Author Interviews, Critical Care - Intensive Care - ICUs, Pharmacology / 17.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21673" align="alignleft" width="200"]Professor Chris Thiemermann Centre for Trauma Sciences Queen Mary University of London Prof. Chris Thiemermann[/caption] Professor Chris Thiemermann Centre for Trauma Sciences Queen Mary University of London Medical Research: What is the background for this study? What are the main findings? Prof. Thiemermann: Trauma is a leading cause of death with five million victims a year. About 40 per cent of trauma deaths are due to hemorrhagic shock, which is when severe blood loss makes it difficult for the heart to pump sufficient blood around the body, leading to multiple organ failure. Multiple organ failure affects one in three severely injured patients, and one in four of those will die.  Those that survive still experience prolonged periods in intensive care, infections and other complications. But despite its catastrophic impact, there are still no specific treatments for organ failure. We’ve now discovered that the drug Artesunate, which has already been used by thousands of people with malaria, is also effective for treating severe haemorrhage and blood loss in rats. Artesunate is based on an ancient Chinese herbal remedy, produced in large quantities in China, and is recommended by the World Health Organization as the treatment of choice for severe malaria. It has also been shown to have anti-cancer, anti-viral and anti-inflammatory effects. My study, which was funded by the Wellcome Trust and the Department of Health, shows that when injured rats were administered Artesunate, the drug had a marked protective impact on organ failure. The drug appears to work by enhancing the protection of organs by reducing the body’s excessive inflammatory response to injury and blood loss, and by activating well-known cell-survival pathways. The lower dose of Artesunate shown in the study to be effective in hemorrhagic shock is identical to the dose used in patients with malaria, many of which also have multiple organ dysfunction.
Author Interviews, Critical Care - Intensive Care - ICUs, PTSD, Vanderbilt / 07.01.2016

[caption id="attachment_20476" align="alignleft" width="133"]Mayur Patel, MD, MPH, FACS Assistant Professor of Surgery & Neurosurgery Vanderbilt University Medical Center Staff Surgeon and Surgical Intensivist Nashville VA Medical Center Dr. Mayur Patel[/caption] MedicalResearch.com Interview with: Mayur Patel, MD, MPH, FACS Assistant Professor of Surgery & Neurosurgery Vanderbilt University Medical Center Staff Surgeon and Surgical Intensivist Nashville VA Medical Center Medical Research: What is the background for this study? Dr. Patel: Post-traumatic stress disorder (PTSD) can occur in patients after the traumatizing events of critical illness. Survivors of critical illness have reported PTSD symptoms months to even years after critical illness, possibly related to nightmare-like experiences, safety restraints creating communication barriers, and protective mechanical ventilation causing feelings of breathlessness and fear of imminent death. But, the epidemiology of PTSD after critical illness is unclear with wide ranging estimates (0-64%) and largely fails to distinguish past PTSD from new PTSD specifically resulting from the critical care experience. Our study provides estimates on new cases of PTSD stemming specifically from the ICU experience. Pre-existing PTSD has rarely been systematically assessed in prior cohorts, and our work took extra effort to distinguish pre-existing PTSD from new PTSD cases. Civilian populations have dominated the literature of PTSD after critical illness, and this research is the first to also include the expanding and aging Veteran population. 
Author Interviews, Critical Care - Intensive Care - ICUs, JAMA, Nutrition / 23.12.2015

[caption id="attachment_20297" align="alignleft" width="110"]Philipp Schuetz, MD, MPH University Department of Medicine Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau, Switzerland Medical Faculty of the University of Basel Basel, Switzerland Dr. Schuetz[/caption] MedicalResearch.com Interview with: Philipp Schuetz, MD, MPH University Department of Medicine Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau, Switzerland Medical Faculty of the University of Basel Basel, Switzerland Medical Research: What is the background for this study? What are the main findings? Dr. Schuetz: Malnutrition is common in hospitalised patients and associated with detrimental metabolic consequences. The current clinical approach is to provide at risk patients nutritional support as a strategy to tackle malnutrition and its associated adverse outcomes. Yet, whether this strategy is effective and improves clinical outcomes in the medical inpatient population is unclear. In addition, recent trials from critical care have shown adverse outcomes when nutritional therapy was used too aggressively. Herein, our metaanalysis is the first to systematically investigate effects of nutritional support in medical inpatients. Our analysis shows that nutritional support is highly effective in increasing energy and protein intake and helps to stabilize weight loss. Also, risk for unplanned readmission after discharge from the hospital was reduced and length of stay was shorter in the patient population with established malnutrition. Yet, for other important clinical outcomes such as mortality and functional outcomes effects of nutritional support remained uncertain. Also, the quality of evidence was found to be moderate to low.
Author Interviews, Cost of Health Care, Critical Care - Intensive Care - ICUs, Johns Hopkins / 26.10.2015

[caption id="attachment_18835" align="alignleft" width="160"]Joseph M Carrington DO, MHA Department of Medicine - PGY3 Johns Hopkins University/Sinai Hospital Dr. Carrington[/caption] MedicalResearch.com Interview with: Joseph M Carrington DO, MHA Department of Medicine - PGY3 Johns Hopkins University/Sinai Hospital Medical Research: What is the background for this study? What are the main findings? Dr. Carrington: This study looked at a total of 886 patients at a community hospital. We were faced with the dilemma that our ICU beds were frequently over utilized with severely ill patients for whom our interventions had minimal impact. This prevented patients who were less ill from coming to the ICU who may have benefited from our services. We made a hospital wide culture change to lower ICU admission thresholds. Any patient felt to be "borderline" received an automatic ICU evaluation without any push-back. The result of these earlier interventions was a decrease in complications from patients decompensating in the ED and floors. In turn, the overall ICU length of stay, mortality, and ICU transfers all decreased. By decreasing these overall complications and mortality, our number of ICU over-utilizes decreased. This saved our hospital an annualized amount of over $2 million and freed up ICU beds and resources.
Author Interviews, Critical Care - Intensive Care - ICUs, NEJM / 05.10.2015

Dr. Paul Jeffrey Young MD Intensive Care Unit, Wellington Regional Hospital Wellington South, New ZealandMedicalResearch.com Interview with: Dr. Paul Jeffrey Young MD Intensive Care Unit, Wellington Regional Hospital Wellington South, New Zealand Medical Research: What is the background for this study? What are the main findings? Response: Fever is a response to infection that is broadly conserved across many animal species and it seems reasonable to presume that the components of the immune response have adapted to function optimally in the physiological febrile range.  We have previously shown that among patients with fever and infection, increasing degrees of fever in the first 24 hours in ICU are generally associated with reducing mortality risk after adjusting for illness severity.  Although acetaminophen (paracetamol) is commonly used to treat fever in the ICU, there are no previous data to demonstrate the safety and efficacy of this practice.  The HEAT trial was designed by a group of ICU clinicians to test the hypothesis that treating fever with acetaminophen in critically ill patients with infections would worsen outcomes, or more specifically that it would reduce the number of days patients spent alive and free from requiring intensive care. Medical Research: What are the main findings? Response: The primary finding was that early administration of acetaminophen to treat fever did not alter the number of ICU-free days in adult ICU patients with infections.  The mortality rates of acetaminophen and placebo patients were similar.  Patients who received acetaminophen had lower body temperature than patients who received placebo and did not have significantly more adverse events.  Acetaminophen use was associated with a shorter ICU stay than placebo among survivors and a longer ICU stay among patients who died.
Author Interviews, Critical Care - Intensive Care - ICUs, JAMA, Pulmonary Disease, University of Michigan / 23.09.2015

