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1. Academic and Community ICUs Participating in a Critical Care Randomized Trial: A Comparison of Patient Characteristics and Trial Metrics

Author

Jennifer L. Y. Tsang, MD, PhD, Alexandra Binnie, MD, DPhil, Erick H. Duan, MD, MSc, Jennie Johnstone, MD, PhD, Diane Heels-Ansdell, MSc, Brenda Reeve, MD, Sebastien Trop, MD, PhD, Paul Hosek, MD, Joanna C. Dionne, MD, PhD, Patrick Archambault, MD, MSc, Paul Lysecki, MD, Robert Cirone, MD, Nicole L. Zytaruk, RN, William Dechert, MSc, Mercedes Peñuela Camargo, MSc, Rebecca Jesso, MN, NP, Elliot McMillan, RN, PhD, Zaynab Panchbhaya, MSN, Tracy Campbell, MSc, Lois Saunders, Mary Copland, BA, Kanthi Kavikondala, BSc, Deborah J. Cook, MD, MSc, and for the Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT) Investigators and the Canadian Critical Care Trials Group

Subjects
Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

OBJECTIVES:. Clinical research in Canada is conducted primarily in “academic” hospitals, whereas most clinical care is provided in “community” hospitals. The objective of this nested observational study was to compare patient characteristics, outcomes, process-of-care variables, and trial metrics for patients enrolled in a large randomized controlled trial who were admitted to academic and community hospitals in Canada. DESIGN:. We conducted a preplanned observational study nested within the Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT, a randomized controlled trial comparing probiotics to placebo in mechanically ventilated patients) Research Program. SETTING:. ICUs. PATIENTS:. Mechanically ventilated patients. MEASUREMENTS:. We compared patient characteristics, interventions, outcomes, and trial metrics between patients enrolled in PROSPECT from academic and community hospitals. MAIN RESULTS:. Participating centers included 34 (82.9%) academic and seven (17.1%) community hospitals, which enrolled 2,203 (86.2%) and 352 (13.8%) patients, respectively. Compared with academic hospitals, patients enrolled in community hospitals were older (mean [sd] 62.7 yr [14.9 yr] vs 59.5 yr [16.4 yr]; p = 0.044), had longer ICU stays (median [interquartile range {IQR}], 13 d [8–23 d] vs 11 d [7–8 d]; p = 0.012) and higher mortality (percentage, [95% CI] in the ICU, 30.4% [25.8–35.4%]vs 20.5% [18.9–11.3%]; p = 0.002) and hospital (40.6% [35.6–45.8%] vs 26.1% [24.3–27.9%]; p < 0.001). Trial metrics, including informed consent rate (85.9% vs 76.3%; p = 0.149), mean (sd) monthly enrolment rate (2.1 [1.4] vs 1.1 [0.7]; p = 0.119), and protocol adherence (90.6% vs 91.6%; p = 0.207), were similar between community and academic ICUs. CONCLUSIONS:. Community hospitals can conduct high-quality research, with similar trial metrics to academic hospitals. Patient characteristics differed between community and academic hospitals, highlighting the need for broader engagement of community hospitals in clinical research to ensure generalizability of study results.

Published
2022
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2. A pilot randomized controlled trial of 7 versus 14 days of antibiotic treatment for bloodstream infection on non-intensive care versus intensive care wards

Author

Nick Daneman, Asgar H. Rishu, Ruxandra Pinto, Yaseen Arabi, Emilie P. Belley-Cote, Robert Cirone, Mark Downing, Deborah J. Cook, Richard Hall, Shay McGuinness, Lauralyn McIntyre, John Muscedere, Rachael Parke, Steven Reynolds, Benjamin A. Rogers, Yahya Shehabi, Phillip Shin, Richard Whitlock, Robert A. Fowler, and on behalf of the Canadian Critical Care Trials Group

Subjects
Bacteremia, Bloodstream infection, Critical care, Intensive care, Duration of treatment, Medicine (General), R5-920
Abstract

Abstract Background The optimal treatment duration for patients with bloodstream infection is understudied. The Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE) pilot randomized clinical trial (RCT) determined that it was feasible to enroll and randomize intensive care unit (ICU) patients with bloodstream infection to 7 versus 14 days of treatment, and served as the vanguard for the ongoing BALANCE main RCT. We performed this BALANCE-Ward pilot RCT to examine the feasibility and impact of potentially extending the BALANCE main RCT to include patients hospitalized on non-ICU wards. Methods We conducted an open pilot RCT among a subset of six sites participating in the ongoing BALANCE RCT, randomizing patients with positive non-Staphylococcus aureus blood cultures on non-ICU wards to 7 versus 14 days of antibiotic treatment. The co-primary feasibility outcomes were recruitment rate and adherence to treatment duration protocol. We compared feasibility outcomes, patient/pathogen characteristics, and overall outcomes among those enrolled in this BALANCE-Ward and prior BALANCE-ICU pilot RCTs. We estimated the sample size and non-inferiority margin impacts of expanding the BALANCE main RCT to include non-ICU patients. Results A total of 134 patients were recruited over 47 site-months (mean 2.9 patients/site-month, median 1.0, range 0.1–4.4 patients/site-month). The overall recruitment rate exceeded the BALANCE-ICU pilot RCT (mean 1.10 patients/site-month, p

