of the pre- and postoperative supine low-dose computed tomography (CT) scans. Additionally, the intraoperative parameters were described and the patients completed the Scoliosis Research Society outcomes and the 3-level version of EuroQol Group questionnaires postoperatively.

Results.

Fifty-three patients with Lenke curve type 1 idiopathic scoliosis (26 in the anterior cohort and 27 in the posterior cohort) were analyzed. Fewer vertebrae were instrumented in the anterior cohort compared with the posterior cohort (P < 0.001), with less surgery time and lower intraoperative blood loss (P < 0.001). The Cobb angle correction of the primary thoracic curve directly after surgery was 57 ± 12% in the anterior cohort and 73 ± 12% in the posterior cohort (P < 0.001) and 55 ± 13% and 66 ± 12% (P = 0.001) at 2 years follow-up. Postoperative 3D alignment restoration and questionnaires showed no significant differences between the cohorts.

Conclusion.

This study suggests that Lenke type 1 curves can be effectively managed surgically with either an open anterior or posterior approach. Each approach, however, has specific advantages and challenges, as described in this study, which must be considered before treating each patient.

Level of Evidence: 3
Failure of Pelvic Compensation in Patients With Severe Positive Sagittal Imbalance
Authors: Kim Ho-Joong , Shen Feng , Kang Kyoung-Tak , Chun Heoung-Jae , Kim Sung Taeck , Chang Bong-Soon , Lee Choon-Ki , Yeom Jin S.
Published: January 2019

Study Design.

Case–control study for motion analysis.

Objective.

To compare spinopelvic parameters using static radiographs with the values obtained using motion analysis during gait between adult spinal deformity (ASD) or lumbar spinal stenosis (LSS).

Summary of Background Data.

It is still unclear whether measurement of radiological parameters using static radiographs can reflect natural sagittal balance during gait in the patients with severe positive sagittal imbalance.

Methods.

In this age- and sex-matched case control study, a total of 40 patients, each 20 subjects with either ASD or LSS who were scheduled to undergo surgery were included. Both clinical outcomes and sagittal spinopelvic parameters, including sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), and pelvic incidence (PI) were measured. In motion analysis during walking, the angle of anterior pelvic tilt and the angles of the pelvis, hip, and knee were estimated. The correlation between variables was analyzed.

Results.

On standing lateral x-rays, SVA, PT, and PI – LL were significantly higher in the ASD group while SS and LL were significantly lower in the ASD group. However, on motion analysis, the average mean anterior pelvic tilt ± SD values in the ASD group were 8.3 ± 10.7 and 8.5 ± 10.7 on the right and left, respectively, and were not different from matched values in the LSS group. A Bland–Altman plot demonstrated a good agreement between the SS in the x-ray and anterior pelvic tilt in the motion analysis. In the ASD group, SS and SVA showed a significant positive correlation with mean anterior pelvic tilt in motion analysis during gait.

Conclusion.

The present study showed that the failure of pelvic compensation would likely occur in patients with severe positive sagittal imbalance during walking.

Level of Evidence: 3
Treatment of Proximal Pole Scaphoid Fracture Nonunions With Intramedullary Cancellous Autograft and Cannulated Headless Compression Screw
Authors: Trupia Evan P. , Strauch Robert J.
Published: January 2019

Management of proximal pole scaphoid nonunion remains a challenging problem. Multiple surgical techniques have been described, although no treatment has proven superior. Recent studies have questioned the need for vascularized bone grafting, even in in the setting of avascular proximal poles. We present a relatively simple technique of intramedullary autogeneous cancellous bone grafting that does not disturb the intact cortical shell of the nonunion, which has so far provided gratifying clinical results.
Open Surgery for Trigger Finger Required Combined a1-a2 Pulley Release. A Retrospective Study on 1305 Case
Authors: Strigelli Vanni , Mingarelli Luigi , Fioravanti Giulio , Merendi Gianfranco , Merolli Antonio , Fanfani Francesco , Rocchi Lorenzo
Published: January 2019

Objectives:

We retrospectively reviewed 1305 open-surgery for idiopathic trigger finger performed by 4 senior hand surgeons between 2014 and 2016.

