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ObjectivesFew surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic.DesignCross-sectional survey using four validated instruments.SettingSixty-two sites in Canada and the United States.SubjectsAttending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs.InterventionNone.Measurements and main resultsWe analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures.ConclusionsDespite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.

The paper presents an online version of the identification method for estimating the impulse responses in the case of a two-input single-output linear empirical model of type 1 diabetes that allows us to adapt the model parameters due to the intra-subject time variability in real time. The method builds on and augments our original research by providing important enhancements concerning the online parameter estimation, recursive formulation of essential equations, improved regularization, and new effective approaches to numerically solve the estimation problem. Recursive equations are derived to update the covariance matrix of the sample cross-correlation function, as well as the inverse of this covariance matrix, where the customized Sherman-Morrison formula was considered. To efficiently update the parameter estimate at each sample while avoiding direct calculation of the Hessian matrix inverse, two alternative strategies are proposed to be applied instead. The first is based on the numeric minimization by the conjugate gradient method, whereas the second takes advantage of the Schulz method to approximate the inverse Hessian matrix. As a result, all steps of the identification algorithm were designed so that only basic linear operations are required. Features to robustify the estimate were also involved, as the optimal regularization strategies based on the inverse of the covariance matrix of the actual parameter distribution and the inter-sample parameter drift were applied. In the end of the paper, a series of simulation-based experiments was carried out to assess the effectiveness of the proposed method and to demonstrate all of its aspects and important characteristics. The documented results showed that the method can yield valid estimates of impulse responses and also effectively adapt parameters in real time under the influence of time-varying physiology.

Abstract Background This update summarizes key changes made to the protocol for the Frequency of Screening and Spontaneous Breathing Trial (SBT) Technique Trial—North American Weaning Collaborative (FAST-NAWC) trial since the publication of the original protocol. This multicenter, factorial design randomized controlled trial with concealed allocation, will compare the effect of both screening frequency (once vs. at least twice daily) to identify candidates to undergo a SBT and SBT technique [pressure support + positive end-expiratory pressure vs. T-piece] on the time to successful extubation (primary outcome) in 760 critically ill adults who are invasively ventilated for at least 24 h in 20 North American intensive care units. Methods/design Protocols for the pilot, factorial design trial and the full trial were previously published in J Clin Trials ( https://doi.org/10.4172/2167-0870.1000284 ) and Trials (https://doi: 10.1186/s13063-019–3641-8). As planned, participants enrolled in the FAST pilot trial will be included in the report of the full FAST-NAWC trial. In response to the onset of the coronavirus disease of 2019 (COVID-19) pandemic when approximately two thirds of enrollment was complete, we revised the protocol and consent form to include critically ill invasively ventilated patients with COVID-19. We also refined the statistical analysis plan (SAP) to reflect inclusion and reporting of participants with and without COVID-19. This update summarizes the changes made and their rationale and provides a refined SAP for the FAST-NAWC trial. These changes have been finalized before completion of trial follow-up and the commencement of data analysis. Trial registration Clinical Trials.gov NCT02399267.

This paper presents the design of a model-based bolus calculator algorithm aimed at optimizing insulin therapy for patients with type 1 diabetes. The proposed concept functions as an advisory system to assist in decision-making regarding insulin administration. In contrast to traditional artificial pancreas systems based on model predictive control, which involve continuous insulin dosing and rely on frequent feedback from continuous glucose monitoring, the proposed bolus calculator processes sporadic, impulse-like inputs without requiring regularly sampled glycemia feedback. This design prioritizes simplicity and practicality for eventual clinical use. The bolus calculator is fundamentally based on the principles of mathematical modeling, prediction, and optimization. The primary objective is to minimize deviations in glycemic response from the basal glucose level by adjusting both the insulin bolus size and its timing. Mathematically, this problem can be formulated as a bivariate, mixed real-integer optimization problem. The optimal insulin bolus size was derived in closed form, reducing the problem to a univariate, constrained integer optimization focused on determining the administration time. Two variants of the bolus calculator are distinguished: the offline variant, which provides general, personalized recommendations applicable to any situation regardless of the patient’s current state, and the online variant, which offers tailored advice for each disturbance event. The online variant accounts for previously administered insulin, prior carbohydrate intake, and, when available, preprandial finger-stick glucose measurements. To mitigate the risk of hypoglycemia, additional constraints are imposed on the predicted glycemic trajectory, ensuring the recommended insulin bolus does not induce hypoglycemia. The proposed strategy was validated through simulation-based experiments and compared to ideal bolus treatment and model predictive control strategies.