Published
2020
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3. The Effect of an Accelerated Renal Replacement Therapy Initiation Is Not Modified by Baseline Risk

Author

Federico Angriman, Bruno L. Ferreyro, Natalia Angeloni, Bruno R. da Costa, Ron Wald, Sean M. Bagshaw, Neill K.J. Adhikari, Rinaldo Bellomo, Didier Dreyfuss, Bin Du, Martin P. Gallagher, Stéphane Gaudry, François Lamontagne, Michael Joannidis, Kathleen D. Liu, Daniel F. McAuley, Shay P. McGuinness, Alistair D. Nichol, Marlies Ostermann, Paul M. Palevsky, Haibo Qiu, Ville Pettilä, Antoine G. Schneider, Orla M. Smith, Suvi T. Vaara, Matthew Weir, Glenn M. Eastwood, Leah Peck, Helen Young, Peter Kruger, Gordon Laurie, Emma Saylor, Jason Meyer, Ellen Venz, Krista Wetzig, Craig French, Forbes McGain, John Mulder, Gerard Fennessy, Sathyajith Koottayi, Samantha Bates, Miriam Towns, Rebecca Morgan, Anna Tippett, Andrew Udy, Chris Mason, Elisa Licari, Dashiell Gantner, Jason McClure, Alistair Nichol, Phoebe McCracken, Jasmin Board, Emma Martin, Shirley Vallance, Meredith Young, Chelsey Vladic, Steve McGloughlin, David Gattas, Heidi Buhr, Jennifer Coles, Debra Hutch, James Wun, Louise Cole, Christina Whitehead, Julie Lowrey, Kristy Masters, Rebecca Gresham, Victoria Campbell, David Gutierrez, Jane Brailsford, Loretta Forbes, Lauren Murray, Teena Maguire, Martina NiChonghaile, Neil Orford, Allison Bone, Tania Elderkin, Tania Salerno, Tim Chimunda, Jason Fletcher, Emma Broadfield, Sanjay Porwal, Cameron Knott, Catherine Boschert, Julie Smith, Angus Richardson, Dianne Hill, Graeme Duke, Peter Oziemski, Santiago Cegarra, Peter Chan, Deborah Welsh, Stephanie Hunter, Owen Roodenburg, John Dyett, Nicos Kokotsis, Max Moser, Yang Yang, Laven Padayachee, Joseph Vetro, Himangsu Gangopadhyay, Melissa Kaufman, Angaj Ghosh, Simone Said, Alpesh Patel, Shailesh Bihari, Elisha Matheson, Xia Jin, Tapaswi Shrestha, Kate Schwartz, Rosalba Cross, Winston Cheung, Helen Wong, Mark Kol, Asim Shah, Amanda Y. Wang, Zoltan Endre, Celia Bradford, Pierre Janin, Simon Finfer, Naomi Diel, Jonathan Gatward, Naomi Hammond, Anthony Delaney, Frances Bass, Elizabeth Yarad, Hergen Buscher, Claire Reynolds, Nerilee Baker, Romuald Bellmann, Andreas Peer, Julia Hasslacher, Paul Koglberger, Sebastian Klein, Klemens Zotter, Anna Brandtner, Armin Finkenstedt, Adelheid Ditlbacher, Frank Hartig, Dietmar Fries, Mirjam Bachler, Bettina Schenk, Martin Wagner, Philipp Eller, Thomas Staudinger, Esther Tiller, Peter Schellongowski, Andja Bojic, Eric A. Hoste, Stephanie Bracke, Luc De Crop, Daisy Vermeiren, Fernando Thome, Bianca Chiella, Lucia Fendt, Veronica Antunes, Frédérick D'Aragon, Charles St-Arnaud, Michael Mayette, Élaine Carbonnaeu, Joannie Marchand, Marie-Hélène Masse, Marilène Ladouceur, Alexis F. Turgeon, François Lauzier, David Bellemare, Charles Langis Francoeur, Guillaume LeBlanc, Gabrielle Guilbault, Stéphanie Grenier, Eve Cloutier, Annick Boivin, Charles Delisle-Thibault, Panagiota Giannakouros, Olivier Costerousse, Jean-François Cailhier, François-Martin Carrier, Ali Ghamraoui, Martine Lebrasseur, Fatna Benettaib, Maya Salamé, Dounia Boumahni, Ying Tung Sia, Jean-François Naud, Isabelle Roy, Henry T. Stelfox, Stacey Ruddell, Braden J. Manns, Shelley Duggan, Dominic Carney, Jennifer Barchard, Richard P. Whitlock, Emilie Belley-Cote, Nevena Savija, Alexandra Sabev, Troy Campbell, Thais Creary, Kelson Devereaux, Shira Brodutch, Claudio Rigatto, Bojan Paunovic, Owen Mooney, Anna