Material and Methods:

Medical records and a telephone interview made with a minimum follow-up of 1 year were used to identify the recurrent rate of triggering and other complications.

Results:

This retrospective study let us note that 169 fingers (13%) required simultaneous release of the A1-A2 pulleys because the sectioning of the A1 pulley alone did not lead to complete free sliding of the tendons. We did not record any bowstring complication and we ascribe this to both surgery and bandaging technique. Overall rate of complication was 11.8% and relapse triggering or permanent proximal interphalangeal joint flexion (PPIJF) were among them; notably, however, they occurred only in patients where the A2 pulley was not sectioned.

Conclusions:

Is possible to reduce the percentage of relapse triggering or PPIJF after trigger finger surgery, by performing that combined A1-A2 pulley release.

Level of Evidence:

Level III.
Femoral Derotation for the Acutely Malrotated Femur Following Intramedullary Nail Fixation
Authors: Sloan Matthew , Lim Daniel , Mehta Samir
Published: January 2019

Clinically significant malrotation is one of the common complications following intramedullary treatment of femoral shaft fractures. We provide our experience revising an acutely malrotated femoral shaft fracture treated by intramedullary nail fixation. Following clinical examination, radiographic evaluation must include computed tomography scan for evaluation of femoral torsion. Derotation should be pursued after discussion of risks and benefits with the patient, if the malrotation exceeds 15 degrees in comparison with the uninjured limb. Revision surgery must include careful intraoperative clinical examination, as well as bilateral fluoroscopic imaging to confirm improved total femoral neck version. Our preferred technique includes proximal and distal Schanz pins in parallel, which can be used as “joysticks” for performing derotation as well as a measurement tool to evaluate the adjustment angle. A sterile goniometer is required to confirm that adequate derotation has been obtained, before replacing distal interlock screws. Confirmatory imaging and examination is then performed as a second check before waking the patient.
Clinician Perspectives Regarding In-Hospital Cardiac Arrest Resuscitation: A Multicenter Survey
Authors: Peltan Ithan D. , Poll Justin , Sorensen Jeffrey , Guidry David , Chandler Marni , Beninati William , Brown Samuel M.
Published: January 2019

Objectives:

Evaluate clinicians’ sentiments about participating in cardiac arrest resuscitations and identify factors associated with confidence in resuscitation of cardiac arrest.

Design:

Electronic survey.

Setting:

Twenty-one hospitals in Utah and Idaho.

Subjects:

All attending physicians, residents, and nurses in a multilevel healthcare system likely to participate in an in-hospital cardiac arrest resuscitation at least once every 2 years.

Interventions:

None.

Measurements and Methods:

A survey instrument evaluating clinician perceptions of in-hospital cardiac arrest resuscitation participation was developed after literature review and iteratively revised based on expert input and cognitive pretesting. Survey responses were collected anonymously. Sixty percent of 1,642 contacted clinicians (n = 977) submitted complete responses, of whom 874 met study inclusion criteria (190 attending physicians, 576 nurses, and 110 residents). Most respondents (74%) participated in less than or equal to six in-hospital cardiac arrest events per year, and 41% of respondents were most likely to participate in in-hospital cardiac arrest resuscitation at a community, rural, or critical access hospital. Confidence in in-hospital cardiac arrest participation was high overall (92%), but lower among residents (86%) than nurses (91%) or attending physicians (96%; p = 0.008). Fewer residents (52%) than nurses (73%) or attending physicians (95%; p < 0.001) reported feeling confident leading in-hospital cardiac arrest teams. Residents (63%) and attending physicians (36%) were more likely to worry about making errors during an in-hospital cardiac arrest event than nurses (18%; p < 0.001). Only 15% of residents and 50% of respondents overall reported they were both confident participating in in-hospital cardiac arrest resuscitation and did not worry about making errors. In-hospital cardiac arrest participation frequency was the dominant predictor of respondents’ confidence leading or participating in an in-hospital cardiac arrest resuscitation.