The primary objective of this paper is the custom design of an effective, yet relatively easyto- implement, predictive control algorithm to maintain normoglycemia in patients with type 1 diabetes. The proposed patient-tailorable empirical model featuring the separated feedback dynamics to model the effect of insulin administration and carbohydrate intake was proven to be suitable for the synthesis of a high-performance predictive control algorithm for artificial pancreas.Within the introduced linear model predictive control law, the constraints were applied to the manipulated variable in order to reflect the technical limitations of insulin pumps and the typical nonnegative nature of the insulin administration. Similarly, inequalities constraints for the controlled variable were also assumed while anticipating suppression of hypoglycemia states during the automated insulin treatment. However, the problem of control infeasibility has emerged, especially if one uses too tight constraints of the manipulated and the controlled variable concurrently. To this end, exploiting the Farkas lemma, it was possible to formulate the helper linear programming problem based on the solution of which this infeasibility could be identified and the optimality of the control could be restored by adapting the constraints. This adaptation of constraints is asymmetrical, thus one can force to fully avoid hypoglycemia at the expense of mild hyperglycemia. Finally, a series of comprehensive in-silico experiments were carried out to validate the presented control algorithm and the proposed improvements. These simulations also addressed the control robustness in terms of the intersubject variability and the meal announcements uncertainty.

Abstract Introduction Sepsis is a common, life-threatening syndrome of physiologic, pathologic, and biochemical abnormalities that are caused by infection and propagated by a dysregulated immune response. In 2017, the estimated annual incidence of sepsis around the world was 508 cases per 100,000 (95% confidence interval [CI], 422–612 cases per 100,000), however, reported incidence rates vary significantly by country. A scoping review will identify knowledge gaps by systematically investigating the incidence of sepsis. Methods and analysis This scoping review will be guided by the updated JBI (formerly Joanna Briggs Institute) methodology. We will search the following electronic databases: MEDLINE, EMBASE, CINAHL, and Cochrane Database of Systematic Reviews/Central Register of Controlled Trials. In addition, we will search websites of trial and study registries. We will review titles and abstracts of potentially eligible studies and then full-texts by two independent reviewers. We will include any study that is focused on the incidence of sepsis or septic shock in any population. Data will be abstracted independently using pre-piloted data extraction forms, and we will present results according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews. Ethics and dissemination The results of this review will be used to create a publicly available indexed and searchable electronic registry of existing sepsis research relating to incidence in neonates, children, and adults. With input from stakeholders, we will identify the implications of study findings for policy, practice, and research. Ethics approval was not required given this study reports on existing literature.

This work describes a novel nonparametric identification method for estimating impulse responses of the general two-input single-output linear system with its target application to the individualization of an empirical model of type 1 diabetes. The proposed algorithm is based on correlation functions and the derived generalization of the Wiener-Hopf equation for systems with two inputs, while taking the stochastic properties of the output measurements into account. Ultimately, this approach to solving the deconvolution problem can be seen as an alternative to widely used prediction error methods. To estimate the impulse response coefficients, the generalized least squares method was used in order to reflect nonuniform variances and nonzero covariances of the stochastic estimate of the cross-correlation functions, hence yielding the minimum variance estimator. Estimate regularization strategies were also involved, while three different types of penalties were applied. The combination of smoothing, stability, and causality regularization was proposed to improve the general validity of the estimate and also to lower its variance. The findings of this identification method are meant to be applied within an eventual predictive control synthesis for the artificial pancreas, so a procedure for transforming the nonparametric model into the transfer function-based parametric model was also described. A discussion on the results of a comprehensive simulation-based experiment concludes the paper.