Glybina, Oksana Harasemiw, Michelle Di Nella, John Harmon, Navdeep Mehta, Louis Lakatos, Nicole Haslam, Francois Lellouche, Mathieu Simon, Ying Tung, Patricia Lizotte, Pierre-Alexandre Bourchard, Bram Rochwerg, Tim Karachi, Tina Millen, John Muscedere, David Maslove, J. Gordon Boyd, Stephanie Sibley, John Drover, Miranda Hunt, Ilinca Georgescu, Randy Wax, Ilan Lenga, Kavita Sridhar, Andrew Steele, Kelly Fusco, Taneera Ghate, Michael Tolibas, Holly Robinson, Matthew A. Weir, Ravi Taneja, Ian M. Ball, Amit Garg, Eileen Campbell, Athena Ovsenek, Sean van Diepen, Nadia Baig, Sheldon Magder, Han Yao, Ahsan Alam, Josie Campisi, Erika MacIntyre, Ella Rokosh, Kimberly Scherr, Stephen Lapinsky, Sangeeta Mehta, Sumesh Shah, Daniel J. Niven, Michael Russell, Kym Jim, Gillian Brown, Kerry Oxtoby, Adam Hall, Luc Benoit, Colleen Sokolowski, Bhanu Prasad, Jag Rao, Shelley Giebel, Demetrios J. Kutsogiannis, Patricia Thompson, Tayne Thompson, Robert Cirone, Kanthi Kavikondala, Mark Soth, France Clarke, Alyson Takaoka, David Mazer, Karen Burns, Jan Friedrich, David Klein, Gyan Sandhu, Marlene Santos, Imrana Khalid, Jennifer Hodder, Peter Dodek, Najib Ayas, Victoria Alcuaz, Gabriel Suen, Oleksa Rewa, Gurmeet Singh, Sean Norris, Neil Gibson, Castro Arias, Aysha Shami, Celine Pelletier, Alireza Zahirieh, Andre Amaral, Nicole Marinoff, Navjot Kaur, Adic Perez, Jane Wang, Gregory Haljan, Christopher Condin, Lauralyn McIntyre, Brigette Gomes, Rebecca Porteous, Irene Watpool, Swapnil Hiremath, Edward Clark, Margaret S. Herridge, Felicity Backhouse, M. Elizabeth Wilcox, Karolina Walczak, Vincent Ki, Asheer Sharman, Martin Romano, R.T. Noel Gibney, Adam S. Romanovsky, Lorena McCoshen, Gordon Wood, Daniel Ovakim, Fiona Auld, Gayle Carney, Meili Duan, Xiaojun Ji, Dongchen Guo, Zhili Qi, Jin Lin, Meng Zhang, Lei Dong, Jingfeng Liu, Pei Liu, Deyuan Zhi, Guoqiang Bai, Yu Qiu, Ziqi Yang, Jing Bai, Zhuang Liu, Haizhou Zhuang, Haiman Wang, Jian Li, Mengya Zhao, Xiao Zhou, Xianqing Shi, Baning Ye, Manli Liu, Jing Wu, Yongjian Fu, Dali Long, Yu Pan, Jinlong Wang, Huaxian Mei, Songsong Zhang, Mingxiang Wen, Enyu Yang, Sijie Mu, Jianquan Li, Tingting Hu, Bingyu Qin, Min Li, Cunzhen Wang, Xin Dong, Kaiwu Wang, Haibo Wang, Jianxu Yang, Chuanyao Wang, Dongxin Wang, Nan Li, Zhui Yu, Song Xu, Lan Yao, Guo Hou, Zhou Liu, Liping Lu, Yingtao Lian, Chunting Wang, Jichen Zhang, Ruiqi Ding, Guoqing Qi, Qizhi Wang, Peng Wang, Zhaoli Meng, Man Chen, Xiaobo Hu, Xiandi He, Shibing Zhao, Lele Hang, Rui Li, Suhui Qin, Kun Lu, Shijuan Dun, Cheng Liu, Qi Zhou, Zhenzhen Chen, Jing Mei, Minwei Zhang, Hao Xu, Jincan Lin, Qindong Shi, Lijuan Fu, Qinjing Zeng, Hongye Ma, Jinqi Yan, Lan Gao, Hongjuan Liu, Lei Zhang, Hao Li, Xiaona He, Jingqun Fan, Litao Guo, Yu Liu, Xue Wang, Jingjing Sun, Zhongmin Liu, Juan Yang, Lili Ding, Lulu Sheng, Xingang Liu, Jie Yan, Quihui Wang, Yifeng Wang, Dan Zhao, Shuangping Zhao, Chenghuan Hu, Jing Li, Fuxing Deng, Haibo Qui, Yi Yang, Min Mo, Chun Pan, Changde Wu, Yingzi Huang, Lili Huang, Airan Liu, Anna-Maija Korhonen, Sanna Törnblom, Sari Sutinen, Leena Pettilä, Jonna Heinonen, Eliria Lappi, Taria Suhonen, Sari Karlsson, Sanna Hoppu, Ville Jalkanen, Anne Kuitunen, Markus Levoranta, Jaakko Långsjö, Sanna Ristimäki, Kaisa Malila, Anna Wootten, Simo Varila, Mikko J Järvisalo, Outi Inkinen, Satu Kentala, Keijo Leivo, Paivi Haltia, Jean-Damien Ricard, Jonathan Messika, Abirami Tiagarajah, Malo Emery, Aline Dechanet, Coralie Gernez, Damien Roux, Laurent