Conclusions:

Many clinicians, especially residents, who participate in or lead in-hospital cardiac arrest resuscitation events lack confidence or worry about management errors. Hospitals—particularly smaller hospitals—should consider methods to provide in-hospital cardiac arrest teams additional “effective experience,” potentially using simulation or telemedicine consultation.
Being Convinced and Taking Responsibility: A Qualitative Study of Family Members’ Experience of Organ Donation Decision and Bereavement After Brain Death*
Authors: Kentish-Barnes Nancy , Cohen-Solal Zoé , Souppart Virginie , Cheisson Gaëlle , Joseph Liliane , Martin-Lefèvre Laurent , Si Larbi Anne Gaelle , Viquesnel Gérald , Marqué Sophie , Donati Stéphane , Charpentier Julien , Pichon Nicolas , Zuber Benjamin , Lesieur Olivier , Ouendo Martial , Renault Anne , Le Maguet Pascale , Kandelman Stanislas , Thuong Marie , Floccard Bernard , Mezher Chaouki , Duranteau Jacques , Azoulay Elie
Published: January 2019

Objectives:

Family members of brain dead patients experience an unprecedented situation in which not only they are told that their loved one is dead but are also asked to consider organ donation. The objective of this qualitative study was to determine 1) what it means for family members to make the decision and to take responsibility, 2) how they interact with the deceased patient in the ICU, 3) how family members describe the impact of the process and of the decision on their bereavement process.

Design:

Qualitative study using interviews with bereaved family members who were approached for organ donation after the death of their relative in the ICU (brain death).

Setting:

Family members from 13 ICUs in France.

Subjects:

Bereaved family members who were approached for organ donation after the death of their relative in the ICU (brain death).

Intervention:

None.

Measurements and Results:

Twenty-four interviews were conducted with 16 relatives of organ donor patients and with eight relatives of nonorgan donor patients. Three themes emerged: 1) taking responsibility—relatives explain how they endorse decisional responsibility but do not experience it as a burden, on the contrary; 2) ambiguous perceptions of death—two groups of relatives emerge: those for whom ambiguity hinders their acceptance of the patient’s death; those for whom ambiguity is an opportunity to accept the death and say goodbye; and 3) donation as a comfort during bereavement.

Conclusions:

In spite of caregivers’ efforts to focus organ donation discussions and decision on the patient, family members feel a strong decisional responsibility that is not experienced as a burden but a proof of their strong connection to the patient. Brain death however creates ambivalent experiences that some family members endure whereas others use as an opportunity to perform separation rituals. Last, organ donation can be experienced as a form of comfort during bereavement provided family members remain convinced their decision was right.
Hemodynamic-Directed Cardiopulmonary Resuscitation Improves Neurologic Outcomes and Mitochondrial Function in the Heart and Brain
Authors: Lautz Andrew J. , Morgan Ryan W. , Karlsson Michael , Mavroudis Constantine D. , Ko Tiffany S. , Licht Daniel J. , Nadkarni Vinay M. , Berg Robert A. , Sutton Robert M. , Kilbaugh Todd J.
Published: January 2019

Objectives:

Less than half of the thousands of children who suffer in-hospital cardiac arrests annually survive, and neurologic injury is common among survivors. Hemodynamic-directed cardiopulmonary resuscitation improves short-term survival, but its impact on longer term survival and mitochondrial respiration—a potential neurotherapeutic target—remains unknown. The primary objectives of this study were to compare rates of 24-hour survival with favorable neurologic outcome after cardiac arrest treated with hemodynamic-directed cardiopulmonary resuscitation versus standard depth-guided cardiopulmonary resuscitation and to compare brain and heart mitochondrial respiration between groups 24 hours after resuscitation.

Design:

Randomized preclinical large animal trial.

Setting:

A large animal resuscitation laboratory at a large academic children’s hospital.

Subjects:

Twenty-eight 4-week-old female piglets (8–11 kg).

Interventions:

Twenty-two swine underwent 7 minutes of asphyxia followed by ventricular fibrillation and randomized treatment with either hemodynamic-directed cardiopulmonary resuscitation (n = 10; compression depth titrated to aortic systolic pressure of 90 mm Hg, vasopressors titrated to coronary perfusion pressure ≥ 20 mm Hg) or depth-guided cardiopulmonary resuscitation (n = 12; depth 1/3 chest diameter, epinephrine every 4 min). Six animals (sham group) underwent anesthesia and instrumentation without cardiac arrest. The primary outcomes were favorable neurologic outcome (swine Cerebral Performance Category ≤ 2) and mitochondrial maximal oxidative phosphorylation utilizing substrate for complex I and complex II (OXPHOSCI+CII) in the cerebral cortex and hippocampus.

Measurements and Main Results:

Favorable neurologic outcome was more likely with hemodynamic-directed cardiopulmonary resuscitation (7/10) than depth-guided cardiopulmonary resuscitation (1/12; p = 0.006). Hemodynamic-directed cardiopulmonary resuscitation resulted in higher intra-arrest coronary perfusion pressure, aortic pressures, and brain tissue oxygenation. Hemodynamic-directed cardiopulmonary resuscitation resulted in higher OXPHOSCI+CII (pmol oxygen/s × mg/citrate synthase) in the cortex (6.00 ± 0.28 vs 3.88 ± 0.43; p < 0.05) and hippocampus (6.26 ± 0.67 vs 3.55 ± 0.65; p < 0.05) and higher complex I respiration (pmol oxygen/s × mg) in the right (20.62 ± 1.06 vs 15.88 ± 0.81; p < 0.05) and left ventricles (20.14 ± 1.40 vs 14.17 ± 1.53; p < 0.05).

Conclusions:

In a model of asphyxia-associated pediatric cardiac arrest, hemodynamic-directed cardiopulmonary resuscitation increases rates of 24-hour survival with favorable neurologic outcome, intra-arrest hemodynamics, and cerebral and myocardial mitochondrial respiration.
A Pilot Study Identifying Brain-Targeting Adaptive Immunity in Pediatric Extracorporeal Membrane Oxygenation Patients With Acquired Brain Injury
Authors: Ortega Sterling B. , Pandiyan Poornima , Windsor Jana , Torres Vanessa O. , Selvaraj Uma M. , Lee Amy , Morriss Michael , Tian Fenghua , Raman Lakshmi , Stowe Ann M.
Published: January 2019

Objectives:

Extracorporeal membrane oxygenation provides short-term cardiopulmonary life support, but is associated with peripheral innate inflammation, disruptions in cerebral autoregulation, and acquired brain injury. We tested the hypothesis that extracorporeal membrane oxygenation also induces CNS-directed adaptive immune responses which may exacerbate extracorporeal membrane oxygenation-associated brain injury.

Design:

A single center prospective observational study.

Setting:

Pediatric and cardiac ICUs at a single tertiary care, academic center.

Patients:

Twenty pediatric extracorporeal membrane oxygenation patients (0–14 yr; 13 females, 7 males) and five nonextracorporeal membrane oxygenation Pediatric Logistic Organ Dysfunction score matched patients

Interventions:

None.

Measurements and Main Results:

Venous blood samples were collected from the extracorporeal membrane oxygenation circuit at day 1 (10–23 hr), day 3, and day 7 of extracorporeal membrane oxygenation. Flow cytometry quantified circulating innate and adaptive immune cells, and CNS-directed autoreactivity was detected using an in vitro recall response assay. Disruption of cerebral autoregulation was determined using continuous bedside near-infrared spectroscopy and acquired brain injury confirmed by MRI. Extracorporeal membrane oxygenation patients with acquired brain injury (n = 9) presented with a 10-fold increase in interleukin-8 over extracorporeal membrane oxygenation patients without brain injury (p < 0.01). Furthermore, brain injury within extracorporeal membrane oxygenation patients potentiated an inflammatory phenotype in adaptive immune cells and selective autoreactivity to brain peptides in circulating B cell and cytotoxic T cell populations. Correlation analysis revealed a significant relationship between adaptive immune responses of extracorporeal membrane oxygenation patients with acquired brain injury and loss of cerebral autoregulation.

Conclusions:

We show that pediatric extracorporeal membrane oxygenation patients with acquired brain injury exhibit an induction of pro-inflammatory cell signaling, a robust activation of adaptive immune cells, and CNS-targeting adaptive immune responses. As these patients experience developmental delays for years after extracorporeal membrane oxygenation, it is critical to identify and characterize adaptive immune cell mechanisms that target the developing CNS.
Incidence, Risk Factors, and Outcomes of Intra-Abdominal Hypertension in Critically Ill Patients—A Prospective Multicenter Study (IROI Study)
Authors: Reintam Blaser Annika , Regli Adrian , De Keulenaer Bart , Kimball Edward J. , Starkopf Liis , Davis Wendy A. , Greiffenstein Patrick , Starkopf Joel
Published: January 2019

Objectives:

To identify the prevalence, risk factors, and outcomes of intra-abdominal hypertension in a mixed multicenter ICU population.

Design:

Prospective observational study.

Setting:

Fifteen ICUs worldwide.

Patients:

Consecutive adult ICU patients with a bladder catheter.

Interventions:

None.

Measurements and Main Results:

Four hundred ninety-one patients were included. Intra-abdominal pressure was measured a minimum of every 8 hours. Subjects with a mean intra-abdominal pressure equal to or greater than 12 mm Hg were defined as having intra-abdominal hypertension. Intra-abdominal hypertension was present in 34.0% of the patients on the day of ICU admission (159/467) and in 48.9% of the patients (240/491) during the observation period. The severity of intra-abdominal hypertension was as follows: grade I, 47.5%; grade II, 36.6%; grade III, 11.7%; and grade IV, 4.2%. The severity of intra-abdominal hypertension during the first 2 weeks of the ICU stay was identified as an independent predictor of 28- and 90-day mortality, whereas the presence of intra-abdominal hypertension on the day of ICU admission did not predict mortality. Body mass index, Acute Physiology and Chronic Health Evaluation II score greater than or equal to 18, presence of abdominal distension, absence of bowel sounds, and positive end-expiratory pressure greater than or equal to 7 cm H2O were independently associated with the development of intra-abdominal hypertension at any time during the observation period. In subjects without intra-abdominal hypertension on day 1, body mass index combined with daily positive fluid balance and positive end-expiratory pressure greater than or equal to 7 cm H2O (as documented on the day before intra-abdominal hypertension occurred) were associated with the development of intra-abdominal hypertension during the first week in the ICU.

Conclusions:

In our mixed ICU patient cohort, intra-abdominal hypertension occurred in almost half of all subjects and was twice as prevalent in mechanically ventilated patients as in spontaneously breathing patients. Presence and severity of intra-abdominal hypertension during the observation period significantly and independently increased 28- and 90-day mortality. Five admission day variables were independently associated with the presence or development of intra-abdominal hypertension. Positive fluid balance was associated with the development of intra-abdominal hypertension after day 1.
A Prognostic Enrichment Strategy for Selection of Patients With Acute Respiratory Distress Syndrome in Clinical Trials
Authors: Villar Jesús , Ambrós Alfonso , Mosteiro Fernando , Martínez Domingo , Fernández Lorena , Ferrando Carlos , Carriedo Demetrio , Soler Juan A. , Parrilla Dácil , Hernández Mónica , Andaluz-Ojeda David , Añón José M. , Vidal Anxela , González-Higueras Elena , Martín-Rodríguez Carmen , Díaz-Lamas Ana M. , Blanco Jesús , Belda Javier , Díaz-Domínguez Francisco J. , Rico-Feijoó Jesús , Martín-Delgado Carmen , Romera Miguel A. , González-Martín Jesús M. , Fernández Rosa L. , Kacmarek Robert M.
Published: January 2019

Objectives:

Incomplete or ambiguous evidence for identifying high-risk patients with acute respiratory distress syndrome for enrollment into randomized controlled trials has come at the cost of an unreasonable number of negative trials. We examined a set of selected variables early in acute respiratory distress syndrome to determine accurate prognostic predictors for selecting high-risk patients for randomized controlled trials.

Design:

A training and testing study using a secondary analysis of data from four prospective, multicenter, observational studies.

Setting:

A network of multidisciplinary ICUs.

Patients:

We studied 1,200 patients with moderate-to-severe acute respiratory distress syndrome managed with lung-protective ventilation.

Interventions:

None.

Measurements and Main Results:

We evaluated different thresholds for patient’s age, Pao
2/Fio
2, plateau pressure, and number of extrapulmonary organ failures to predict ICU outcome at 24 hours of acute respiratory distress syndrome diagnosis. We generated 1,000 random scenarios as training (n = 900, 75% of population) and testing (n = 300, 25% of population) datasets and averaged the logistic coefficients for each scenario. Thresholds for age (< 50, 50–70, > 70 yr), Pao
2/Fio
2 (≤ 100, 101–150, > 150 mm Hg), plateau pressure (< 29, 29–30, > 30 cm H2O), and number of extrapulmonary organ failure (< 2, 2, > 2) stratified accurately acute respiratory distress syndrome patients into categories of risk. The model that included all four variables proved best to identify patients with the highest or lowest risk of death (area under the receiver operating characteristic curve, 0.86; 95% CI, 0.84–0.88). Decision tree analyses confirmed the accuracy and robustness of this enrichment model.

Conclusions:

Combined thresholds for patient’s age, Pao
2/Fio
2, plateau pressure, and extrapulmonary organ failure provides prognostic enrichment accuracy for stratifying and selecting acute respiratory distress syndrome patients for randomized controlled trials.
Six Hours of Manual Ventilation With a Bag-Valve-Mask Device Is Feasible and Clinically Consistent
Authors: Halpern Pinchas , Dang Tru , Epstein Yoram , Van Stijn–Bringas Dimitriades Diana , Koenig Kristi L.
Published: January 2019

Objectives:

Manual ventilation of intubated patients is a common intervention. It requires skill as well as physical effort and is typically restricted to brief periods. Prolonged manual ventilation may be unavoidable in some scenarios, for example, extreme mass casualty incidents. The present study tested whether nurses are capable of appropriately manually ventilating patients for 6 hours.

Design:

Volunteers performed ventilation on an electronic simulator for 6 hours while their own cardiorespiratory variables and the quality of the delivered ventilation were measured and recorded. The volunteers scored their perceived level of effort on a standard Borg Scale.

Setting:

Research laboratory at the Emergency Department, Tel Aviv Medical Center.

Subjects:

Ten nursing staff members of the Tel Aviv Sourasky Medical Center, 25–43 years old.

Interventions:

Volunteers ventilated manually a lung simulator for 6 hours.

Measurements and Main Results:

The subjects’ physiologic states, including blood pressure, heart rate, respiratory rate, and oxygen saturation, showed no significant changes over time. The quality of delivered ventilation was somewhat variable, but it was stable on the average: average tidal volume ranged between 524.8 and 607.0 mL (p = 0.33). There was a slight but significant increase (7.3–10.9 L/min [p = 0.048]) in minute volume throughout the test period, reaching values consistent with mild hyperventilation. The subjects scored their perceived working effort as very light to fairly light, with a nonsignificant gradual increase in the Borg score as the study progressed.

Conclusions:

Manual ventilation of intubated patients can be performed continuously for 6 hours without excessive physical effort on the part of the operator. The quality of delivered ventilation was clinically adequate for all of them. There was a mild but significant trend toward hyperventilation, albeit within safe clinical levels, which was due to an increasing ventilatory rate rather than an increase in tidal volume.
Transvenous Renal Biopsy of Critically Ill Patients: Safety and Diagnostic Yield
Authors: de Chambrun Marc Pineton , Cluzel Philippe , Brocheriou Isabelle , Bréchot Nicolas , Hékimian Guillaume , Turki Mohamed-Wafik , Franchineau Guillaume , Rouvier Philippe , Bourcier Simon , Bureau Côme , Nieszkowska Ania , Le Guennec Loïc , Mathian Alexis , Amoura Zahir , Schmidt Matthieu , Combes Alain , Luyt Charles-Edouard
Published: January 2019

Objectives:

Transvenous renal biopsy is an alternative way to obtain kidney samples from patients with bleeding risk factors (e.g., antiplatelet therapy and anticoagulation or coagulation disorders). This study was undertaken to determine the safety and diagnostic yield of transvenous renal biopsy of critically ill patients.

Design:

Monocenter, retrospective, observational cohort study.

Setting:

A 26-bed French tertiary ICU.

Patients:

All patients undergoing in-ICU transvenous renal biopsy between January 2002 and February 2018.

Interventions:

None.

Measurements and Main Results:

Eighty patients (male/female sex ratio, 0.95; mean ± sd age, 47.3 ± 18.3 yr) were included. A histologic diagnosis was obtained for 77 patients (96.3%), with acute tubular necrosis being the most frequent: 23 (29.9%). A potentially treatable cause was found for 47 patients (58.7%). The numbers of patients with 0, 1, 2, or 3 factors (i.e., antiplatelet therapy, thrombopenia [< 150 G/L], and preventive or curative anticoagulation) at the time of the biopsy were, respectively: seven (8.8%), 37 (46.2%), 31 (38.7%), and five (6.3%). Four (5%) and two (2.5%) patients, respectively, had renal hematoma and macroscopic hematuria; none required any specific treatment. Six patients (7.5%) died in-ICU, and 90-day mortality was 8 of 80 (10%). No death was related to transvenous renal biopsy, and median biopsy-to-death interval was 38 days (interquartile range, 19.7–86 d).

Conclusions:

Based on this cohort of ICU patients with acute kidney injury, transvenous renal biopsy was safe and obtained a high diagnostic yield for these selected critically ill patients, even in the presence of multiple bleeding risk factors.
Continuous Electroencephalography After Moderate to Severe Traumatic Brain Injury
Authors: Lee Hyunjo , Mizrahi Moshe A. , Hartings Jed A. , Sharma Sameer , Pahren Laura , Ngwenya Laura B. , Moseley Brian D. , Privitera Michael , Tortella Frank C. , Foreman Brandon
Published: January 2019

Objectives:

After traumatic brain injury, continuous electroencephalography is widely used to detect electrographic seizures. With the development of standardized continuous electroencephalography terminology, we aimed to describe the prevalence and burden of ictal-interictal patterns, including electrographic seizures after moderate-to-severe traumatic brain injury and to correlate continuous electroencephalography features with functional outcome.

Design:

Post hoc analysis of the prospective, randomized controlled phase 2 multicenter INTREPID2566 study (ClinicalTrials.gov: NCT00805818). Continuous electroencephalography was initiated upon admission to the ICU. The primary outcome was the 3-month Glasgow Outcome Scale-Extended. Consensus electroencephalography reviews were performed by raters certified in standardized continuous electroencephalography terminology blinded to clinical data. Rhythmic, periodic, or ictal patterns were referred to as “ictal-interictal continuum”; severe ictal-interictal continuum was defined as greater than or equal to 1.5 Hz lateralized rhythmic delta activity or generalized periodic discharges and any lateralized periodic discharges or electrographic seizures.

Setting:

Twenty U.S. level I trauma centers.

Patients:

Patients with nonpenetrating traumatic brain injury and postresuscitation Glasgow Coma Scale score of 4–12 were included.

Interventions:

None.

Measurements and Main Results:

Among 152 patients with continuous electroencephalography (age 34 ± 14 yr; 88% male), 22 (14%) had severe ictal-interictal continuum including electrographic seizures in four (2.6%). Severe ictal-interictal continuum burden correlated with initial prognostic scores, including the International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (r = 0.51; p = 0.01) and Injury Severity Score (r = 0.49; p = 0.01), but not with functional outcome. After controlling clinical covariates, unfavorable outcome was independently associated with absence of posterior dominant rhythm (common odds ratio, 3.38; 95% CI, 1.30–9.09), absence of N2 sleep transients (3.69; 1.69–8.20), predominant delta activity (2.82; 1.32–6.10), and discontinuous background (5.33; 2.28–12.96) within the first 72 hours of monitoring.