IMPORTANCE:. Moral distress is common among critical care physicians and can impact negatively healthcare individuals and institutions. Better understanding inter-individual variability in moral distress is needed to inform future wellness interventions. OBJECTIVES:. To explore when and how critical care physicians experience moral distress in the workplace and its consequences, how physicians’ professional interactions with colleagues affected their perceived level of moral distress, and in which circumstances professional rewards were experienced and mitigated moral distress. DESIGN:. Interview-based qualitative study using inductive thematic analysis. SETTING AND PARTICIPANTS:. Twenty critical care physicians practicing in Canadian ICUs who expressed interest in participating in a semi-structured interview after completion of a national, cross-sectional survey of moral distress in ICU physicians. RESULTS:. Study participants described different ways to perceive and resolve morally challenging clinical situations, which were grouped into four clinical moral orientations: virtuous, resigned, deferring, and empathic. Moral orientations resulted from unique combinations of strength of personal moral beliefs and perceived power over moral clinical decision-making, which led to different rationales for moral decision-making. Study findings illustrate how sociocultural, legal, and clinical contexts influenced individual physicians’ moral orientation and how moral orientation altered perceived moral distress and moral satisfaction. The degree of dissonance between individual moral orientations within care team determined, in part, the quantity of “negative judgments” and/or “social support” that physicians obtained from their colleagues. The levels of moral distress, moral satisfaction, social judgment, and social support ultimately affected the type and severity of the negative consequences experienced by ICU physicians. CONCLUSIONS AND RELEVANCE:. An expanded understanding of moral orientations provides an additional tool to address the problem of moral distress in the critical care setting. Diversity in moral orientations may explain, in part, the variability in moral distress levels among clinicians and likely contributes to interpersonal conflicts in the ICU setting. Additional investigations on different moral orientations in various clinical environments are much needed to inform the design of effective systemic and institutional interventions that address healthcare professionals’ moral distress and mitigate its negative consequences.

The aim of this paper was to design a repeated drug administration strategy to reach and maintain the requested drug concentration in the body. Conservative designs require an exact knowledge of pharmacokinetic parameters, which is considered an unrealistic demand. The problem is usually resolved using the trial-and-error open-loop approach; yet, this can be considered insufficient due to the parametric uncertainties as the dosing strategy may induce an undesired behavior of the drug concentrations. Therefore, the presented approach is rather based on the paradigms of system and control theory. An algorithm was designed that computes the required doses to be administered based on the blood samples. Since repeated drug dosing is essentially a discrete time process, the entire design considers the discrete time domain. We have also presented the idea of applying this methodology for the stabilization of an unstable model, for instance, a model of tumor growth. The simulation experiments demonstrated that all variants of the proposed control algorithm can reach and maintain the desired drug concentration robustly, i.e., despite the presence of parametric uncertainties, in a way that is superior to that of the traditional open-loop approach. It was shown that the closed-loop control with the integral controller and stabilizing state feedback is robust against large parametric uncertainties.

Abstract Objectives Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions because of constraints or barriers. We aimed to assess the validity and reliability of the Japanese translation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP). Methods We translated the questionnaire into Japanese according to the instructions of EORTC Quality of Life group translation manual. All physicians and nurses who were directly involved in patient care at nine departments of four tertiary hospitals in Japan were invited to a survey to assess the construct validity, reliability and factor structure. Construct validity was assessed with the relation to the intention to leave the clinical position, and internal consistency was assessed with Cronbach’s alpha. Confirmatory factor analysis was conducted. Results 308 responses were eligible for the analysis. The mean total score of MMD-HP (range, 0–432) was 98.2 (SD, 59.9). The score was higher in those who have or had the intention to leave their clinical role due to moral distress than in those who do not or did not have the intention of leaving (mean 113.7 [SD, 61.3] vs. 86.1 [56.6], t-test p

The paper proposes a new model-based optimization approach to improve the clinical efficiency of compensatory insulin bolus treatment in diabetic patients, aiming to mitigate the consequences of diabetes. The most important contribution of this paper is a novel methodology for determining the optimal parameters of insulin treatment, namely the size and timing of insulin boluses, to effectively compensate for carbohydrate intake. This concept can be seen as the so-called optimal model-based bolus calculator. The presented theoretical framework deals with the problem of optimal disturbance rejection in impulsive systems by minimizing an integral quadratic cost function. The methodology considers a personalized empirical transfer function model with static gains and time constants as the only parameters assumed to be known, making the bolus calculator more straightforward to implement in clinical practice. Contrary to other techniques, the proposed methodology considers impulsive insulin administration in the form of boluses, which is more feasible than continuous infusion. In contrast to the conventional bolus calculator, the proposed algorithm allows for maximizing therapy performance by optimizing the relative time of insulin bolus administration with respect to carbohydrate intake. Another feature to highlight is that the solution of the optimization problem can be obtained analytically, hence no numerical iterative solvers are required. Additionally, the continuous-time domain approach allows for a much finer adjustments of the insulin administration timing compared to discrete-time models. The proposed approach was validated in an in-silico study, which demonstrated the importance of systematically determined insulin–carbohydrate ratio and the relative delay between disturbance and its compensation. The results showed that the proposed optimal bolus calculator outperforms the traditional suboptimal formula. [ABSTRACT FROM AUTHOR]