Martin-Lefevre, Maud Fiancette, Isabelle Vinatier, Jean Claude Lacherade, Gwenhaël Colin, Christine Lebert, Marie-Ange Azais, Aihem Yehia, Caroline Pouplet, Matthieu Henry- Lagarrigue, Amélie Seguin, Laura Crosby, Julien Maizel, Dimitri Titeca-Beauport, Alain Combes, Ania Nieszkowska, Paul Masi, Alexandre Demoule, Julien Mayaux, Martin Dres, Elise Morawiec, Maxens Decalvele, Suela Demiri, Morgane Faure, Clémence Marios, Maxime Mallet, Marie Amélie Ordon, Laura Morizot, Marie Cantien, François Pousset, Florent Poirson, Yves Cohen, Laurent Argaud, Martin Cour, Laurent Bitker, Marie Simon, Romain Hernu, Thomas Baudry, Sylvie De La Salle, Adrien Robine, Nicholas Sedillot, Xavier Tchenio, Camille Bouisse, Sylvie Roux, Fabienne Tamion, Steven Grangé, Dorothée Carpentier, Guillaume Chevrel, Luis Ensenyat-Martin, Sophie Marque, Jean-Pierre Quenot, Pascal Andreu, Auguste Dargent, Audrey Large, Nicolas Chudeau, Mickael Landais, Benoit Derrien, Jean Christophe Callahan, Christophe Guitton, Charlène Le Moal, Alain Robert, Karim Asehnoune, Raphaël Cinotti, Nicolas Grillot, Dominique Demeure, Christophe Vinsonneau, Imen Rahmani, Mehdi Marzouk, Thibault Dekeyser, Caroline Sejourne, Mélanie Verlay, Fabienne Thevenin, Lucie Delecolle, Didier Thevenin, Bertrand Souweine, Elisabeth Coupez, Mireille Adda, Jean-Pierre Eraldi, Antoine Marchalot, Nicolas De Prost, Armand Mekontso Dessap, Keyvan Razazi, Ferhat Meziani, Julie Boisrame-Helms, Raphael Clere-Jehl, Xavier Delabranche, Christine Kummerlen, Hamid Merdji, Alexandra Monnier, Yannick Rabouel, Hassene Rahmani, Hayat Allam, Samir Chenaf, Vincenta Franja, Bertrand Pons, Michel Carles, Frédéric Martino, Régine Richard, Benjamin Zuber, Guillaume Lacave, Karim Lakhal, Bertrand Rozec, Hoa Dang Van, Éric Boulet, Fouad Fadel, Cedric Cleophax, Nicolas Dufour, Caroline Grant, Marie Thuong, Jean Reignier, Emmanuel Canet, Laurent Nicolet, Thierry Boulain, Mai-Anh Nay, Dalila Benzekri, François Barbier, Anne Bretagnol, Toufik Kamel, Armelle Mathonnet, Grégoire Muller, Marie Skarzynski, Julie Rossi, Amandine Pradet, Sandra Dos Santos, Aurore Guery, Lucie Muller, Luis Felix, Julien Bohé, Guillaume Thiéry, Nadia Aissaoui, Damien Vimpere, Morgane Commeureuc, Jean-Luc Diehl, Emmanuel Guerot, Orfeas Liangos, Monika Wittig, Alexander Zarbock, Mira Küllmar, Thomas van Waegeningh, Nadine Rosenow, Kathy Brickell, Peter Doran, Patrick T. Murray, Giovanni Landoni, Rosalba Lembo, Alberto Zangrillo, Giacomo Monti, Margherita Tozzi, Matteo Marzaroli, Gaetano Lombardi, Gianluca Paternoster, Michelangelo Vitiello, Shay McGuinness, Rachael Parke, Magdalena Butler, Eileen Gilder, Keri-Anne Cowdrey, Samantha Wallace, Jane Hallion, Melissa Woolett, Philippa Neal, Karina Duffy, Stephanie Long, Colin McArthur, Catherine Simmonds, Yan Chen, Rachael McConnochie, Lynette Newby, David Knight, Seton Henderson, Jan Mehrtens, Stacey Morgan, Anna Morris, Kymbalee Vander Hayden, Tara Burke, Matthew Bailey, Ross Freebairn, Lesley Chadwick, Penelope Park, Christine Rolls, Liz Thomas, Ulrike Buehner, Erin Williams, Jonathan Albrett, Simon Kirkham, Carolyn Jackson, Troy Browne, Jennifer Goodson, David Jackson, James Houghton, Owen Callender, Vicki Higson, Owen Keet, Clive Dominy, Paul Young, Anna Hunt, Harriet Judd, Cassie Lawrence, Shaanti Olatunji, Yvonne Robertson, Charlotte Latimer-Bell, Deborah Hendry, Agnes Mckay-Vucago, Nina Beehre, Eden Lesona, Leanlove Navarra, Chelsea Robinson, Ryan Jang, Andrea Junge, Bridget