Author Interviews, Critical Care - Intensive Care - ICUs, JAMA, Mental Health Research, Outcomes & Safety / 16.07.2019

MedicalResearch.com Interview with: MedicalResearch.com Interview with: Regis Goulart Rosa, MD, PhD Responsabilidade Social - PROADI Hospital Moinhos de Vento MedicalResearch.com: What is the background for this study? Response: The debate about visiting policies in adult ICUs is of broad and current interest in critical care, with strong advocacy in favour of flexible family visitation models in order to promote patient- and family-centred care. However, the proportion of adult ICUs with unrestricted visiting hours is very low. Data from the literature show that 80% of hospitals in the United Kingdom and USA adopt restrictive ICU visiting policies. Among ICUs with restrictive visiting hours, published studies show that the daily visiting time ranges from a median of 1 hour in Italy to a mean of 4.7 hours in France. In agreement with this scenario, most adult ICUs in Brazil follow a restrictive visitation model, in which family members are allowed to visit the critically ill patient from 30 minutes to 1 hour, once or twice a day. These restrictive visitation models have been justified by the theoretical risks associated with unrestricted visiting hours, mainly infectious complications, disorganization of care, and burnout. Controversially, these risks have not been consistently confirmed by the scarce literature on the subject, and flexible ICU visiting hours have been proposed as a means to prevent delirium among patients and improve family satisfaction. MedicalResearch.com: What are the main findings? Response: Disappointingly, studies evaluating the effectiveness and safety of flexible ICU visiting hours are scarce. To date, no large randomized trials have assessed the impact of a flexible visiting model on patients, family members, and ICU staff, and this evidence gap may constitute a barrier to the understanding of the best way to implement and improve ICU visiting policies. In the present pragmatic cluster-randomized crossover trial (The ICU Visits Study), we engaged 1,685 patients, 1,295 family members, and 826 ICU professionals from 36 adult ICUs in Brazil to compare a flexible visitation model (12 hours/day plus family education) vs. the standard restricted visitation model (median 90 minutes per day). We found that the flexible visitation did not significantly reduce the incidence of delirium among patients, but was associated with fewer symptoms of anxiety and depression and higher satisfaction with care among family members in comparison to the usual restricted visitation. Also, the flexible visitation did not increase the incidence of ICU-acquired infections and ICU staff burnout, which are major concerns when adopting this intervention. MedicalResearch.com: What should readers take away from your report? Response: Considering the evidence suggesting that most adult ICUs restrict the presence of family members, our results provide useful and relevant information that may influence the debate about current ICU visitation policies around the world. First, a flexible visitation policy that permits flexible family visitation in ICU (up to 12 hour per day) is feasible, given the high adherence of participant ICUs to implementation in The ICU Visits Study. Second, the flexible family supported by family education is safe regarding the occurrence of infections, disorganization of care or staff burnout. Third, family members - a commonly missing piece of the critical care puzzle - seem to benefit from the flexible visitation model through higher satisfaction with care and less symptoms of anxiety and depression. MedicalResearch.com: What recommendations do you have for future research as a result of this work? Response: Future research might focus on the following topics: 1) methods of implementation of flexible visiting models in ICUs; 2) Family support interventions in the context of flexible ICU visiting hours (e.g.: psychological and social support, support for shared decision making, peer support, and comfort); and 3) How flexible ICU visiting hours affects patient, family member and staff outcome at long-term. Disclosures: The ICU Visits study was funded by the Brazilian Ministry of Health through the Brazilian Unified Health System Institutional Development Program (PROADI-SUS). Citation: Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit [wysija_form id="3"] [last-modified] The information on MedicalResearch.com is provided for educational purposes only, and is in no way intended to diagnose, cure, or treat any medical or other condition. Always seek the advice of your physician or other qualified health and ask your doctor any questions you may have regarding a medical condition. In addition to all other limitations and disclaimers in this agreement, service provider and its third party providers disclaim any liability or loss in connection with the content provided on this website.Regis Goulart Rosa, MD, PhD Responsabilidade Social - PROADI Hospital Moinhos de Vento  MedicalResearch.com: What is the background for this study? Response: The debate about visiting policies in adult ICUs is of broad and current interest in critical care, with strong advocacy in favour of flexible family visitation models in order to promote patient- and family-centred care. However, the proportion of adult ICUs with unrestricted visiting hours is very low. Data from the literature show that 80% of hospitals in the United Kingdom and USA adopt restrictive ICU visiting policies. Among ICUs with restrictive visiting hours, published studies show that the daily visiting time ranges from a median of 1 hour in Italy to a mean of 4.7 hours in France. In agreement with this scenario, most adult ICUs in Brazil follow a restrictive visitation model, in which family members are allowed to visit the critically ill patient from 30 minutes to 1 hour, once or twice a day. These restrictive visitation models have been justified by the theoretical risks associated with unrestricted visiting hours, mainly infectious complications, disorganization of care, and burnout. Controversially, these risks have not been consistently confirmed by the scarce literature on the subject, and flexible ICU visiting hours have been proposed as a means to prevent delirium among patients and improve family satisfaction. 
Author Interviews, Brain Injury, Columbia, Critical Care - Intensive Care - ICUs, NEJM, Neurology / 27.06.2019