Thomas Valley, MD Fellow, Division of Pulmonary and Critical Care University of Michigan Ann Arbor, MIMedicalResearch.com Interview with: Thomas Valley, MD Fellow, Division of Pulmonary and Critical Care University of Michigan Ann Arbor, MI Medical Research: What is the background for this study? What are the main findings? Dr. Valley: There has been dramatic growth in intensive care unit (ICU) use over the past 30 years. As the reasons for this growth are not entirely clear, some have suggested that the ICU is a meaningful source of low-value care. The value of the ICU, however, depends on the net benefit that ICUs provide patients. Prior observational studies assessing the effectiveness of the ICU were limited because patients admitted to the ICU are inherently sicker and more likely to die than patients admitted to the general ward. Given the substantial number of patients with pneumonia who are admitted to an ICU, it is vital to understand whether admission to the ICU is beneficial. In our study of 1.1 million Medicare beneficiaries with pneumonia between 2010 and 2012, we used an instrumental variable, a statistical technique to pseudo-randomize patients based on their proximity to a hospital that uses the ICU frequently for pneumonia, in order to determine whether ICU admission saved lives and at what financial cost. An estimated 13 percent of patients were admitted to the ICU solely because they lived closest to a hospital that used the ICU frequently for pneumonia. Among these patients, ICU admission was associated with a nearly six percent reduction in 30-day mortality compared to general ward admission. In addition, there were no significant differences in hospital costs or Medicare reimbursement between patients admitted to the ICU and to the general ward.
Author Interviews, Critical Care - Intensive Care - ICUs, Infections, Outcomes & Safety / 01.09.2015

Leonard Mermel, DO, ScM, AM (Hon), FSHEA, FIDSA, FACP Professor of Medicine, Warren Alpert Medical School of Brown University Medical Director, Dept. of Epidemiology & Infection Control, Rhode Island Hospital   MedicalResearch.com Interview with: Leonard Mermel, DO, ScM, AM (Hon), FSHEA, FIDSA, FACP  Professor of Medicine, Warren Alpert Medical School of Brown University Medical Director, Dept. of Epidemiology & Infection Control, Rhode Island Hospital Adjunct Clinical Professor, University of Rhode Island College of Pharmacy     Medical Research: What is the background for this study? What are the main findings? Dr. Mermel: Arterial catheters are an under recognized source of hospital-associated bloodstream infection. As a result, arterial catheter infection prevention strategies are less well studied than with central lines.  We did a national survey and our findings reaffirmed the fact that physicians using these catheters underestimate the risk of infection.  Additionally and not surprisingly, infection prevention strategies are variable particularly concerning barrier precautions at insertion. Medical Research: What should clinicians and patients take away from your report? Dr. Mermel: Arterial catheters can cause catheter-related bloodstream infections.  These devices should be aseptically inserted and managed post-insertion and removed as soon as no longer required for patient care.  We are also in need of better studies to clearly delineate the ideal infection prevention strategies with these catheters based on our understanding of the pathogenesis of such infections. 
Author Interviews, Critical Care - Intensive Care - ICUs, Dermatology / 16.06.2015

MedicalResearch.com Interview with: Rémi Coudroy MD CHU de Poitiers, Service de Réanimation Médicale CIC 1402 (ALIVE group), Université de Poitiers, Poitiers, France Medical Research: What is the background for this study? What are the main findings? Dr. Coudroy: Skin mottling is characterized by a red-violaceous discoloration of the skin. Its occurrence, as impaired consciousness and decreased urinary output are well-known clinical signs of shock. Skin mottling has been investigated only in patients with septic shock and recent studies have found that the extent and the persistence of skin mottling for more than 6 hours were associated with mortality. However, in daily clinical practice, we noticed that skin mottling occurred in patients without septic shock, and there was no data supporting the impact of skin mottling on the prognosis of critically ill patients. In a retrospective monocentric observational study over a 1-year period in a 15-bed tertiary medical ICU where skin mottling over the knees is assessed by nurses, we found that skin mottling occurred in 29% of patients admitted to ICU. Nurses’ evaluation of skin mottling was highly reliable. In 60% of cases, mean arterial pressure was ≥ 65 mmHg without vasopressors. The occurrence of skin mottling was associated with mortality independently from calculated severity scores at admission (i.e. Simplified Acute Physiology Score II). Similarly, the persistence of skin mottling for more than 6 hours was associated with mortality independently from organ failure at the onset of skin mottling (i.e. the use of vasopressors, the need for mechanical ventilation and hyperlactatemia).
Author Interviews, Cancer Research, Critical Care - Intensive Care - ICUs, Infections / 12.02.2015