Conclusions:

Severe ictal-interictal continuum patterns, including electrographic seizures, were associated with clinical markers of injury severity but not functional outcome in this prospective cohort of patients with moderate-to-severe traumatic brain injury. Importantly, continuous electroencephalography background features were independently associated with functional outcome and improved the area under the curve of existing, validated predictive models.
Evolution and Impact of Thrombocytopenia in Septic Shock: A Retrospective Cohort Study
Authors: Menard Chantalle E. , Kumar Anand , Houston Donald S. , Turgeon Alexis F. , Rimmer Emily , Houston Brett L. , Doucette Steven , Zarychanski Ryan
Published: January 2019

Objectives:

To characterize the prevalence, incidence, and temporal evolution of thrombocytopenia (platelets < 100 × 109/L) in septic shock and to investigate the independent association of thrombocytopenia on clinical outcomes.

Design:

Retrospective, propensity-matched, cohort study.

Setting:

Two academic ICUs in Winnipeg, Canada.

Patients:

Nine-hundred eighty adult patients diagnosed with septic shock between 2007 and 2012.

Interventions:

Propensity-matched cohort analysis and Cox proportional hazard model evaluating thrombocytopenia over time.

Measurements and Main Results:

Of 980 adults, 165 patients (16.8%) had thrombocytopenia at ICU admission (prevalent), whereas 271 (27.7%) developed thrombocytopenia during ICU admission (incident). Among patients with incident thrombocytopenia, the median time from ICU admission to thrombocytopenia was 2 days (interquartile range, 1–3 d). Among survivors, the median time from incident thrombocytopenia to platelet recovery was 6 days (interquartile range, 4–8 d). The median time from liberation of vasopressors to recovery of platelets concentration (≥ 100 × 109/L) was 2 days (interquartile range, 0–4 d). In a propensity-matched analysis, thrombocytopenia was associated with increased durations of ICU length of stay (9 vs 6 d; p < 0.01), mechanical ventilation (7 vs 4 d; p < 0.01), and vasopressor use (4 vs 3 d; p < 0.01), as well as increased major bleeding events (41% vs 18%; p < 0.01). In an adjusted Cox proportional hazards model, thrombocytopenia was significantly associated with both increased ICU mortality (hazard ratio, 1.99; 95% CI, 1.51–2.63) and hospital mortality (hazard ratio, 1.93; 95% CI, 1.48–2.51).

Conclusions:

Both the prevalence and incidence of thrombocytopenia are high in septic shock. Incident thrombocytopenia occurs early in septic shock, and platelet recovery lags behind clinical recovery. In septic shock, thrombocytopenia is associated with increased length of stay, longer duration of organ support, major bleeding events, and mortality.
A Fate Worse Than Death: Prognostication of Devastating Brain Injury
Authors: Pratt Alexandra K. , Chang Jason J. , Sederstrom Nneka O.
Published: January 2019

Objectives:

To describe the sources of uncertainty in prognosticating devastating brain injury, the role of the intensivist in prognostication, and ethical considerations in prognosticating devastating brain injury in the ICU.

Data Sources:

A PubMed literature review was performed.

Study Selection:

Articles relevant to prognosis in intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and postcardiac arrest anoxic encephalopathy were selected.

Data Extraction:

Data regarding definition and prognosis of devastating brain injury were extracted. Themes related to how clinicians perform prognostication and their accuracy were reviewed and extracted.

Data Synthesis:

Although there are differences in pathophysiology and therefore prognosis in the various etiologies of devastating brain injury, some common themes emerge. Physicians tend to have fairly good prognostic accuracy, especially in severe cases with poor prognosis. Full supportive care is recommended for at least 72 hours from initial presentation to maximize the potential for recovery and minimize secondary injury. However, physician approaches to the timing of and recommendations for withdrawal of life-sustaining therapy have a significant impact on mortality from devastating brain injury.

Conclusions:

Intensivists should consider the modern literature describing prognosis for devastating brain injury and provide appropriate time for patient recovery and for discussions with the patient’s surrogates. Surrogates wish to have a prognosis enumerated even when uncertainty exists. These discussions must be handled with care and include admission of uncertainty when it exists. Respect for patient autonomy remains paramount, although physicians are not required to provide inappropriate medical therapies.