Lambert, Michel Thibault, Philippe Eckert, Sébastien Kissling, Erietta Polychronopoulos, Elettra Poli, Marco Altarelli, Madeleine Schnorf, Samia Abed Mallaird, Claudia Heidegger, Aurelie Perret, Philippe Montillier, Frederic Sangla, Seigenthaller Neils, Aude De Watteville, Mandeep-Kaur Phull, Aparna George, Nauman Hussain, Tatiana Pogreban, Steve Lobaz, Alison Daniels, Mishell Cunningham, Deborah Kerr, Alice Nicholson, Pradeep Shanmugasundaram, Judith Abrams, Katarina Manso, Geraldine Hambrook, Elizabeth McKerrow, Juvy Salva, Stephen Foulkes, Matthew Wise, Matt Morgan, Jenny Brooks, Jade Cole, Tracy Michelle Davies, Helen Hill, Emma Thomas, Marcela Vizcaychipi, Behrad Baharlo, Jaime Carungcong, Patricia Costa, Laura Martins, Ritoo Kapoor, Tracy Hazelton, Angela Moon, Janine Musselwhite, Ben Shelley, Philip McCall, Gill Arbane, Aneta Bociek, Martina Marotti, Rosario Lim, Sara Campos, Neus Grau Novellas, Armando Cennamo, Andrew Slack, Duncan Wyncoll, Luigi Camporota, Simon Sparkes, Rosalinde Tilley, Austin Rattray, Gayle Moreland, Jane Duffy, Elizabeth McGonigal, Philip Hopkins, Clare Finney, John Smith, Harriet Noble, Hayley Watson, Claire-Louise Harris, Emma Clarey, Eleanor Corcoran, James Beck, Clare Howcroft, Nora Youngs, Elizabeth Wilby, Bethan Ogg, Adam Wolverson, Sandra Lee, Susie Butler, Maryanne Okubanjo, Julia Hindle, Ingeborg Welters, Karen Williams, Emily Johnson, Julie Patrick-Heselton, David Shaw, Victoria Waugh, Richard Stewart, Esther Mwaura, Lynn Wren, Louise Mew, Sara-Beth Sutherland, Jane Adderley, Jim Ruddy, Margaret Harkins, Callum Kaye, Teresa Scott, Wendy Mitchell, Felicity Anderson, Fiona Willox, Vijay Jagannathan, Michele Clark, Sarah Purv, Andrew Sharman, Megan Meredith, Lucy Ryan, Louise Conner, Cecilia Peters, Dan Harvey, Ashraf Roshdy, Amy Collins, Malcolm Sim, Steven Henderson, Nigel Chee, Sally Pitts, Katie Bowman, Maria Dilawershah, Luke Vamplew, Elizabeth Howe, Paula Rogers, Clara Hernandez, Clara Prendergast, Jane Benton, Alex Rosenberg, Lui G. Forni, Alice Grant, Paula Carvelli, Ajay Raithatha, Sarah Bird, Max Richardson, Matthew Needham, Claire Hirst, Jonathan Ball, Susannah Leaver, Luisa Howlett, Carlos Castro Delgado, Sarah Farnell-Ward, Helen Farrah, Geraldine Gray, Gipsy Joseph, Francesca Robinson, Ascanio Tridente, Clare Harrop, Karen Shuker, Derek McLaughlan, Judith Ramsey, Sharon Meehan, Bernd Oliver Rose, Rosie Reece-Anthony, Babita Gurung, Tony Whitehouse, Catherine Snelson, Tonny Veenith, Andy Johnston, Lauren Cooper, Ron Carrera, Karen Ellis, Emma Fellows, Samanth Harkett, Colin Bergin, Elaine Spruce, Liesl Despy, Stephanie Goundry, Natalie Dooley, Tracy Mason, Amy Clark, Gemma Dignam, Geraldine Ward, Ben Attwood, Penny Parsons, Sophie Mason, Michael Margarson, Jenny Lord, Philip McGlone, Luke E. Hodgson, Indra Chadbourn, Raquel Gomez, Jordi Margalef, Rinus Pretorius, Alexandra Hamshere, Joseph Carter, Hazel Cahill, Lia Grainger, Kate Howard, Greg Forshaw, Zoe Guy, Kianoush B. Kashani, Robert C. Albright, Amy Amsbaugh, Anita Stoltenberg, Alexander S. Niven, Matthew Lynch, AnnMarie O'Mara, Syed Naeem, Sairah Sharif, Joyce McKenney Goulart, Ashita Tolwani, Claretha Lyas, Laura Latta, Azra Bihorac, Haleh Hashemighouchani, Philip Efron, Matthew Ruppert, Julie Cupka, Sean Kiley, Joshua Carson, Peggy White, George Omalay, Sherry Brown, Laura Velez, Alina Marceron, Javier A. Neyra, Juan Carlos Aycinena, Madona Elias, Victor M. Ortiz-Soriano, Caroline Hauschild, and Robert Dorfman

