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RationaleExposure to air pollution has molecular and physiologic effects on the lung that may increase the risk of acute respiratory distress syndrome (ARDS) after injury.ObjectivesTo determine the association of short- and long-term air pollutant exposures and ARDS risk after severe trauma.MethodsWe analyzed data from a prospective cohort of 996 critically ill patients presenting with acute trauma and an injury severity score greater than 15. Exposures to ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and particulate matter less than 2.5 μm were assessed by weighted averages of daily levels from all monitors within 50 km of the geocoded location of a patient's residence. Patients were followed for 6 days for the development of ARDS according to Berlin Criteria. The association between each exposure and ARDS was determined via multivariable logistic regression adjusting for potential confounders.Measurements and main resultsARDS developed in 243 (24%) patients. None of the short-term exposures averaged over the 3 days before presentation was associated with ARDS, except sulfur dioxide, which demonstrated a nonlinear association. Nitrogen dioxide, sulfur dioxide, and particulate matter less than or equal to 2.5 μm in aerodynamic diameter exposure over the 6 weeks before presentation was significantly associated with ARDS (P

PurposeMany medical schools have implemented learning communities (LCs) to improve the learning environment (LE) for students. The authors conducted this study to determine whether a relationship exists between medical student perceptions of the LE and presence of LCs during the preclerkship years.MethodStudents from 24 schools participating in the American Medical Association Learning Environment Study completed the 17-item Medical Student Learning Environment Survey (MSLES) at the end of their first and second years of medical school between 2011 and 2013. Mean total MSLES scores and individual item scores at the end of the first and second years in schools with and without LCs were compared with t tests, and effect sizes were calculated. Mixed-effects longitudinal models were used to control for student demographics and random school and student effects on the relationship between LC status and MSLES score.ResultsA total of 4,980 students (81% of 6,148 matriculants) from 18 schools with LCs and 6 without LCs participated. Mean [SD] MSLES scores were significantly higher in LC schools compared with non-LC schools at the end of year one (3.72 [0.44] versus 3.57 [0.43], P < .001) and year two (3.69 [0.49] versus 3.42 [0.54], P < .001). The effect size increased from 0.35 (small) at the end of year one to 0.53 (medium) at the end of year two.ConclusionsThis large multi-institutional cohort study found that LCs at medical schools were associated with more positive perceptions of the LE by preclerkship students.

BackgroundTreatment of severe sepsis is expensive, often encompassing a number of discretionary modalities. The objective of the present study was to assess intercenter variation in resource and therapeutic modality use in patients with severe sepsis.MethodsWe conducted a prospective cohort study of 1028 adult admissions with severe sepsis from a stratified random sample of patients admitted to eight academic tertiary care centers. The main outcome measures were length of stay (LOS; total LOS and LOS after onset of severe sepsis) and total hospital charges.ResultsThe adjusted mean total hospital charges varied from 69 429 dollars to US237 898 dollars across centers, whereas the adjusted LOS after onset varied from 15.9 days to 24.2 days per admission. Treatments used frequently after the first onset of sepsis among patients with severe sepsis were pulmonary artery catheters (19.4%), ventilator support (21.8%), pressor support (45.8%) and albumin infusion (14.4%). Pulmonary artery catheter use, ventilator support and albumin infusion had moderate variation profiles, varying 3.2-fold to 4.9-fold, whereas the rate of pressor support varied only 1.92-fold across centers. Even after adjusting for age, sex, Charlson comorbidity score, discharge diagnosis-relative group weight, organ dysfunction and service at onset, the odds for using these therapeutic modalities still varied significantly across centers. Failure to start antibiotics within 24 hours was strongly correlated with a higher probability of 28-day mortality (r2 = 0.72).ConclusionThese data demonstrate moderate but significant variation in resource use and use of technologies in treatment of severe sepsis among academic centers. Delay in antibiotic therapy was associated with worse outcome at the center level.

BACKGROUND. The ABO histo-blood group is defined by carbohydrate modifications and is associated with risk for multiple diseases, including acute respiratory distress syndrome (ARDS). We hypothesized that genetically determined blood subtype A1 is associated with increased risk of ARDS and markers of microvascular dysfunction and coagulation. METHODS. We conducted analyses in 3 cohorts of critically ill trauma and sepsis patients (n = 3710) genotyped on genomewide platforms to determine the association of the A1 blood type genotype with ARDS risk. We subsequently determined whether associations were present in FUT2-defined nonsecretors who lack ABO antigens on epithelium, but not endothelium. In a patient subgroup, we determined the associations of blood type with plasma levels of endothelial glycoproteins and disseminated intravascular coagulation (DIC). Lastly, we tested whether blood type A was associated with less donor lung injury recovery during human ex vivo lung perfusion (EVLP). RESULTS. The A1 genotype was associated with a higher risk of moderate to severe ARDS relative to type O in all 3 populations. In sepsis, this relationship was strongest in nonpulmonary infections. The association persisted in nonsecretors, suggesting a vascular mechanism. The A1 genotype was also associated with higher DIC risk as well as concentrations of thrombomodulin and von Willebrand factor, which in turn were associated with ARDS risk. Blood type A was also associated with less lung injury recovery during EVLP. CONCLUSION. We identified a replicable association between ABO blood type A1 and risk of ARDS among the critically ill, possibly mediated through microvascular dysfunction and coagulation. FUNDING. NIH HL122075, HL125723, HL137006, HL137915, DK097307, HL115354, HL101779, and the University of Pennsylvania McCabe Fund Fellowship Award., Introduction Acute respiratory distress syndrome (ARDS) is a common complication of critical illness characterized by lung inflammation, epithelial and endothelial dysfunction, alveolar capillary leak, and microthrombosis (1, 2). Clinically, it [...]

Sepsis syndrome is relatively common in hospitalized patients, even those not in the intensive care unit (ICU). Sepsis syndrome occurs when a bacterial infection in the bloodstream causes serious complications. Among 12,759 hospital patients at eight academic medical centers, 1,342 had sepsis syndrome. The incidence of sepsis syndrome was about 2 cases for every 100 admissions. Forty percent of the patients were not in the ICU at the time. One-fourth had septic shock and mortality rates were 34% at 28 days and 45% at five months. Gram-positive bacteria were responsible in most cases., Context.--Sepsis syndrome is a leading cause of mortality in hospitalized patients. However, few studies have described the epidemiology of sepsis syndrome in a hospitalwide population. Objective.--To describe the epidemiology of sepsis syndrome in the tertiary care hospital setting. Design.--Prospective, multi-institutional, observational study including 5-month follow-up. Setting.--Eight academic tertiary care centers. Methods.--Each center monitored a weighted random sample of intensive care unit (ICU) patients, non-IC patients who had blood cultures drawn, and all patients who received a novel therapeutic agent or who died in an emergency department or ICU. Sepsis syndrome was defined as the presence of either a positive blood culture or the combination of fever, tachypnea, tachycardia, clinically suspected infection, and any 1 of 7 confirmatory criteria. Estimates of total cases expected annually were extrapolated from the number of cases, the period of observation, and the sampling fraction. Results.--From January 4, 1993, to April 2, 1994, 12 759 patients were monitored and 1342 episodes of sepsis syndrome were documented. The extrapolated, weighted estimate of hospitalwide incidence (mean [+ or -] 95% confidence limit) of sepsis syndrome was 2.0 [+ or -] 0.16 cases per 100 admissions, or 2.8 [+ or -] 0.17 per 1000 patient-days. The unadjusted attack rate for sepis syndrome between individual centers differed by as much as 3-fold, but after adjustment for institutional differences in organ transplant populations, variation from the expected number of cases was reduced to 2-fold and was not statistically significant overall. Patients in ICUs accounted for 59% of total extrapolated cases, non-ICU patients with positive blood cultures for 11 %, and non-ICU patients with negative blood cultures for 30%. Septic shock was present at onset of sepsis syndrome in 25% of patients. Bloodstream infection was documented in 28%, with gram-positive organisms being the most frequent isolates. Mortality was 34% at 28 days and 45% at 5 months. Conclusions.--Sepsis syndrome is common in academic hospitals, although the overall rates vary considerably with the patient population. A substantial fraction of cases occur outside ICUs. An understanding of the hospitalwide epidemiology of sepsis syndrome is vital for rational planning and treatment of hospitalized patients with sepsis syndrome, especially as new and expensive therapeutic agents become available. JAMA. 1997;278:284-240

Sedatives and neuromuscular blocking agents are often used to treat patients on mechanical ventilators at many hospitals that train pulmonary specialists. A survey of 164 hospitals found that all but one used sedatives and 98% used neuromuscular blockers to treat patients with respiratory failure who are on a ventilator. Thirty-six percent used sedatives routinely in more than 70% of their patients and most (48%) used them frequently. Opiates and benzodiazepines were the most commonly used sedatives. Sedatives were used to decrease anxiety and induce sleep. Only two percent of the hospitals used neuromuscular blockers routinely. Seventy percent used these drugs only occasionally, and in less than 20% of their patients. These drugs were used to reduce spontaneous breathing, muscle movement and oxygen intake. The cost of using sedatives and neuromuscular blockers can be up to $1,000 per day and they may cause side effects such as coma and paralysis.