Abstract Rationale In critically ill patients receiving invasive mechanical ventilation (MV), research supports the use of daily screening to identify patients who are ready to undergo a spontaneous breathing trial (SBT) followed by conduct of an SBT. However, once daily (OD) screening is poorly aligned with the continuous care provided in most intensive care units (ICUs) and the best SBT technique for clinicians to use remains controversial. Objectives To identify the optimal screening frequency and SBT technique to wean critically ill adults in the ICU. Methods We aim to conduct a multicenter, factorial design randomized controlled trial with concealed allocation, comparing the effect of both screening frequency (once versus at least twice daily [ALTD]) and SBT technique (Pressure Support [PS] + Positive End-Expiratory Pressure [PEEP] vs T-piece) on the time to successful extubation (primary outcome) in 760 critically ill adults who are invasively ventilated for at least 24 h in 20 North American ICUs. In the OD arm, respiratory therapists (RTs) will screen study patients between 06:00 and 08:00 h. In the ALTD arm, patients will be screened at least twice daily between 06:00 and 08:00 h and between 13:00 and 15:00 h with additional screens permitted at the clinician’s discretion. When the SBT screen is passed, an SBT will be conducted using the assigned technique (PS + PEEP or T-piece). We will follow patients until successful extubation, death, ICU discharge, or until day 60 after randomization. We will contact patients or their surrogates six months after randomization to assess health-related quality of life and functional status. Relevance The around-the-clock availability of RTs in North American ICUs presents an important opportunity to identify the optimal SBT screening frequency and SBT technique to minimize patients’ exposure to invasive ventilation and ventilator-related complications. Trial registration Clinical Trials.gov, NCT02399267. Registered on Nov 21, 2016 first registered.

Objective To determine the prevalence of physician burnout during the pandemic and differences by gender, ethnicity or sexual orientation.Design, setting and participants We conducted a cross-sectional survey (August–October in 2020) of internal medicine physicians at two academic hospitals in Vancouver, Canada.Primary and secondary outcomes Physician burnout and its components, emotional exhaustion, depersonalisation and personal accomplishment were measured using the Maslach Burnout Inventory.Results The response rate was 38% (n=302/803 respondents, 49% women,). The prevalence of burnout was 68% (emotional exhaustion 63%, depersonalisation 39%) and feeling low personal accomplishment 22%. In addition, 21% reported that they were considering quitting the profession or had quit a position. Women were more likely to report emotional exhaustion (OR 2.00, 95% CI: 1.07 to 3.73, p=0.03) and feeling low personal accomplishment (OR 2.26, 95% CI: 1.09 to 4.70, p=0.03) than men. Visible ethnic minority physicians were more likely to report feeling lower personal accomplishment than white physicians (OR 1.81, 95% CI: 1.28 to 2.55, p=0.001). There was no difference in emotional exhaustion or depersonalisation by ethnicity or sexual orientation. Physicians who reported that COVID-19 affected their burnout were more likely to report any burnout (OR: 3.74, 95% CI: 1.99 to 7.01, p

In the first part of this paper, the problem of using an uncertain pharmacokinetic model is resolved to determine drug concentrations in rats after the oral administration of drug suspensions with and without added tenside. To this end, a generalized pharmacokinetic model determining the guaranteed limits of drug concentrations was designed. Based on this, the design of the so-called state-bounding observer is described in the second part. Rather than being driven by the output of the pharmacokinetic model, the observer can be driven exclusively by a concentration collected from a suitable part of the body and predict the possible risk of the drug concentration not remaining within the therapeutic range for a sufficiently long time. Specifically, the observer determines the upper and lower limits of the concentrations in all the compartments, especially those that are inaccessible for the collection of samples. The proposed approaches are demonstrated by examples.

Introduction Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection in the intensive care unit (ICU). Probiotics are defined as live microorganisms that may confer health benefits when ingested. Prior randomised trials suggest that probiotics may prevent infections such as VAP and Clostridioides difficile–associated diarrhoea (CDAD). PROSPECT (Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial) is a multicentre, double-blinded, randomised controlled trial comparing the efficacy of the probiotic Lactobacillus rhamnosus GG with usual care versus usual care without probiotics in preventing VAP and other clinically important outcomes in critically ill patients admitted to the ICU.Methods and analysis The objective of E-PROSPECT is to determine the incremental cost-effectiveness of L. rhamnosus GG plus usual care versus usual care without probiotics in critically ill patients. E-PROSPECT will be performed from the public healthcare payer’s perspective over a time horizon from ICU admission to hospital discharge.We will determine probabilities of in-ICU and in-hospital events from all patients alongside PROSPECT. We will retrieve unit costs for each resource use item using jurisdiction-specific public databases, supplemented by individual site unit costs if such databases are unavailable. Direct costs will include medications, personnel costs, radiology/laboratory testing, operative/non-operative procedures and per-day hospital ‘hoteling’ costs not otherwise encompassed. The primary outcome is the incremental cost per VAP prevented between the two treatment groups. Other clinical events such as CDAD, antibiotic-associated diarrhoea and in-hospital mortality will be included as secondary outcomes. We will perform pre-specified subgroup analyses (medical/surgical/trauma; age; frailty status; antibiotic use; prevalent vs no prevalent pneumonia) and probabilistic sensitivity analyses for VAP, then generate confidence intervals using the non-parametric bootstrapping approach.Ethics and dissemination Study approval for E-PROSPECT was granted by the Hamilton Integrated Research Ethics Board of McMaster University on 29 July 2019. Informed consent was obtained from the patient or substitute decision-maker in PROSPECT. The findings of this study will be published in peer-reviewed journals.Trial registration number NCT01782755; Pre-results.

Abstract Background Admission to the intensive care unit (ICU) outside daytime hours has been shown to be variably associated with increased morbidity and mortality. We aimed to describe the characteristics and outcomes of patients admitted to the ICU afterhours (22:00–06:59 h) in a large Canadian health region. We further hypothesized that the association between afterhours admission and mortality would be modified by indicators of strained ICU capacity. Methods This is a population-based cohort study of 12,265 adults admitted to nine ICUs in Alberta from June 2012 to December 2014. We used a path-analysis modeling strategy and mixed-effects multivariate regression analysis to evaluate direct and integrated associations (mediated through Acute Physiology and Chronic Health Evaluation (APACHE) II score) between afterhours admission (22:00–06:59 h) and ICU mortality. Further analysis examined the effects of strained ICU capacity and varied definitions of afterhours and weekend admissions. ICU occupancy ≥ 90% or clustering of admissions (≥ 0.15, defined as number of admissions 2 h before or after the index admission, divided by the number of ICU beds) were used as indicators of strained capacity. Results Of 12,265 admissions, 34.7% (n = 4251) occurred afterhours. The proportion of afterhours admissions varied amongst ICUs (range 26.7–37.8%). Patients admitted afterhours were younger (median (IQR) 58 (44–70) vs 60 (47–70) years, p

Abstract Background Shorter-duration antibiotic treatment is sufficient for a range of bacterial infections, but has not been adequately studied for bloodstream infections. Our systematic review, survey, and observational study indicated equipoise for a trial of 7 versus 14 days of antibiotic treatment for bloodstream infections; a pilot randomized clinical trial (RCT) was a necessary next step to assess feasibility of a larger trial. Methods We conducted an open, pilot RCT of antibiotic treatment duration among critically ill patients with bloodstream infection across 11 intensive care units (ICUs). Antibiotic selection, dosing and route were at the discretion of the treating team; patients were randomized 1:1 to intervention arms consisting of two fixed durations of treatment – 7 versus 14 days. We recruited adults with a positive blood culture yielding pathogenic bacteria identified while in ICU. We excluded patients with severe immunosuppression, foci of infection with an established requirement for prolonged treatment, single cultures with potential contaminants, or cultures yielding Staphylococcus aureus or fungi. The primary feasibility outcomes were recruitment rate and adherence to treatment duration protocol. Secondary outcomes included 90-day, ICU and hospital mortality, relapse of bacteremia, lengths of stay, mechanical ventilation and vasopressor duration, antibiotic-free days, Clostridium difficile, antibiotic adverse events, and secondary infection with antimicrobial-resistant organisms. Results We successfully achieved our target sample size (n = 115) and average recruitment rate of 1 (interquartile range (IQR) 0.3–1.5) patient/ICU/month. Adherence to treatment duration was achieved in 89/115 (77%) patients. Adherence differed by underlying source of infection: 26/31 (84%) lung; 18/29 (62%) intra-abdominal; 20/26 (77%) urinary tract; 8/9 (89%) vascular-catheter; 4/4 (100%) skin/soft tissue; 2/4 (50%) other; and 11/12 (92%) unknown sources. Patients experienced a median (IQR) 14 (8–17) antibiotic-free days (of the 28 days after blood culture collection). Antimicrobial-related adverse events included hepatitis in 1 (1%) patient, Clostridium difficile infection in 4 (4%), and secondary infection with highly resistant microorganisms in 10 (9%). Ascertainment was complete for all study outcomes in ICU, in hospital and at 90 days. Conclusion It is feasible to conduct a RCT to determine whether 7 versus 14 days of antibiotic treatment is associated with comparable 90-day survival. Trial registration ClinicalTrials.gov, identifier: NCT02261506. Registered on 26 September 2014.

Abstract Background Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks. Methods This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients. Results A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9–2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p

Abstract Background Decisions about care options and the use of life-sustaining treatments should be informed by a person’s values and treatment preferences. The objective of this study was to examine the consistency of ratings of the importance of the values statements and the association between values statement ratings and the patient’s expressed treatment preference. Methods We conducted a multi-site survey in 20 family practices. Patients aged 50 and older self-completed a questionnaire assessing the importance of eight values (rated 1 to 10), and indicated their preference for use of life-sustaining treatment (5 options). We compared correlations among values to a priori hypotheses based on whether the value related to prolonging or shortening life, and examined expected relationships between importance of values and the preference option for life-sustaining treatment. Results Eight hundred ten patients participated (92% response rate). Of 24 a priori predicted correlations among values statements, 14 were statistically significant but nearly all were negligible in their magnitude and some were in the opposite direction than expected. For example, the correlation between importance of being comfortable and suffering as little as possible and the importance of living as long as possible should have been inversely correlated but was positively correlated (r = 0.08, p = 0.03). Correlations between importance of values items and preference were negligible, ranging from 0.03 to 0.13. Conclusions Patients may not recognize that trade-offs in what is most important may be needed when considering the use of treatments. In the context of preparation for decision-making during serious illness, decision aids that highlight these trade-offs and connect values to preferences more directly may be more helpful than those that do not.

Introduction Research supports the use of specific strategies to discontinue mechanical ventilation (MV) in critically ill patients. Little is known about how clinicians actually wean and discontinue MV in practice or the association between different discontinuation strategies and outcomes. The primary objective of this study is to describe international practices in the use of (1) daily screening for readiness to discontinue MV, (2) modes of MV used before initial discontinuation attempts, (3) weaning and spontaneous breathing trial (SBT) protocols, (4) SBT techniques and (5) sedation and mobilisation practices to facilitate weaning and discontinuation. The secondary objectives are to identify patient characteristics and time-dependent factors associated with use of selected strategies, investigate associations between SBT outcome (failure vs success) and outcomes, explore differences between patients who undergo an SBT early versus later in their intensive care unit (ICU) stay, and investigate the associations between different SBT techniques and humidification strategies on outcomes.Methods and analysis We will conduct an international, prospective, observational study of MV discontinuation practices among critically ill adults who receive invasive MV for at least 24 hours at approximately 150 ICUs in six geographic regions (Canada, USA, UK, Europe, India and Australia/New Zealand). Research personnel at participating ICUs will collect demographic data, data to characterise the initial strategy or event that facilitated discontinuation of MV (direct extubation, direct tracheostomy, initial successful SBT, initial failed SBT or death before any attempt could be made), clinical outcomes and site information. We aim to collect data on at least 10 non-death discontinuation events in each ICU (at least 1500 non-death discontinuation events).Ethics and dissemination This study received Research Ethics Approval from St. Michael’s Hospital (11-024) Research ethics approval will be sought from all participating sites. The results will be disseminated through publications in peer-reviewed journals.Trial registration number NCT03955874.