Subjects
Renal Replacement Therapy, Pulmonary and Respiratory Medicine, Critical Illness, Medicine and Health Sciences, Humans, Acute Kidney Injury
Published
2022
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4. Diarrhea during critical illness: a multicenter cohort study

Author

Joanna C, Dionne, Lawrence, Mbuagbaw, John W, Devlin, Matthew S, Duprey, Rodrigo, Cartin-Ceba, Jennifer, Tsang, Kristen, Sullivan, John, Muscedere, Mohammed, Alshahrani, Wojciech, Szczeklik, Paul, Lysecki, Alyson, Takaoka, Brenda, Reeve, Tracy, Campbell, Karolina, Borowska, Wojciech, Serednicki, Robert, Cirone, Waleed, Alhazzani, Paul, Moayyedi, David, Armstrong, Lehana, Thabane, Roman, Jaeschke, Cindy, Hamielec, Tim, Karachi, Deborah J, Cook, and K, Borowska

Subjects
Adult, Diarrhea, Intensive Care Units, Enteral Nutrition, Critical Illness, Humans, Prospective Studies, Length of Stay
Abstract

To study the incidence, predictors, and outcomes of diarrhea during the stay in the intensive care unit (ICU).Prospective cohort of consecutive adults in the ICU for 24 h during a 10-week period across 12 intensive care units (ICUs) internationally. The explored outcomes were: (1) incidence of diarrhea, (2) Clostridioides difficile-associated diarrhea (CDAD); (3) ICU and hospital length of stay (LOS) and mortality in patients with diarrhea. We fit generalized linear models to evaluate the predictors, management, morbidity and mortality associated with diarrhea.Among 1109 patients aged 61.4 (17.5) [mean (standard deviation)] years, 981(88.5%) were medical and 645 (58.2%) were mechanically ventilated. The incidence was 73.8% (818 patients, 73.8%, 95% confidence interval [CI] 71.1-76.6) using the definition of the World Health Organisation (WHO). Incidence varied across definitions (Bristol 53.5%, 95% CI 50.4-56.7; Bliss 37.7%, 95% CI 34.9-40.4). Of 99 patients with diarrhea undergoing CDAD testing, 23 tested positive (2.2% incidence, 95% CI 1.5-3.4). Independent predictors included enteral nutrition (RR 1.23, 95% CI 1.16-1.31, p 0.001), antibiotic days (RR 1.02, 95% CI 1.02-1.03, p 0.001), and suppositories (RR 1.14 95% CI 1.06-1.22, p 0.001). Opiates decreased diarrhea risk (RR 0.76, 95% CI 0.68-0.86, p 0.001). Diarrhea prompted management modifications (altered enteral nutrition or medications: RR 10.25, 95% CI 5.14-20.45, p 0.001) or other consequences (fecal management device or CDAD testing: RR 6.16, 95% CI 3.4-11.17, p 0.001). Diarrhea was associated with a longer time to discharge for ICU or hospital stay, but was not associated with hospital mortality.Diarrhea is common, has several predictors, and prompts changes in patient care, is associated with longer time to discharge but not mortality.

Published
2021

5. Effect of Probiotics on Incident Ventilator-Associated Pneumonia in Critically Ill Patients: A Randomized Clinical Trial

Author

Peter Dodek, Lehana Thabane, Arnold S. Kristof, Michael G. Surette, Joanna C. Dionne, Francois Lamontagne, Ryan Zarychanski, James Kutsogiannis, Lauralyn McIntyre, David Williamson, Daniel Ovakim, Diane Heels-Ansdell, François Lauzier, Daphnée Lamarche, Dave Nagpal, Deborah J. Cook, Henry T. Stelfox, Neill K. J. Adhikari, Daniel J. Niven, Robert Cirone, Frédérick D’Aragon, Sangeeta Mehta, Rodrigo Cartin-Ceba, Erick Duan, François Marquis, Charles St-Arnaud, Alberto Goffi, Paul Hosek, Eyal Golan, Osama Loubani, Kosar Khwaja, William R. Henderson, Jan O. Friedrich, Maureen O. Meade, John Granton, Jennifer L Y Tsang, Robert W. Taylor, Paul J Lysecki, John Muscedere, Yaseen M. Arabi, Endotracheal Colonization Trial (Prospect) Investigators, Tim Karachi, Richard I. Hall, M. Elizabeth Wilcox, Nicole Zytaruk, John Marshall, François Lellouche, Alexandra Binnie, Jennie Johnstone, Patrick Archambault, Martin Girard, Margaret S. Herridge, Wendy I. Sligl, Bram Rochwerg, Gordon Wood, Ian M Ball, Shane W. English, Emmanuel Charbonney, Sébastien Trop, Steve Reynolds, Brenda Reeve, Bojan Paunovic, and Pierre Aslanian

Subjects
Diarrhea, Male, medicine.medical_specialty, Population, Placebo, law.invention, Randomized controlled trial, Lactobacillus rhamnosus, law, Internal medicine, medicine, Humans, Treatment Failure, education, Adverse effect, Aged, Original Investigation, education.field_of_study, biology, business.industry, Lacticaseibacillus rhamnosus, Probiotics, Hazard ratio, Ventilator-associated pneumonia, Pneumonia, Ventilator-Associated, General Medicine, Bacterial Infections, Middle Aged, medicine.disease, biology.organism_classification, Intensive care unit, Respiration, Artificial, Anti-Bacterial Agents, Intensive Care Units, Female, business
Abstract

IMPORTANCE: Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported. OBJECTIVE: To evaluate the effect of Lactobacillus rhamnosus GG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU). DESIGN, SETTING, AND PARTICIPANTS: Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020). INTERVENTIONS: Enteral L rhamnosus GG (1 × 10(10) colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU. MAIN OUTCOMES AND MEASURES: The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections including Clostridioides difficile infection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality. RESULTS: Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.] with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22; P = .73, absolute difference, 0.6%, 95% CI, –2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event of L rhamnosus in a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58; P

Published
2021

6. A pilot randomized controlled trial of 7 versus 14 days of antibiotic treatment for bloodstream infection on non-intensive care versus intensive care wards

Author

Robert Cirone, Ruxandra Pinto, Shay McGuinness, Richard P. Whitlock, Richard I. Hall, Deborah J. Cook, Rachael Parke, John Muscedere, Asgar H. Rishu, Nick Daneman, Steven Reynolds, Yahya Shehabi, Lauralyn McIntyre, Robert A. Fowler, Phillip Shin, Yaseen M. Arabi, Benjamin A. Rogers, Mark Downing, and Emilie P. Belley-Côté