MedicalResearch.com Interview with: [caption id="attachment_49981" align="alignleft" width="134"]Jan Claassen, MD, PhD, FNCS Associate Professor of Neurology Division of Division of Critical Care and Hospitalist Neurology Columbia University Medical Center Dr. Claassen[/caption] Jan Claassen, MD, PhD, FNCS Associate Professor of Neurology Division of Division of Critical Care and Hospitalist Neurology Columbia University Medical Center MedicalResearch.com: What is the background for this study? What are the main findings? Response: Unconsciousness is common and predicting recovery is challenging – often inaccurate. Many patients do not show movements on commands and typically this is interpreted as unconsciousness. Some of these patients may be able to have brain response to these commands raising the possibility of some preservation of consciousness. This has previously been shown months or years after the injury mostly using MRI. We were able to detect this activation at the bedside in the ICU shortly after brain injury. For this we applied machine learning to the EEG to distinguish the brain’s responses to commands. Patients that showed this activation were more likely to follow commands prior to discharge and had better outcomes one year later. 
Annals Internal Medicine, Author Interviews, Critical Care - Intensive Care - ICUs, Infections, University of Pittsburgh / 15.05.2019

MedicalResearch.com Interview with: [caption id="attachment_49126" align="alignleft" width="160"]Minh-Hong Nguyen, MDInfectious DiseasesProfessor of MedicineDirector, Transplant Infectious DiseasesDirector, Antimicrobial Management ProgramDepartment of Medicine University of Pittsburgh School of Medicine Dr, Minh-Hong Nguyen[/caption] Minh-Hong Nguyen, MD Infectious Diseases Professor of Medicine Director, Transplant Infectious Diseases Director, Antimicrobial Management Program Department of Medicine University of Pittsburgh School of Medicine MedicalResearch.com: What is the background for this study? What are the main findings?  Response: Blood cultures, the gold standard for diagnosing blood stream infections, are insensitive and limited by prolonged time to results. Early institution of appropriate antibiotics is a crucial determinant of improved outcomes in patients with sepsis and blood stream infections (BSI). For these reasons, development of rapid non-culture diagnostic tests for blood stream infections is a top priority. The T2Bacteria panel is the first direct from blood, non-culture test cleared by FDA for diagnosis of blood stream infections .  It detects within 4-6 hours the 5 most common ESKAPE bacteria that are frequent causes of hospital infection, and which are often multi-drug resistant.  This study shows that the T2Bacteria panel rapidly and accurately diagnosed and identified ESKAPE bacterial BSIs, and identified probable and possible BSIs that were missed by blood cultures (in particular among patients who were already receiving antibiotics).
Accidents & Violence, Author Interviews, Emergency Care, NEJM, University Texas / 27.03.2019

MedicalResearch.com Interview with: [caption id="attachment_48175" align="alignleft" width="200"]Jeffrey Howard, PhDAssistant ProfessorDepartment of Kinesiology, Health and NutritionUniversity of Texas at San AntonioSan Antonio, TX 78249 Dr. Howard[/caption] Jeffrey Howard, PhD Assistant Professor Department of Kinesiology, Health and Nutrition University of Texas at San Antonio San Antonio, TX 78249 MedicalResearch.com: What is the background for this study? Response:  There is a saying that “the only winner in war is medicine”, which is the first sentence in the article.  The point of that quote is that many medical advances over the last 500 years or more have been learned or propagated as a result of war. With that as the backdrop, the purpose of our study was to provide a more comprehensive assessment of the trauma system than previous work.  We accomplished this by compiling the most complete data to-date on the conflicts, using data from both Afghanistan and Iraq, and analyzing multiple interventions/policy changes simultaneously rather than in isolation.  Previous work had focused primarily on single interventions and within more narrow timeframes.  We wanted to expand the scope to include multiple interventions and encompass the entirety of the conflicts through the end of 2017. 
Author Interviews, Brigham & Women's - Harvard, Critical Care - Intensive Care - ICUs, End of Life Care, JAMA / 21.03.2019

MedicalResearch.com Interview with: Joanna Paladino, MD Director of Implementation, Serious Illness Care Program | Ariadne Labs Brigham and Women's Hospital | Harvard T.H. Chan School of Public Health Palliative Care | Dana-Farber Cancer Institute Instructor | Harvard Medical School and Dr. Rachelle Bernacki MD MS Director of Quality Initiatives Psychosocial Oncology and Palliative Care Senior Physician, Assistant Professor of Medicine Harvard Medical School Dr. Paladino's responses: MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Paladino: People living with serious illness face many difficult decisions over the course of their medical care. These decisions, and the care patients receive, should be guided by what matters most to patients, including their personal values, priorities, and wishes. These conversations don’t often happen in clinical practice or do so very late in the course of illness, leaving patients exposed to getting care they don’t want. Doctors and nurses want to have these important discussions, but there are real challenges, including insufficient training and uncertainties about when and how to start the conversation. We designed an intervention with clinical tools, clinician training, and systems-changes to address these challenges. When tested in a randomized clinical trial in oncology, we found that the intervention led to more, earlier, and better conversations between oncology clinicians and their patients with life-limiting cancer. These findings demonstrate that it is possible to ensure reliable, timely, and patient-centered serious illness conversations in an outpatient oncology practice.
Author Interviews, Brigham & Women's - Harvard, Critical Care - Intensive Care - ICUs, Infections, JAMA / 12.03.2019

MedicalResearch.com Interview with: [caption id="attachment_47886" align="alignleft" width="125"]Chanu Rhee, MD,MPHAssistant Professor of Population MedicineHarvard Medical School / Harvard Pilgrim Health Care InstituteAssistant Hospital EpidemiologistBrigham and Women’s Hospital Dr. Rhee[/caption] Chanu Rhee, MD,MPH Assistant Professor of Population Medicine Harvard Medical School / Harvard Pilgrim Health Care Institute Assistant Hospital Epidemiologist Brigham and Women’s Hospital  MedicalResearch.com: What is the background for this study? Response: Sepsis is the body’s reaction to a serious infection that results a cascade of inflammation in the body and organ dysfunction, such as low blood pressure, confusion, or failure of the lungs, kidneys, or liver.   Sepsis is a major cause of death, disability, and cost in the U.S. and around the world.  Growing recognition of this problem has led to numerous sepsis performance improvement initiatives in hospitals around the country.  Some of these efforts have also been catalyzed by high-profile tragic cases of missed sepsis leading to death, which may have contributed to a perception that most sepsis deaths are preventable if doctors and hospitals were only better at recognizing it. However, the extent to which sepsis-related deaths might be preventable with better hospital-based care is unknown.  In my own experience as a critical care physician, a lot of sepsis patients we treat are extremely sick and even when they receive timely and optimal medical care, many do not survive.  This led myself and my colleagues to conduct this study to better understand what types of patients are dying from sepsis and how preventable these deaths might be. 
Author Interviews, Critical Care - Intensive Care - ICUs, Infections, JAMA / 26.12.2018

MedicalResearch.com Interview with: [caption id="attachment_46701" align="alignleft" width="200"]Dr. Jianguo Xu, MD West China Hospital, Sichuan University Chengdu, Sichuan, China West China Hospital Sichuan University[/caption] Dr. Jianguo Xu, MD West China Hospital, Sichuan University Chengdu, Sichuan, China MedicalResearch.com: What is the background for this study? Response: Since the mid-20th century, corticosteroids have been used as adjuvant therapy in the context of sepsis. Although evaluated in numerous randomized clinical trials and meta-analyses, both the safety and efficacy of corticosteroids remain controversial.
Author Interviews, Blood Pressure - Hypertension, Critical Care - Intensive Care - ICUs, Emergency Care, JAMA / 17.12.2018

MedicalResearch.com Interview with:
"intravenous" by thorney torkelson is licensed under CC BY-NC-ND 2.0 <a href="https://creativecommons.org/licenses/by-nc-nd/2.0"> CC BY-NC-ND 2.0</a>Daniel J. Lane PhD
Institute of Health Policy, Management and Evaluation
Dalla Lana School of Public Health, University of Toronto
Rescu, Li Ka Shing Knowledge Institute, St Michael’s Hospital
Toronto, Ontario, Canada

MedicalResearch.com:  What is the background for this study?  What are the main findings?

Response: Early resuscitation and early antibiotics have become the mainstay treatment for patients with sepsis. The time to initiation of these treatments is thought to be an important factor in patients surviving their disease; however, the independent benefits or harms of intravenous fluid resuscitation, in particular a more aggressive versus more conservative approach to this therapy, remains difficult to evaluate given the concurrent use of these therapies in hospital.

To gain a better understanding of this treatment independent of antibiotic use, we assessed intravenous fluid resuscitation by paramedics on the in-hospital mortality of patients with sepsis. By accounting for the interaction between initial systolic blood pressure and the treatment, we found that earlier resuscitation by paramedics was associated with decreased mortality in patients with low initial blood pressures but not associated with mortality for patients with normal or higher initial blood pressures. 

Author Interviews, Cost of Health Care, Critical Care - Intensive Care - ICUs, Electronic Records, JAMA / 03.11.2018

MedicalResearch.com Interview with: [caption id="attachment_45715" align="alignleft" width="150"]Deborah D. Gordon, MBA Mossavar-Rahmani Center for Business and Government Harvard Kennedy School Cambridge, Massachusetts Deborah  Gordon[/caption] Deborah D. Gordon, MBA Mossavar-Rahmani Center for Business and Government Harvard Kennedy School Cambridge, Massachusetts MedicalResearch.com: What is the background for this study? What are the main findings? Response: Against the backdrop of rising health care costs, and the increasing share of those costs that consumers bear, studies show people are interested in finding health care cost information and engaging with their providers on issues of cost. We were interested in learning to what extent, if any, discussion or consideration of cost would be documented in electronic health records. Using machine learning techniques to extract data from unstructured notes, we examined 46,146 narrative clinical notes from ICU admissions. We found that approximately 4% of admissions had at least one note with financially relevant content. That financial content included documentation of cost as a barrier to adhering to treatment prior to admission, and as a consideration in treatment and discharge planning.   
Author Interviews, Cognitive Issues, Critical Care - Intensive Care - ICUs, NEJM, Vanderbilt / 31.10.2018

MedicalResearch.com Interview with: [caption id="attachment_45592" align="alignleft" width="160"]Brenda Truman Pun, DNP, RN Program Clinical Manager Vanderbilt University Medical Center Dr. Truman Pun[/caption] Brenda Truman Pun, DNP, RN Program Clinical Manager Vanderbilt University Medical Center MedicalResearch.com: What is the background for this study? Response: Delirium is a serious problem in Intensive Care Units around the world. Approximately 80% of mechanically ventilated patients develop delirium, acute confusion, while in the ICU. Once thought to be a benign side effect of the ICU environment, research now shows that delirium is linked to a myriad of negative outcomes for patients which include longer ICU and Hospital stays, prolonged time on the ventilator, increased cost, long-term cognitive impairment and even mortality. For a half a century clinicians have been using haloperidol, an typical antipsychotic, to treat delirium in the ICU. However, there has never been evidence to support the use of haloperidol or its pharmacologic cousins, the atypical antipsychotics, to treat delirium. These drugs have serious side effects that include heart arrhythmias, muscle spasms, restlessness and are associated with increased mortality when given for prolonged periods in the outpatient settings leading to a black box warning for their use in this setting. The MIND-USA study was a double blind placebo controlled trial which evaluated the efficacy and safety of antipsychotics (i.e., haloperidol and ziprasidone) in the treatment delirium in adult ICU patients.  
Author Interviews, Brain Injury, Heart Disease, JAMA, Neurology / 31.10.2018

MedicalResearch.com Interview with: [caption id="attachment_45585" align="alignleft" width="133"]Dr-Marion Moseby-Knappe Dr. Moseby-Knappe[/caption] Marion Moseby-Knappe, MD Neurologist and Researcher Center for Cardiac Arrest at Lund University and Skane University Hospital Lund, Sweden MedicalResearch.com: What is the background for this study? What are the main findings? Response: Our research focuses on improving methods for examining unconscious patients treated on intensive care units after cardiac arrest. If a patient does not wake up within the first days after cardiac arrest, physicians need to evaluate how likely it is that the patient will awaken at all and to which extent there is brain injury. According to European and American guidelines, decisions on further medical treatment of cardiac arrest patients should always be based on a combination of examinations and not only one single method. Various methods are combined when assessing the patient such as examining different neurologic reflexes, head scans (computed tomography or magnetic resonance imaging), other specialist examinations (electroencephalogram or somatosensory evoked potentials) or blood markers. Our research focuses on patients included in the largest cardiac arrest trial to date, the Targeted Temperature Management after Out-of-Hospital Cardiac Arrest (TTM) Trial.
Author Interviews, Brain Injury, Critical Care - Intensive Care - ICUs, JAMA / 25.10.2018

MedicalResearch.com Interview with: [caption id="attachment_45433" align="alignleft" width="200"]Jamie Cooper AO BMBS MD FRACP FCICM FAHMS Professor of Intensive Care Medicine Monash University Deputy Director & Head of Research,  Intensive Care & Hyperbaric Medicine The Alfred, Melbourne Prof. Cooper[/caption] Jamie Cooper AO BMBS MD FRACP FCICM FAHMS Professor of Intensive Care Medicine Monash University Deputy Director & Head of Research, Intensive Care & Hyperbaric Medicine The Alfred, Melbourne MedicalResearch.com: What is the background for this study? Response: 50-60 million people each year suffer a traumatic brain injury (TBI) . When the injury is severe only one half are able to live independently afterwards. Cooling the brain (hypothermia) is often used in intensive care units for decades to  decrease inflammation and brain swelling and hopefully to improve outcomes, but clinical staff have had uncertainty whether benefits outweigh complications. We conducted the largest randomised trial of hypothermia in TBI, in 500 patients, in 6 countries, called POLAR. We started cooling by ambulance staff, to give hypothermia the best chance to benefit patients. We continued for 3-7 days in hospital ind ICU. We measured functional outcomes at 6 months.
Author Interviews, Critical Care - Intensive Care - ICUs, Mental Health Research, NEJM, Vanderbilt / 24.10.2018

MedicalResearch.com Interview with: [caption id="attachment_45381" align="alignleft" width="133"]Eugene Wesley Ely, M.D. Dr. E. Wesley Ely is a Professor of medicine at Vanderbilt University School of Medicine with subspecialty training in Pulmonary and Critical Care Medicine. Dr. Ely
Photo: Anne Rayner, VU[/caption] Eugene Wesley Ely, M.D. Dr. E. Wesley Ely is a Professor of medicine at Vanderbilt University School of Medicine with subspecialty training in Pulmonary and Critical Care Medicine.  MedicalResearch.com: What is the background for this study? Response: Critically ill patients are not benefitting from antipsychotic medications that have been used to treat delirium in intensive care units (ICUs) for more than four decades, according to a study released today in the New England Journal of Medicine. Each year, more than 7 million hospitalized patients in the United States experience delirium, making them disoriented, withdrawn, drowsy or difficult to wake. The large, multi-site MIND USA (Modifying the INcidence of Delirium) study sought to answer whether typical and atypical antipsychotics — haloperidol or ziprasidone —affected delirium, survival, length of stay or safety. Researchers screened nearly 21,000 patients at 16 U.S. medical centers. Of the 1,183 patients on mechanical ventilation or in shock, 566 became delirious and were randomized into groups receiving either intravenous haloperidol, ziprasidone or placebo (saline).
Author Interviews, Critical Care - Intensive Care - ICUs, Emergency Care / 17.10.2018

MedicalResearch.com Interview with: [caption id="attachment_45264" align="alignleft" width="128"]Dr Anne Kristine Servais Iversen, Anne Kristine Servais Iversen Department of Obstetrics and Gynecology Rigshospitalet Copenhagen, Denmark  Dr. Servais Iversen[/caption] Dr Anne Kristine Servais Iversen, Anne Kristine Servais Iversen Department of Obstetrics and Gynecology Rigshospitalet Copenhagen, Denmark  MedicalResearch.com: What is the background for this study? What are the main findings? Response: Systematic triage has been implemented worldwide with different triage scales in use all over the world. Prior to the introduction of formalised triage, patients were prioritised based on clinical assumption. After the introduction of formalised triage only a few studies have assessed agreement between formal and informal triage. Additionally, the majority of formalised triage scales are supported by limited and often insufficient evidence. This is troublesome since formalised triage forces clinicians to follow an algorithm rather than use their experience and clinical judgement. During my own residency at a Danish Emergency ward I was often contacted by the nurse performing formalised triage telling me that a patient she was assessing scored to be very acute (high triage level), but that she didn’t believe that to be the case. In order for her to prioritise the patient to a lower (less acute) triage level the patient had to be assessed by a doctor. Very often my colleagues and I would agree with the nurse in that the scoring was to high, and we therefore had to overrule the formalised triage decision. In cases like these you ask yourself whether or not we are using the most effective and best form of triage for initial patient sorting. Our study found that agreement between formalised triage and a quick clinical assessment in the form of Eyeball triage is poor. It also suggest that eyeball triage better predicts those at highest risk of death within 48-hours and 30 days after assessment.
Author Interviews, Critical Care - Intensive Care - ICUs, Infections, Urinary Tract Infections / 09.10.2018

MedicalResearch.com Interview with: [caption id="attachment_45084" align="alignleft" width="142"]Thomas P. Lodise Jr., PharmD, PhD Clinical Pharmacist at the Stratton VA Medical Center in Albany, NY Albany College of Pharmacy and Health Sciences Albany, NY Dr. Lodise[/caption] Thomas P. Lodise Jr., PharmD, PhD Clinical Pharmacist at the Stratton VA Medical Center in Albany, NY Albany College of Pharmacy and Health Sciences Albany, NY MedicalResearch.com: What is the background for this study? How does Ceftolozane/Tazobactam differ from other antibiotics for serious Gram-negative infections including Pseudomonas aeruginosa? Response: Treatment of patients with Gram-negative infections is increasingly difficult due to rising resistance to commonly used agents. Ceftolozane/tazobactam (C/T) is a potent anti-pseudomonal agent with broad Gram-negative coverage that is indicated for complicated urinary tract infections (cUTI) and complicated intra-abdominal infections (cIAI) and is currently being studied for ventilated nosocomial pneumonia. C/T differs from other antibiotics in terms of its potency against multi-drug resistant Pseudomonas aeruginosa, one of the most concerning and difficult-to-treat Gram-negative pathogens. This study evaluates C/T in a large database of US hospitals to better understand treatment patterns and associated outcomes.