Dr. Cornejo-Juárez Department of Infectious Disease, Instituto Nacional de Cancerología Tlalpan MexicoMedicalResearch.com Interview with: Dr. Cornejo-Juárez Department of Infectious Disease, Instituto Nacional de Cancerología Tlalpan Mexico MedicalResearch: What is the background for this study? Dr. Cornejo: Critically ill patients in the intensive care unit are at major risk of hospital-acquired infections. Immunosuppressed patients have a higher risk related with continuous exposure to the hospital setting, mucositis and disruption of skin integrity, presence of indwelling catheters and abnormal immune system because of primary malignancy or chemotherapy. Our aimed was to investigate prevalence and outcome of hospital-acquired infections in an oncology ICU. MedicalResearch: What are the main findings? Dr. Cornejo: We found that hospital-acquired infections are a major problem in the ICU. Hospital-acquired infections are related with higher mortality. Multidrug resistant bacteria are frequently involved in these infections, and are associated with increased mortality.
Author Interviews, Critical Care - Intensive Care - ICUs, Hospital Acquired, Vanderbilt / 21.01.2015

Michael Noto, MD, PhD Pulmonary and Critical Care Medicine Vanderbilt University Medical CenterMedicalResearch.com Interview with: Michael Noto, MD, PhD Pulmonary and Critical Care Medicine Vanderbilt University Medical Center Medical Research: What is the background for this study? What are the main findings? Dr. Noto: Health care-associated infections are the most common complication for hospitalized patients and several studies have suggested that bathing critically ill patients with the antimicrobial chlorhexidine reduces health care-associated infections.  In the largest study of chlorhexidine bathing to date, however, we were unable to demonstrate a reduction in infections.
Author Interviews, Critical Care - Intensive Care - ICUs, Kidney Disease, University of Pittsburgh / 22.12.2014

MedicalResearch.com Interview with: Florentina E. Sileanu BS Center for Critical Care Nephrology and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center Departments of Critical Care Medicine and Department of Biostatistics, University of Pittsburgh Graduate School of Public Health and Dr. John A. Kellum, MD, MCCM Professor of Medicine, Bioengineering and Clinical & Translational Science Vice Chair for Research Center for Critical Care Nephrology, University of Pittsburgh School of Medicine Pittsburgh, PA Medical Research: What is the background for this study? What are the main findings? Response: Acute Kidney Injury (AKI) affects millions of Americans each year resulting in increased short and long-term complications including need for dialysis and death. Many trials recruiting subjects at risk for AKI have focused on those with other (e.g. cardiovascular and respiratory) organ failures because these patients are at highest for AKI. However, patients without these conditions might not be at low-risk for AKI. We explored whether Acute Kidney Injury occurring as a single organ failure or occurring before other organ failures would be associated with the same outcomes as in sicker patients. Using a large, academic medical center database, with records from July 2000 through October 2008, we identified a "low-risk" cohort as patients without cardiovascular and respiratory organ failures defined as not receiving vasopressor support or mechanical ventilation within the first 24 hours of ICU admission. We were able to show that low-risk patients have a substantial likelihood of developing AKI and that the relative impact on mortality of AKI is actually greater for low-risk patients (OR, 2.99; 95% 2.62-3.41) than for high-risk patients (OR, 1.19; 95% 1.09-1.3).
Author Interviews, Critical Care - Intensive Care - ICUs, NEJM, Nutrition / 26.11.2014

MedicalResearch.com Interview with: Sheila E. Harvey, Ph.D. CTU Manager/Senior Research Fellow ICNARC Napier House London Medical Research: What is the background for this study? Dr. Harvey: The CALORIES trial was set-up in the context of concerns about malnutrition in critically ill patients in NHS hospitals and conflicting evidence as to the optimal route for delivery of early nutritional support to critically ill patients. The enteral route is the mainstay of nutritional support in the critically ill but it is frequently associated with gastrointestinal intolerance and underfeeding. In contrast, the parenteral route, though more invasive and expensive, is more likely to secure delivery of the intended nutrition but has been associated with more risks and complications (e.g. infectious complications) compared with the enteral route. In light of the uncertainty surrounding the most effective route for delivery of early nutritional support and, given recent improvements in the delivery, formulation and monitoring of parenteral nutrition, the UK National Institute of Health Research (NIHR) Health Technology Assessment (HTA) Programme put out a “call” for a large pragmatic randomised controlled trial to be conducted in critically ill patients to determine the optimal route of delivery of early nutritional support. CALORIES was set up to test the hypothesis that early nutritional support delivered via the parenteral route is superior to early nutritional support delivered via the enteral route in adults who had an unplanned admission to an intensive care unit and who could be fed via either route. The primary outcome was all-cause mortality at 30 days. The secondary outcomes included infectious and non-infectious complications (hypoglycaemia, elevated liver enzymes, nausea requiring treatment, abdominal distension, vomiting, new or substantially worsened pressure ulcers).
Author Interviews, Critical Care - Intensive Care - ICUs, Outcomes & Safety / 25.11.2014

Alexandra Laurent Maître de conférences de psychologie clinique et psychopathologie Laboratoire de psychologie EA3188 Université de Franche-ComtéMedicalResearch.com Interview with : Alexandra Laurent Maître de conférences de psychologie clinique et psychopathologie Laboratoire de psychologie EA3188 Université de Franche-Comté Medical Research : What is the background for this study? What are the main findings? Dr. Laurent: Human error among healthcare professionals is a subject of current affairs and especially in ICUs which are among the services with a high risk of error. If the error affects the patient and his/her family, it will also have an impact on the caregivers involved, their colleagues, and even the entire service. In an editorial in the BMJ, Wu introduced the term “the second victim” to define a caregiver implicated in and traumatised by an medical error for which he/she feels personally responsible. Therefore, it’s important to improve understanding of the psychological repercussions of error on professionals in ICUs, and to identify the defense mechanisms used by professionals to cope with errors. In the month following the error, We found that the professionals (doctors and nurses) described feelings of guilt and shame. These feelings were associated with: anxiety states with rumination and fear for the patient; a loss of confidence; an inability to verbalize one’s error; questioning oneself at a professional level; and anger towards the team.
Author Interviews, JAMA, Vitamin D / 01.10.2014

Karin Amrein, MD, MSc Assistant Professor Department of Internal Medicine Division of Endocrinology and Metabolism Medical University of Graz 8036 Graz, AustriaMedicalResearch.com Interview with: Karin Amrein, MD, MSc Assistant Professor Department of Internal Medicine Division of Endocrinology and Metabolism Medical University of Graz 8036 Graz, Austria Medical Research: What are the main findings of the study? Dr. Amrein: This is the first large clinical trial on vitamin D in critical care. In a double-blind, randomized, placebo-controlled clinical trial, a population of mixed adult ICU patients with vitamin D deficiency (defined as 25-hydroxyvitamin D [25(OH)D] level ≤ 20ng/ml) was assigned to receive either vitamin D3 or placebo. We used a high loading dose of vitamin D3 followed by monthly maintenance doses of 90,000 IU for a total of 5 months. Because of a substantially increased risk for skeletal complications below 12ng/ml of 25-hydroxyvitamin D, we used this threshold for a predefined subgroup analysis. Overall, high-dose vitamin D3 compared with placebo did not reduce hospital length of stay (primary endpoint), intensive care unit (ICU) length of stay, hospital mortality, or 6 month-mortality
Author Interviews, CHEST, Critical Care - Intensive Care - ICUs, Ebola, General Medicine / 29.08.2014

The American College of Chest Physicians released an expert consensus statement, Care of the Critically Ill and Injured During Pandemics and Disasters while the global health-care community cares for patients with the Ebola virus.Three of the authors discussed this important statement with MedicalResearch.com. Asha V. Devereaux, MD, MPH Sharp Hospital, Coronado, CAAsha V. Devereaux, MD, MPH Sharp Hospital Coronado, CA Jeffrey R. Dichter, MD Allina Health, Minneapolis, MN, and Aurora Health, Milwaukee, WIJeffrey R. Dichter, MD Allina Health, Minneapolis, MN and Aurora Health, Milwaukee, WI   Niranjan Kissoon, MBBS, FRCP(C) BC Children's Hospital and Sunny Hill Health Centre University of British Columbia, Vancouver, CanadaNiranjan Kissoon, MBBS, FRCP(C) BC Children's Hospital and Sunny Hill Health Centre University of British Columbia, Vancouver, Canada Medical Research: What are the main ethical concerns and criteria for evaluating who may be eligible for treatment during a pandemic or disaster? Dr. Asha Devereaux: The main ethical concerns regarding eligibility for treatment during a pandemic will be access to limited or scarce resources. Who should get treatment and who decides will be some significant questions whenever there is a scarcity of healthcare resources. Transparency and the fairness of the ethical framework for decision-making will need to be made public and updated based upon the changing dynamics of resources and disease process. Dr. Niranjan Kissoon: There is work to be done in this area and engagement of citizens, government, medical community, ethicists and legal experts in the process is important.
Author Interviews, Critical Care - Intensive Care - ICUs, JAMA, Nutrition, Protein / 10.10.2013

Zudin Puthucheary MBBS B.Med.Sci D.UHM EDICM MRCP FHEA NIHR Research Fellow, Respiratory and Critical Care Institute of Health and Human Performance, UCL Post-CCT Fellow in Trauma and Critical Care, Kings College HospitalMedicalResearch.com Interview with: Zudin Puthucheary MBBS B.Med.Sci D.UHM EDICM MRCP FHEA NIHR Research Fellow, Respiratory and Critical Care Institute of Health and Human Performance, UCL Post-CCT Fellow in Trauma and Critical Care, Kings College Hospital MedicalResearch.com: What are the main findings of the study? Answer: That muscle wasting occurs rapidly and early in critical illness, with up to 2-3% loss of muscle mass per day. This is related to the numbers of organs failed, and is made worse by the degree of acute lung injury, and increased protein delivery. Muscle wasting is the result of both decreased muscle protein synthesis and increased muscle protein breakdown. In addition 40% of these patients developed muscle necrosis over the study period.
Author Interviews, Cost of Health Care, Critical Care - Intensive Care - ICUs, JAMA / 11.09.2013

Thanh N. Huynh, MD, MSHS Clinical Instructor UCLA Division of Pulmonary Critical CareMedicalResearch.com Interview with: Thanh N. Huynh, MD, MSHS Clinical Instructor UCLA Division of Pulmonary Critical Care MedicalResearch.com: What are the main findings of the study? Dr. Huynh: Our study shows that it is common for ICU doctors to recognize that futile treatment is provided to patients who cannot benefit from it.  In our study, 11% of ICU patients were perceived as receiving futile treatment.  The outcomes of these 123 patients were uniformly poor, with 85% dying within 6 months.  Advances in critical care medicine has allowed us to save lives, but it has also allowed us provide aggressive life-sustaining treatments that may not benefit all patients.  When aggressive treatment is poorly matched with a patient’s prognosis, doctors will consider such treatment as futile and our study shows that this is not an uncommon occurrence in our health system.