Subjects
Male, medicine.medical_specialty, Time Factors, medicine.drug_class, Antibiotics, Medicine (miscellaneous), Bacteremia, Comorbidity, Bloodstream infection, law.invention, 03 medical and health sciences, 0302 clinical medicine, Clinical Protocols, Randomized controlled trial, law, Intensive care, Internal medicine, medicine, Humans, Pharmacology (medical), 030212 general & internal medicine, Mortality, Aged, Aged, 80 and over, 0303 health sciences, lcsh:R5-920, 030306 microbiology, business.industry, Research, Mortality rate, Middle Aged, medicine.disease, Intensive care unit, Anti-Bacterial Agents, 3. Good health, Intensive Care Units, Critical care, Treatment Outcome, Sample size determination, Case-Control Studies, Feasibility Studies, Female, business, Duration of treatment, lcsh:Medicine (General)
Abstract

Background The optimal treatment duration for patients with bloodstream infection is understudied. The Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE) pilot randomized clinical trial (RCT) determined that it was feasible to enroll and randomize intensive care unit (ICU) patients with bloodstream infection to 7 versus 14 days of treatment, and served as the vanguard for the ongoing BALANCE main RCT. We performed this BALANCE-Ward pilot RCT to examine the feasibility and impact of potentially extending the BALANCE main RCT to include patients hospitalized on non-ICU wards. Methods We conducted an open pilot RCT among a subset of six sites participating in the ongoing BALANCE RCT, randomizing patients with positive non-Staphylococcus aureus blood cultures on non-ICU wards to 7 versus 14 days of antibiotic treatment. The co-primary feasibility outcomes were recruitment rate and adherence to treatment duration protocol. We compared feasibility outcomes, patient/pathogen characteristics, and overall outcomes among those enrolled in this BALANCE-Ward and prior BALANCE-ICU pilot RCTs. We estimated the sample size and non-inferiority margin impacts of expanding the BALANCE main RCT to include non-ICU patients. Results A total of 134 patients were recruited over 47 site-months (mean 2.9 patients/site-month, median 1.0, range 0.1–4.4 patients/site-month). The overall recruitment rate exceeded the BALANCE-ICU pilot RCT (mean 1.10 patients/site-month, p p = 0.0003). BALANCE-Ward patients were older, with lower Sequential Organ Failure Assessment scores, and higher proportions of infections caused by Escherichia coli and genito-urinary sources of bloodstream infection. The BALANCE-Ward pilot RCT patients had an overall 90-day mortality rate of 17/133 (12.8%), which was comparable to the 90-day mortality rate in the ICU pilot RCT (17/115, 14.8%) (p = 0.65). Simulation models indicated there would be minimal sample size and non-inferiority margin implications of expanding enrolment to increasing proportions of non-ICU versus ICU patients. Conclusion It is feasible to enroll non-ICU patients in a trial of 7 versus 14 days of antibiotics for bloodstream infection, and expanding the BALANCE RCT hospital-wide has the potential to improve the timeliness and generalizability of trial results. Trial registration Clinicaltrials.gov, NCT02917551. Registered on September 28, 2016.

Published
2020

7. A real-world assessment of procalcitonin combined with antimicrobial stewardship in a community ICU

Author

Robert Cirone, M. Downing, A. Chan, Kevin L Schwartz, Daniel Beriault, J. Seah, M.D. Pasic, and B.J. Langford

Subjects
Adult, medicine.medical_specialty, Critical Care, medicine.drug_class, Antibiotics, Context (language use), Hospitals, Community, Critical Care and Intensive Care Medicine, Procalcitonin, law.invention, 03 medical and health sciences, Antimicrobial Stewardship, 0302 clinical medicine, law, Antibiotic therapy, medicine, Antimicrobial stewardship, Humans, Antibiotic use, Aged, Ontario, business.industry, 030208 emergency & critical care medicine, Middle Aged, Intensive care unit, Community hospital, Anti-Bacterial Agents, Intensive Care Units, 030228 respiratory system, Emergency medicine, Guideline Adherence, business, hormones, hormone substitutes, and hormone antagonists, Biomarkers
Abstract

Purpose We evaluated the feasibility and impact of PCT-guided antibiotic duration combined with an established antibiotic stewardship program (ASP) in a community hospital intensive care unit (ICU). Methods We implemented daily PCT levels for ICU patients receiving antibiotics. Our protocol recommended stopping antibiotic therapy if PCT met an absolute or relative stopping threshold. We evaluated the adherence to stopping criteria within 48 h, antibiotic use [days of therapy (DOT) per 1000 patient-days (PD)], length of stay and ICU-mortality. We performed interrupted time series analysis to compare 24 months before and 12 months after implementation. Results A total of 297 antibiotic courses were monitored with PCT in 217 patients. Protocol adherence was 34% (absolute threshold: 39%, relative threshold: 12%). Antibiotic use pre-PCT was 935 DOTs/1000 PDs and post-PCT was 817 DOTs/1000 PDs (RRadj 0.73, 95% CI: 0.62 to 0.86). No statistically significant changes in clinical outcomes were noted. Conclusion In the context of an established ASP in a community hospital ICU, PCT monitoring was feasible and associated with an adjusted overall decrease of 27% in antibiotic use with no adverse impact on clinical outcomes. Incorporating PCT testing to guide antibiotic duration can be successful if integrated into workflow and paired with ASP guidance.