Objectives:. To determine if a set of time-varying biological indicators can be used to: 1) predict the sepsis mortality risk over time and 2) generate mortality risk profiles. Design:. Prospective observational study. Setting:. Nine Canadian ICUs. Subjects:. Three-hundred fifty-six septic patients. Interventions:. None. Measurements and Main Results:. Clinical data and plasma levels of biomarkers were collected longitudinally. We used a complementary log-log model to account for the daily mortality risk of each patient until death in ICU/hospital, discharge, or 28 days after admission. The model, which is a versatile version of the Cox model for gaining longitudinal insights, created a composite indicator (the daily hazard of dying) from the “day 1” and “change” variables of six time-varying biological indicators (cell-free DNA, protein C, platelet count, creatinine, Glasgow Coma Scale score, and lactate) and a set of contextual variables (age, presence of chronic lung disease or previous brain injury, and duration of stay), achieving a high predictive power (conventional area under the curve, 0.90; 95% CI, 0.86–0.94). Including change variables avoided misleading inferences about the effects of day 1 variables, signifying the importance of the longitudinal approach. We then generated mortality risk profiles that highlight the relative contributions among the time-varying biological indicators to overall mortality risk. The tool was validated in 28 nonseptic patients from the same ICUs who became septic later and was subject to 10-fold cross-validation, achieving similarly high area under the curve. Conclusions:. Using a novel version of the Cox model, we created a prognostic tool for septic patients that yields not only a predicted probability of dying but also a mortality risk profile that reveals how six time-varying biological indicators differentially and longitudinally account for the patient’s overall daily mortality risk.

Background: Residents frequently encounter situations in their workplace that may induce moral distress or burnout. The objective of this study was to measure overall and rotation-specific moral distress and burnout in medical residents, and the relationship between demographics and moral distress and burnout. Methods: The revised Moral Distress Scale and the Maslach Burnout Inventory (Human Service version) were administered to Internal Medicine residents in the 2013-2014 academic year at the University of British Columbia. Results: Of the 88 residents, 45 completed the surveys. Participants (mean age 30+/-3; 46% male) reported a median moral distress score (interquartile range) of 77 (50-96). Twenty-six percent of residents had considered quitting because of moral distress, 21% had a high level of burnout, and only 5% had a low level of burnout. Moral distress scores were highest during Intensive Care Unit (ICU) and Clinical Teaching Unit (CTU) rotations, and lowest during elective rotations (p

Learning occurs in myriad ways yet most art museums remain wedded to visual instruction. Adult visitors touring the galleries are offered audio guides or lecture style tours to complement the visual but are there other ways to enhance learning? This article reports on a case study that found that active, multi-sensory experiences in art museums can encourage adults to construct meaning and more fully engage with art. (Contains 2 graphs and 9 notes.)

BACKGROUND: Prediction scores for pretest probability of pulmonary embolism (PE) validated in outpatient settings are occasionally used in the intensive care unit (ICU).

RATIONALE AND OBJECTIVES: All grants and manuscripts bearing the Canadian Critical Care Trials Group name are submitted for internal peer review before submission. The authors sought to formally evaluate authors’ and reviewers’ perceptions of this process.

Hospital mortality rates are elevated in critically ill patients with bloodstream infections. Given that mortality may be even higher if appropriate treatment is delayed, we sought to determine the effect of inadequate initial empiric treatment on mortality in these patients. A retrospective cohort study was conducted across 13 intensive care units in Canada. We defined inadequate initial empiric treatment as not receiving at least one dose of an antimicrobial to which the causative pathogen(s) was susceptible within one day of initial blood culture. We evaluated the association between inadequate initial treatment and hospital mortality using a random effects multivariable logistic regression model. Among 1,190 patients (1,097 had bacteremia and 93 had candidemia), 476 (40%) died and 266 (22%) received inadequate initial treatment. Candidemic patients more often had inadequate initial empiric therapy (64.5% versus 18.8%), as well as longer delays to final culture results (4 vs 3 days) and appropriate therapy (2 vs 0 days). After adjustment, there was no detectable association between inadequate initial treatment and mortality among bacteremic patients (Odds Ratio (OR): 1.02, 95% Confidence Interval (CI) 0.70-1.48); however, candidemic patients receiving inadequate treatment had nearly three times the odds of death (OR: 2.89, 95% CI: 1.05-7.99). Inadequate initial empiric antimicrobial treatment was not associated with increased mortality in bacteremic patients, but was an important risk factor in the subgroup of candidemic patients. Further research is warranted to improve early diagnostic and risk prediction methods in candidemic patients.