bluuebunny/crossref_metadata_2025_split huggingface dataset:
Age, Pao 2/Fio 2, and Plateau Pressure Score: A Proposal for a Simple Outcome Score in Patients With the Acute Respiratory Distress Syndrome*
Authors: Villar Jesús , Ambrós Alfonso , Soler Juan Alfonso , Martínez Domingo , Ferrando Carlos , Solano Rosario , Mosteiro Fernando , Blanco Jesús , Martín-Rodríguez Carmen , Fernández María del Mar , López Julia , Díaz-Domínguez Francisco J. , Andaluz-Ojeda David , Merayo Eleuterio , Pérez-Méndez Lina , Fernández Rosa Lidia , Kacmarek Robert M. 
Published: April 2016

Objectives:
Although there is general agreement on the characteristic features of the acute respiratory distress syndrome, we lack a scoring system that predicts acute respiratory distress syndrome outcome with high probability. Our objective was to develop an outcome score that clinicians could easily calculate at the bedside to predict the risk of death of acute respiratory distress syndrome patients 24 hours after diagnosis.

Design:
A prospective, multicenter, observational, descriptive, and validation study.

Setting:
A network of multidisciplinary ICUs.

Patients:
Six-hundred patients meeting Berlin criteria for moderate and severe acute respiratory distress syndrome enrolled in two independent cohorts treated with lung-protective ventilation.

Interventions:
None.

Measurements and Main Results:
Using individual demographic, pulmonary, and systemic data at 24 hours after acute respiratory distress syndrome diagnosis, we derived our prediction score in 300 acute respiratory distress syndrome patients based on stratification of variable values into tertiles, and validated in an independent cohort of 300 acute respiratory distress syndrome patients. Primary outcome was in-hospital mortality. We found that a 9-point score based on patient’s age, Pao
2/Fio
2 ratio, and plateau pressure at 24 hours after acute respiratory distress syndrome diagnosis was associated with death. Patients with a score greater than 7 had a mortality of 83.3% (relative risk, 5.7; 95% CI, 3.0–11.0), whereas patients with scores less than 5 had a mortality of 14.5% (p < 0.0000001). We confirmed the predictive validity of the score in a validation cohort.

Conclusions:
A simple 9-point score based on the values of age, Pao
2/Fio
2 ratio, and plateau pressure calculated at 24 hours on protective ventilation after acute respiratory distress syndrome diagnosis could be used in real time for rating prognosis of acute respiratory distress syndrome patients with high probability.
Critical Illness Is Associated With Impaired Gallbladder Emptying as Assessed by 3D Ultrasound
Authors: Plummer Mark P. , Kar Palash , Cousins Caroline E. , Hausken Trygve , Lange Kylie , Chapman Marianne J. , Jones Karen L. , Horowitz Michael , Deane Adam M. 
Published: April 2016

Objective:
To quantify gallbladder dysfunction during critical illness.

Design:
Prospective observational comparison study of nutrient-stimulated gallbladder emptying in health and critical illness.

Setting:
Single-centre mixed medical/surgical ICU.

Patients:
Twenty-four mechanically ventilated critically ill patients suitable to receive enteral nutrition were compared with 12 healthy subjects.

Interventions:
Participants were studied after an 8-hour fast. Between 0 and 120 minutes, high-fat nutrient (20% intralipid) was infused via a postpyloric catheter into the duodenum at 2 kcal/min.

Measurements and Main Results:
Three-dimensional images of the gallbladder were acquired at 30-minute intervals from –30 to 180 minutes. Ejection fraction (%) was calculated as changes between 0 and 120 minutes. Blood samples were obtained at 30-minute intervals for plasma cholecystokinin. Data are mean (sd) or median [interquartile range]. In the critically ill, fasting gallbladder volumes (critically ill, 61 mL [36–100 mL] vs healthy, 22 mL [15–25] mL; p < 0.001] and wall thickness (0.45 mm [0.15 mm] vs 0.26 mm [0.08 mm]; p < 0.001] were substantially greater, and sludge was evident in the majority of patients (71% vs 0%). Nutrient-stimulated emptying was incomplete in the critically ill after 120 minutes but was essentially complete in the healthy individuals (22 mL [9–66 mL] vs 4 mL [3–5 mL]; p < 0.01]. In five critically ill patients (21%), there was no change in gallbladder volume in response to nutrient, and overall ejection fraction was reduced in the critically ill (50% [8–83%] vs 77 [72–84%]; p = 0.01]. There were no differences in fasting or incremental cholecystokinin concentrations.

Conclusions:
Fasted critically ill patients have larger, thicker-walled gallbladders than healthy subjects and nutrient-stimulated gallbladder emptying is impaired with “gallbladder paresis” occurring in approximately 20%.
A Time-Motion Study of ICU Workflow and the Impact of Strain*
Authors: Hefter Yosefa , Madahar Purnema , Eisen Lewis A. , Gong Michelle N. 
Published: April 2016

Objective:
Understanding ICU workflow and how it is impacted by ICU strain is necessary for implementing effective improvements. This study aimed to quantify how ICU physicians spend time and to examine the impact of ICU strain on workflow.

Design:
Prospective, observational time-motion study.

Setting:
Five ICUs in two hospitals at an academic medical center.

Subjects:
Thirty attending and resident physicians.

Interventions:
None.

Measurements and Main Results:
In 137 hours of field observations, the most time—84 hours (62% of total observation time)—was spent on professional communication. Reviewing patient data and documentation occupied a combined 52 hours (38%), whereas direct patient care and education occupied 24 hours (17%) and 13 hours (9%), respectively. The most frequently used tool was the computer, used in tasks that occupied 51 hours (37%). Severity of illness of the ICU on day of observation was the only strain factor that significantly impacted work patterns. In a linear regression model, increase in average ICU Sequential Organ Failure Assessment was associated with more time spent on direct patient care (β = 4.3; 95% CI, 0.9–7.7) and education (β = 3.2; 95% CI, 0.7–5.8), and less time spent on documentation (β = –7.4; 95% CI, –11.6 to –3.2) and on tasks using the computer (β = –7.8; 95% CI, –14.1 to –1.6). These results were more pronounced with a combined strain score that took into account unit census and Sequential Organ Failure Assessment score. After accounting for ICU type (medical vs surgical) and staffing structure (resident staffed vs physician assistant staffed), results changed minimally.

Conclusion:
Clinicians spend the bulk of their time in the ICU on professional communication and tasks involving computers. With the strain of high severity of illness and a full unit, clinicians reallocate time from documentation to patient care and education. Further efforts are needed to examine system-related aspects of care to understand the impact of workflow and strain on patient care.
Elevated Leukocyte Azurophilic Enzymes in Human Diabetic Ketoacidosis Plasma Degrade Cerebrovascular Endothelial Junctional Proteins*
Authors: Woo Martin M. H. , Patterson Eric K. , Clarson Cheril , Cepinskas Gediminas , Bani-Yaghoub Mahmud , Stanimirovic Danica B. , Fraser Douglas D. 
Published: April 2016

Objective:
Diabetic ketoacidosis in children is associated with vasogenic cerebral edema, possibly due to the release of destructive polymorphonuclear neutrophil azurophilic enzymes. Our objectives were to measure plasma azurophilic enzyme levels in children with diabetic ketoacidosis, to correlate plasma azurophilic enzyme levels with diabetic ketoacidosis severity, and to determine whether azurophilic enzymes disrupt the blood-brain barrier in vitro.

Design:
Prospective clinical and laboratory study.

Setting:
The Children’s Hospital, London Health Sciences Centre.

Subjects:
Pediatric type 1 diabetes patients; acute diabetic ketoacidosis or age-/sex-matched insulin-controlled.

Measurements and Main Results:
Acute diabetic ketoacidosis in children was associated with elevated polymorphonuclear neutrophils. Plasma azurophilic enzymes were elevated in diabetic ketoacidosis patients, including human leukocyte elastase (p < 0.001), proteinase-3 (p < 0.01), and myeloperoxidase (p < 0.001). A leukocyte origin of human leukocyte elastase and proteinase-3 in diabetic ketoacidosis was confirmed with buffy coat quantitative real-time polymerase chain reaction (p < 0.01). Of the three azurophilic enzymes elevated, only proteinase-3 levels correlated with diabetic ketoacidosis severity (p = 0.002). Recombinant proteinase-3 applied to human brain microvascular endothelial cells degraded both the tight junction protein occludin (p < 0.05) and the adherens junction protein VE-cadherin (p < 0.05). Permeability of human brain microvascular endothelial cell monolayers was increased by recombinant proteinase-3 application (p = 0.010).

Conclusions:
Our results indicate that diabetic ketoacidosis is associated with systemic polymorphonuclear neutrophil activation and degranulation. Of all the polymorphonuclear neutrophil azurophilic enzymes examined, only proteinase-3 correlated with diabetic ketoacidosis severity and potently degraded the blood-brain barrier in vitro. Proteinase-3 might mediate vasogenic edema during diabetic ketoacidosis, and selective proteinase-3 antagonists may offer future vascular- and neuroprotection.
Comparative Effects of Volutrauma and Atelectrauma on Lung Inflammation in Experimental Acute Respiratory Distress Syndrome
Authors: Güldner Andreas , Braune Anja , Ball Lorenzo , Silva Pedro L. , Samary Cynthia , Insorsi Angelo , Huhle Robert , Rentzsch Ines , Becker Claudia , Oehme Liane , Andreeff Michael , Vidal Melo Marcos F. , Winkler Tilo , Pelosi Paolo , Rocco Patricia R. M. , Kotzerke Jörg , Gama de Abreu Marcelo 
Published: April 2016

Objective:
Volutrauma and atelectrauma promote ventilator-induced lung injury, but their relative contribution to inflammation in ventilator-induced lung injury is not well established. The aim of this study was to determine the impact of volutrauma and atelectrauma on the distribution of lung inflammation in experimental acute respiratory distress syndrome.

Design:
Laboratory investigation.

Setting:
University-hospital research facility.

Subjects:
Ten pigs (five per group; 34.7–49.9 kg)

Interventions:
Animals were anesthetized and intubated, and saline lung lavage was performed. Lungs were separated with a double-lumen tube. Following lung recruitment and decremental positive end-expiratory pressure trial, animals were randomly assigned to 4 hours of ventilation of the left (ventilator-induced lung injury) lung with tidal volume of approximately 3 mL/kg and 1) high positive end-expiratory pressure set above the level where dynamic compliance increased more than 5% during positive end-expiratory pressure trial (volutrauma); or 2) low positive end-expiratory pressure to achieve driving pressure comparable with volutrauma (atelectrauma). The right (control) lung was kept on continuous positive airway pressure of 20 cm H2O, and Co
2 was partially removed extracorporeally.

Measurements and Main Results:
Regional lung aeration, specific [18F]fluorodeoxyglucose uptake rate, and perfusion were assessed using computed and positron emission tomography. Volutrauma yielded higher [18F]fluorodeoxyglucose uptake rate in the ventilated lung compared with atelectrauma (median [interquartile range], 0.017 [0.014–0.025] vs 0.013 min–1 [0.010–0.014 min–1]; p < 0.01), mainly in central lung regions. Volutrauma yielded higher [18F]fluorodeoxyglucose uptake rate in ventilator-induced lung injury versus control lung (0.017 [0.014–0.025] vs 0.011 min–1 [0.010–0.016 min–1]; p < 0.05), whereas atelectrauma did not. Volutrauma decreased blood fraction at similar perfusion and increased normally as well as hyperaerated lung compartments and tidal hyperaeration. Atelectrauma yielded higher poorly and nonaerated lung compartments, and tidal recruitment. Driving pressure increased in atelectrauma.

Conclusions:
In this model of acute respiratory distress syndrome, volutrauma promoted higher lung inflammation than atelectrauma at comparable low tidal volume and lower driving pressure, suggesting that static stress and strain are major determinants of ventilator-induced lung injury.
Histopathology of Septic Acute Kidney Injury: A Systematic Review of Experimental Data
Authors: Kosaka Junko , Lankadeva Yugeesh R. , May Clive N. , Bellomo Rinaldo 
Published: April 2016

Objective:
The histopathologic changes associated with septic acute kidney injury are poorly understood, in part, because of the lack of biopsy data in humans. Animal models of septic acute kidney injury may help define such changes. Therefore, we performed a systematic review of the histopathologic changes found in modern experimental septic acute kidney injury models.

Data Sources:
MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and PubMed (from January 2007 to February 2015).

Study Selection:
We reviewed experimental studies reporting findings on the histopathology of contemporary experimental septic acute kidney injury.

Data Extraction:
We focused on the presence or the absence of acute tubular necrosis, tubular cell apoptosis, and other nonspecific findings.

Data Synthesis:
We identified 102 studies in 1,059 animals. Among the 1,059 animals, 53 (5.0%) did not have any renal histopathologic changes, but acute tubular necrosis was found in 184 (17.4%). The prevalence of acute tubular necrosis was not related to animal size or model of sepsis and was only found in models with low cardiac output and decreased renal blood flow (p < 0.0001). Only 21 studies (170 animals) assessed the prevalence of tubular cell apoptosis, which was reported in 158 animals (92.9%). The prevalence of tubular cell apoptosis was significantly higher in studies using small animals (p < 0.0001) and in peritonitis models (p < 0.0001). Simultaneous acute tubular necrosis and tubular cell apoptosis was rare (55 animals [32.4%]) and only seen with decreased cardiac output and renal blood flow. Nonspecific changes (vacuolization of tubular cells, loss of brush border, and tubular cell swelling) were each observed in 423 (39.9%), 250 (23.6%) and 243 (22.9%) animals, respectively.

Conclusions:
In models of experimental septic acute kidney injury in contemporary articles, acute tubular necrosis was relatively uncommon and, when present, reflected the presence of an associated low cardiac output or low renal blood flow syndrome. Tubular cell apoptosis seemed frequent in the few studies in which it was investigated. Nonspecific morphologic changes, however, were the most common histopathologic findings.
Liberal Versus Conventional Glucose Targets in Critically Ill Diabetic Patients: An Exploratory Safety Cohort Assessment
Authors: Di Muzio Francesca , Presello Barbara , Glassford Neil J. , Tsuji Isabela Y. , Eastwood Glenn M. , Deane Adam M. , Ekinci Elif I. , Bellomo Rinaldo , Mårtensson Johan 
Published: April 2016

Objectives:
To assess the feasibility, safety, and impact on relative hypoglycemia of liberal versus conventional blood glucose concentration targets in critically ill diabetic patients.

Design:
Prospective, open-label, sequential-period exploratory study.

Setting:
A 22-bed multidisciplinary ICU of a tertiary care hospital in Australia.

Patients:
Eighty adult diabetic patients, 40 from the conventional before period and 40 from the liberal after period.

Interventions:
Blood glucose concentration targets were 6–10 mmol/L during the before period and 10–14 mmol/L during the after period.

Measurements and Main Results:
We used admission glycated hemoglobin to estimate premorbid baseline blood glucose concentration. We defined glycemic distance as the difference between blood glucose concentration in ICU and baseline blood glucose concentration. During the first 48 ICU hours, we recorded absolute (blood glucose concentration, < 3.9 mmol/L) and relative (glycemic distance, > 30% below baseline) hypoglycemia rates, insulin administration, and outcomes. The groups had similar baseline characteristics. We observed a negative glycemic distance in 248 of 488 blood glucose concentrations (50.8%) during the before period and 164 of 485 (33.8%) during the after period (p < 0.001). We detected relative hypoglycemia in 20 (50.0%) and nine (22.5%) patients in the before and after periods, respectively (p = 0.01). On day 1, 50.0% and 16.7% received insulin in the before and after periods (p = 0.007). ICU and hospital length of stay and mortality were similar between groups.

Conclusions:
In a safety cohort of critically ill diabetic patients, a blood glucose concentration target of 10–14 mmol/L resulted in fewer episodes of negative glycemic distance or relative hypoglycemia and reduced insulin administration compared with a target of 6–10 mmol/L.
Measuring Adaptive Coping of Hospitalized Patients With a Severe Medical Condition: The Sickness Insight in Coping Questionnaire*
Authors: Boezeman Edwin J. , Hofhuis José G. M. , Hovingh Aly , Cox Christopher E. , de Vries Reinout E. , Spronk Peter E. 
Published: April 2016

Objectives:
Adaptive coping strategies are associated with less psychological distress. However, there is no brief, specific, and validated instrument for assessing adaptive coping among seriously ill patients. Our objective was to examine the validity and patient-proxy agreement of a novel instrument, the Sickness Insight in Coping Questionnaire.

Design:
A cross-sectional design which included two related studies.

Setting:
A single university-affiliated Dutch hospital.

Subjects:
Hospitalized patients (study 1) and ICU-patients and proxies (study 2).

Interventions:
None.

Measurements and Main Results:
Study 1 (n = 103 hospitalized patients) addressed the Sickness Insight in Coping Questionnaire’s performance relative to questionnaires addressing similar content areas. Coping subscales of the BRIEF COPE, Illness Cognition Questionnaire, and Utrecht Coping List were used as comparator measures in testing the construct validity of the Sickness Insight in Coping Questionnaire-subscales (fighting spirit, toughness, redefinition, positivism, and non-acceptance). The Sickness Insight in Coping Questionnaire had good internal consistency (0.64 ≤ α ≤ 0.79), a clear initial factor structure, and fair convergent (0.24 ≤ r ≤ 0.50) and divergent (r, ≤ 0.12) construct validity. Study 2 examined the performance of the Sickness Insight in Coping Questionnaire among 100 ICU patients and their close family members. This study showed that the Sickness Insight in Coping Questionnaire has good structural validity (confirmatory factor analyses with Comparative Fit Index > 0.90 and Root Mean Square Error of Approximation < 0.08) and moderate (r, 0.37; non-acceptance) to strong (r, > 0.50; fighting spirit, toughness, redefinition, and positivism) patient-close proxy agreement.

Conclusions:
Overall, the Sickness Insight in Coping Questionnaire has good psychometric properties. ICU clinicians can use the Sickness Insight in Coping Questionnaire to gain insight in adaptive coping style of patients through ratings of patients or their close family members.
Incidence and Etiology of Potentially Preventable ICU Readmissions*
Authors: Al-Jaghbeer Mohammed J. , Tekwani Seema S. , Gunn Scott R. , Kahn Jeremy M. 
Published: April 2016

Objectives:
The rate of unplanned ICU readmissions is often considered a measure of hospital performance. However, the degree to which these readmissions are preventable and the causes of preventable readmissions are unknown, creating uncertainty about the feasibility and value of reducing ICU readmission rates. To inform this issue, we sought to determine the frequency and underlying causes of potentially preventable ICU readmissions.

Design:
Retrospective cohort study.

Setting:
Urban, academic medical center in the mid-Atlantic United States.

Patients:
Adult patients discharged alive from their first ICU admission with an unplanned readmission within 48 hours of discharge.

Measurements and Main Results:
Each patient’s medical chart was reviewed by two independent investigators who rated each readmission’s preventability according to standardized scale and assessed the etiology of both preventable and nonpreventable readmissions. We assessed concordance between raters using the κ statistic and resolved disagreements through iterative discussion. Of 136 readmissions in the final analysis, 16 (11.8%; 95% CI, 6.9–18.4) were considered preventable and 120 (88.2%; 95% CI, 81.5–93.1) were considered nonpreventable. Of nonpreventable readmissions, 67 were due to a new clinical problem and 53 were due to an existing clinical problem. Among preventable readmissions, six were attributable to system errors, six were attributable to management errors, two were attributable to procedural events, one was attributable to a diagnostic error, and one was attributable to a medication error. Compared to nonpreventable readmissions, preventable readmissions tended to have shorter index ICU lengths of stay (2 vs 3 d; p = 0.05) and a shorter duration of time on the ward prior to readmission (16.6 vs 23.6 hr; p = 0.05).

Conclusions:
The majority of early ICU readmissions are nonpreventable, raising important concerns about ICU readmission rates as a measure of hospital performance.
Coping as a Multifaceted Construct: Associations With Psychological Outcomes Among Family Members of Mechanical Ventilation Survivors
Authors: Nadig Nandita , Huff Nidhi G. , Cox Christopher E. , Ford Dee W. 
Published: April 2016

Objectives:
To develop and evaluate a preliminary multifaceted model for coping among family members of patients who survive mechanical ventilation.

Design and Setting:
In this multicenter cross-sectional survey, we interviewed family members of mechanically ventilated patients at the time of transfer from the ICU to the hospital ward. We constructed a theoretic model of coping that included characteristics attributable to family members, family-clinician rapport, and patients. We then explored relationships between coping factors and symptoms of psychological distress (anxiety, depression, and posttraumatic stress).

Subjects:
Fifty-six family members of survivors of mechanical ventilation.

Measurements and Main Results:
Psychological distress measured by the Hospital Anxiety and Depression Scale and Posttraumatic Stress Scale. Optimism measured using the Life Orientation Test scale, resiliency by Conner-Davidson Resilience Scale, and social support using the Patient Reported Outcomes Measurement Information System inventory. Family members had moderate levels of psychological distress with median total Hospital Anxiety and Depression Scale equal to 14 (interquartile range, 5–20) and Posttraumatic Stress Scale equal to 22 (interquartile range, 15–31). Among family member characteristics, greater optimism (p = 0.001, Hospital Anxiety and Depression Scale; p = 0.010, Posttraumatic Stress Scale), resilience (p = 0.012, Hospital Anxiety and Depression Scale), and social support (p = 0.013, Hospital Anxiety and Depression Scale) were protective against psychological distress. On the contrary, characteristics of family-clinician rapport such as communication quality and presence of conflict did not have any associations with psychological distress.

Conclusion:
To our knowledge, this is the first study to explore coping as a multifaceted construct and its relationship with family psychological outcomes among survivors of mechanical ventilation. We found certain family characteristics of coping such as optimism, resilience, and social support to be associated with less psychological distress. Further research is warranted to identify potentially modifiable aspects of coping that might guide future interventions.