Published
2019

8. 1995. Serial Procalcitonin Measurement in a Community Intensive Care Unit: Is There Value in the Setting of an Established Antibiotic Stewardship Program?

Author

April Chan, Kevin L Schwartz, Bradley J Langford, Maria Pasic, Daniel Beriault, Mark Downing, Jenny Seah, and Robert Cirone

Subjects
medicine.medical_specialty, business.industry, Intensive care unit, law.invention, Abstracts, Infectious Diseases, Oncology, law, Poster Abstracts, medicine, Antibiotic Stewardship, Intensive care medicine, Procalcitonin Measurement, business, Value (mathematics)
Abstract

Background Procalcitonin (PCT) monitoring has been shown to result in reduced antibiotic use without an impact on patient outcomes. However, the real-world value of this biomarker has yet to be determined, particularly when efforts to optimize antibiotic use are already in place. We evaluated the feasibility and impact of PCT-guided antibiotic duration combined with an established antibiotic stewardship program (ASP) in a community hospital intensive care unit (ICU) in Toronto, Canada. Methods We conducted a quality improvement initiative in our ICU from November 2017 to October 2018 measuring daily PCT levels for immunocompetent patients receiving antibiotic therapy for suspected or proven bacterial infection with an expected duration between 48 hours and 21 days. Our protocol recommended stopping antibiotic therapy if PCT fell below 0.5 μg/L (absolute threshold) or if it dropped more than 80% from its peak value (relative threshold). ASP rounds took place twice weekly since 2013, integrating a regular discussion about PCT levels once this initiative was implemented. We evaluated the adherence to stopping criteria within 48h, antibiotic use (days of therapy per 1,000 patient-days), length of stay, 48h re-admission, and ICU-mortality. Interrupted time series with segmented regression was performed to evaluate pre-post intervention differences compared with the 12-months prior to implementation. Results A total of 297 antibiotic courses were monitored with PCT in 217 patients. Respiratory (62%), unknown infection (11%), and intra-abdominal infection (7%) were the most common reasons for antibiotics. Protocol adherence was 34% (absolute threshold: 39%, relative threshold: 12%). Adherence by ICU physician varied widely between 24% and 52%. Antibiotic use pre-PCT was 1,002 DOTs/1,000 PDs and post-PCT was 817 DOTs/1,000 PDs (adjusted change −15%, 95% CI: −28% to +8%) (Figure 1). No statistically significant changes in clinical outcomes were noted. Conclusion In the context of an active ASP in a community hospital ICU, PCT monitoring was associated with a non-significant decrease in antibiotic use. Further evaluation of reasons for inter-physician variability in adherence and opportunities for improved and sustained overall adherence should be explored. Disclosures All authors: No reported disclosures.

Published
2019
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9. Frequency of Screening and SBT Technique Trial

Author

Bram Rochwerg, Deborah J. Cook, Burns Kea, Seely Aje, Francois Lamontagne, Robert Cirone, Peter Dodek, Thomas Piraino, Eric Honig, Maged Tanios, and Leena Rizvi

Subjects
Mechanical ventilation, Pediatrics, medicine.medical_specialty, Critically ill, business.industry, medicine.medical_treatment, Intensive care unit, law.invention, Spontaneous breathing trial, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, law, Emergency medicine, medicine, Breathing, 030212 general & internal medicine, business, Trial registration, 030217 neurology & neurosurgery
Abstract

Rationale: Research supports the use of screening protocols to identify patients who are candidates for weaning from mechanical ventilation, and the use of spontaneous breathing trials (SBTs) to predict ability to breathe spontaneously. However, once daily screening is poorly aligned with 24-hour continuous care in the intensive care unit (ICU) environment and the most effective SBT technique is not known. The optimal strategy to liberate our sickest patients from ventilators remains to be determined. Objectives: To assess our ability to recruit critically ill adults and adhere to the screening and SBT protocols. Methods: We propose a pilot, factorial design, randomized trial comparing once-daily versus at least twice daily screening and pressure support (PS) ± positive end-expiratory pressure (PEEP) (inspiratory ± expiratory support) or T-piece (no support) as the SBT technique in critically ill adults who are invasively ventilated for at least 24 hours in 11 North American ICUs. Respiratory Therapists (RTs) will screen all enrolled patients between 06:00 and 08:00 hours daily to identify SBT candidates. Patients in the at least twice daily screening arms will also be screened between 13:00 and 15:00 hours; additional screening will be permitted at clinician’s discretion. Once a screening assessment is passed, an SBT will be conducted with the assigned technique. Outcomes: The study will be considered feasible if at least 1 to 2 patients per ICU per month are recruited and if the screening and SBT protocols are adhered to >80% of the time. Relevance: The availability of RTs in ICUs presents an important opportunity to screen patients more frequently, conduct more frequent SBTs, and reduce the duration of invasive ventilation and ICU stay. FAST Trial Registration: Clinical Trials.gov NCT02399267.

Published
2016
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10. Abstracts

Author

W. A. C. Mutch, I. W. C. White, N. Donen, I. R. Thomson, M. Rosenbloom, M. Cheang, M. West, Greg Bryson, Christina Mundi, Jean-Yves Dupuis, Michael Bourke, