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•Serious illness communication is pivotal in delivering surgical critical care (SCC).•Limited educational strategies exist for SCC fellows, who often lead decision-making.•Implementation of a multimodal training session tailored for fellows is effective.•Training boosted immediate and long-term confidence in complex communication skills.•Concerted efforts are warranted to integrate training into national curriculums.

Baricitinib and dexamethasone have randomised trials supporting their use for the treatment of patients with COVID-19. We assessed the combination of baricitinib plus remdesivir versus dexamethasone plus remdesivir in preventing progression to mechanical ventilation or death in hospitalised patients with COVID-19.

Artificial prosthetic material used in vascular grafting is known to be thrombogenic, or capable of generating clot formation. It is theorized that by lining the artificial vascular graft with endothelial cells, which have dominant anticoagulant properties, the incidence of clot formation may be reduced. There is incomplete documentation concerning the use of this process in humans. A case is described of a patient who had implantation of a Dacron vascular graft lined with microvascular endothelial cells, which were obtained from her own fat tissue. Although the patient had a postoperative wound infection, she recovered from the surgery. Nine months following artificial graft implantation the patient again required surgery because of mechanical narrowing of the graft due to external pressure on it. During surgery the flattened portion of the graft was removed and replaced by an externally supported graft. Biopsies taken at surgery revealed leiomyosarcoma, as well as cancer of the liver. The graft remained open and the patient was discharged from the hospital. Laboratory examination of the portion of the graft which was removed confirmed the presence of endothelium on the internal surface. The areas of endothelialized graft were free of thrombus. This case demonstrates that the body's response to the artificial graft was altered by the endothelial cell lining. These findings suggest that endothelialization of an artificial vascular graft may result in a durable, non-thrombogenic surface. (Consumer Summary produced by Reliance Medical Information, Inc.)

Purpose To determine if earlier initiation of renal replacement therapy (RRT) is associated with improved survival in patients with severe acute kidney injury.Methods We performed a retrospective case–control study of propensity-matched groups with multivariable logistic regression using Akaike Information Criteria to adjust for non-matched variables in a surgical ICU in a tertiary care hospital.Results We matched 169 of 205 (82%) patients with new initiation of RRT (EARLY group) to 169 similar patients who did not initiate RRT on that day (DEFERRED group). Eighteen (11%) of DEFERRED eventually received RRT before discharge. By univariate analysis, ICU mortality was higher in EARLY (n = 60 (36%) vs. n = 23 (14%), p< 0.001) as was hospital mortality (n = 73 (43%) vs. n = 44 (26%), p= 0.001). Of the 18 RRT patients in DEFERRED, 12 (67%) died in ICU and 13 (72%) in hospital. After propensity matching and logistic regression, we found that EARLY initiation of RRT was associated with a more than doubling of ICU mortality (aOR = 2.310, 95% confidence interval = 1.254–4.257, p= 0.007). However, after similar adjustment, there was no difference in hospital mortality (aOR = 1.283, 95% CI = 0.753–2.186, p= 0.360).Conclusions While ICU mortality was increased in the EARLY group, there was no difference in hospital mortality between EARLY and DEFERRED groups.

The Michigan Trauma Quality Improvement Program (MTQIP) is a collaborative quality initiative sponsored by Blue Cross Blue Shield of Michigan and Blue Care Network (BCBSM/BCN). The MTQIP benchmark reports identified our trauma center as a high outlier for venous thromboembolism (VTE) episodes. This study outlines the performance improvement (PI) process used to reduce the rate of VTE using MTQIP infrastructure.

Surgical palliative care (PC) facilitates communication between surgeons and patients/family about prognosis, symptom control, and therapeutic goals. Surgical critical care (SCC) fellows are at the forefront of the intensive care team; thus, we aim to assess previous and ongoing experiences in delivering PC by surveying fellows at a large academic center. Seventeen surveys were completed in which 59% of fellows reported no previous PC education. Six fellows (35%) reported participating in goals of care/end-of-life (GOC/EOL) discussions “a few times a year” during residency, while 41% responded the same for transitioning patients to comfort-focused care (CFC). When asked if respondents felt comfortable facilitating GOC/EOL discussions prior to fellowship, 7 (41%) answered “disagree” or “strongly disagree.” Most fellows reported that more training in navigating GOC/EOL discussions (88%) and transitioning patients to CFC (76%) is needed. This assessment demonstrates variability in fellows’ prior PC exposure and a strong desire for more structured training.

Infection with influenza virus causes substantial morbidity and mortality globally, although antiviral treatments are available. Previous studies have suggested that anti-influenza immune plasma could be beneficial as treatment, but they were not designed as randomised, blinded, placebo-controlled trials. Therefore, we aimed to prospectively evaluate the clinical efficacy of high-titre immune plasma compared with standard low-titre plasma to improve outcomes in patients with severe influenza A infection.

An association between increased venous thromboembolism (VTE) events and influenza A H1N1 (H1N1) was noted in the first 10 patients with severe acute respiratory distress syndrome (ARDS). An empirical systemic anticoagulation protocol (heparin intravenous infusion) was initiated when autopsy of patients with severe hypoxemia confirmed multiple primary pulmonary thrombi and emboli. The purpose of this study was to examine the relationship between H1N1 and VTE events and to assess the efficacy of empirical systemic heparin anticoagulation in preventing VTE and death in H1N1 severe ARDS patients.

Influenza causes substantial morbidity and mortality despite available treatments. Anecdotal reports suggest that plasma with high antibody titres to influenza might be of benefit in the treatment of severe influenza.

Pulmonary aspiration is an important recognized cause of ARDS. Better characterization of patients who aspirate may allow identification of potential risks for aspiration that could be used in future studies to mitigate the occurrence of aspiration and its devastating complications.

The oxygenation index (mean airway pressure × FIO2divided by PaO2) was originally devised to measure severity of illness and predict outcome in neonatal respiratory failure. We evaluated the discrimination of a modified oxygenation index (modified with age) for predicting 28-day mortality in adults with respiratory failure (adult respiratory distress syndrome ARDS) using the ALVEOLI section of the ARDSNet database and validated the results in the full ARDSNet database.

Objective:To review the current literature on the efficacy and safety of serotonin norepinephrine reuptake inhibitors in the treatment of attention-deficit hyperactivity disorder (ADHD) in the pediatric population. Data Sources:A literature search from 1996 to August 2013 was conducted using MEDLINE, CINAHL, and EMBASE databases. Search terms included attention-deficit hyperactivity disorder, serotonin norepinephrine reuptake inhibitor, pediatric attention-deficit hyperactivity disorder, venlafaxine, duloxetine, desvenlafaxine, milnacipran, and nefazodone. Study Selection and Data Extraction:Relevant articles on duloxetine and venlafaxine for the treatment of pediatric ADHD were reviewed; 5 studies on venlafaxine and 1 study on duloxetine were evaluated. Studies included open-label and randomized, double-blind trials. Case studies in pediatric populations and all studies in adult populations were excluded. Data Synthesis:Patients 6 to 17 years old were evaluated in the venlafaxine and duloxetine studies. Trials on venlafaxine, ranging from 2 to 6 weeks, showed patient improvement as measured by the Conners Rating Scale and ADHD Rating Scale. Venlafaxine was initiated at 12.5 to 25 mg/d and titrated up to 1.4 to 3.8 mg/kg/d to a maximum of 150 mg/d. Duloxetine showed minimal efficacy in treating ADHD symptoms at doses of 60 mg/d at 6 weeks. The most common side effects for venlafaxine and duloxetine included drowsiness and decreased appetite, respectively. Conclusions:Data for venlafaxine and duloxetine are limited. However, venlafaxine may be considered as an alternative agent when patients cannot tolerate or fail stimulants, tricyclic antidepressants, or bupropion. Duloxetine has been studied in children; however, with only 1 study available, it is difficult to recommend.

Venous thromboembolism (VTE), particularly thrombi in the inferior vena cava (IVC) and pulmonary embolism, can occur after successful extracorporeal membrane oxygenation (ECMO) and can be associated with adverse outcomes including death. VTE is related to the presence of a venous cannula and in some cases inadequate anticoagulation caused by clinical bleeding. We have developed a simple method for guidewire exchange of the femoral venous ECMO cannula to a working catheter for intravascular ultrasound (IVUS) IVC filter placement, and describe the specific methodology.

To examine the impact of an ongoing comprehensive performance improvement and patient safety (PIPS) program implemented in 2005 on mortality outcomes for trauma patients at an established American College of Surgeons (ACS)-verified Level I Trauma Center.

To examine the case mix and patient characteristics and outcomes of the nontrauma emergency (NTE) service in an academic Division of Acute Care Surgery.

Background/Aims: Escherichia coliheat-stable enterotoxins (ST) are small peptides of 18 or 19 amino acids that bind to specific cell surface receptors located on the intestinal brush border and activate guanylate cyclase, resulting in an increase in the intracellular cyclic guanosine 3′,5′-monophosphate content of the cell. The present study examined whether receptors for ST are expressed by primary and metastatic human colonic tumors in vivo. Methods:Plasma membranes prepared from surgical tissue samples from normal colon, liver and lung, primary colonic adenocarcinomas, and colon carcinomas metastatic to lung and liver were analyzed for the structural and functional characteristics of constituent ST receptors. Results:All primary and metastatic colonic tumors examined bound ST, showing receptors of high (pmol/L) and low (nmol/L) affinity with densities that were similar to those in normal colon. Also, affinity cross-linking of labeled ST to membranes showed similar binding proteins in primary and metastatic tumors and normal colon. ST binding and affinity-labeled proteins were not detected in normal extraintestinal tissues. Guanylate cyclase was activated by ST in membranes from all colonic tumors studied, with efficacies and potencies that were similar to those in normal colon. ST did not activate this enzyme in normal extraintestinal tissues. Conclusions:Receptors for ST are expressed by primary and metastatic human colonic tumors in vivo, with structural and functional characteristics that are similar to those in normal human colon.

PURPOSE: Receptors forEscherichia coliheat-stable toxin (ST) are selectively expressed in membranes of intestinal mucosa cells and colon carcinoma cellsin vitro,suggesting their use as a marker for colorectal tumorsin vivo.The present studies examined the expression and function of ST receptors in normal human tissues and primary and metastatic colorectal tumors obtained from patients at surgery. METHODS: Surgical specimens were obtained as follows: from normal colon; from primary adenocarcinomas from all anatomic divisions of the colon and rectum; from gallbladder, kidney, liver, lung, lymph node, ovary, peritoneum, stomach; and from colon carcinomas metastatic to liver, lung, lymph node, ovary, and peritoneum. Membranes prepared from these specimens were assessed for the presence and functional characteristics of ST receptors. RESULTS: ST bound specifically to membranes from each division of normal colon and rectum and all primary and metastatic colorectal tumors examined. The affinity and density of ST receptors were similar in tumors of different grades and from various metastatic sites. ST-receptor interaction was coupled to activation of guanylyl cyclase in all normal samples of colon and rectum and all primary and metastatic colorectal tumors examined. In contrast, neither ST binding nor ST activation of guanylyl cyclase was detected in any extraintestinal tissues examined. CONCLUSIONS: Functional ST receptors are expressed in normal colonic tissue and primary and metastatic colorectal tumors but not by extraintestinal tissues in humans. Expression of ST receptors does not vary as a function of the metastatic site or grade of these tumors. Receptors expressed by colorectal tumors retain their characteristic function, with binding of ST coupled to activation of guanylyl cyclase. These studies support the suggestion that ST receptors represent a specific marker for human colorectal tumors that may have use as a target for directing diagnostics and therapeutics to these tumorsin vivo.

Although specific interventions previously demonstrated benefit in patients with the ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown.

Granulomatous mastitis, a rare, benign breast condition characterized by granulomas and abscess formation, is mistaken frequently for inflammatory breast carcinoma. Although it has been reported in reproductive-age women, it is unusual in pregnancy.

The usual duration of extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome is 7–10 days. Prolonged duration ECMO (defined as greater than 14 days) is increasingly being documented with native lung recovery or as a bridge to lung transplantation. We report a case of prolonged duration ECMO (6,364 hours, 265 days) requiring no complete circuit exchange. As critical care improves, prolonged ECMO will continue to pose unique technological and ethical challenges that test our expectations of this treatment modality. There is a critical need for diagnostic modalities to provide objective assessment of native lung recovery in patients requiring prolonged duration ECMO.

In this article, the author comments on the image of love. According to the author, it irritates her that teen magazines, books and surveys show love as a great thing. She claims that love can be dismal, especially if there is not exactly a significant other to ponder. She suggests to concentrate on studying instead of focusing on romantic pursuits.

The article reviews the music release "Hybrid Theory," by Linkin Park.

The article features Pomona College in Claremont, California. The college is said to have one of the most rigorous liberal arts programs in the U.S. One of the advantage of Pomona over other Ivy League schools is its location. The author claims that the students recruited by Pomona are academically promising and possess talent.

Presents information on the conference titled TransWorld II: Strengthening Community sponsored by the Audre Lorde Project on April 15, 2000 held at Greenwich Village in Manhattan, New York. Workshop facilitators of the event; Activities of the convention; Members of the organizing committee of the conference.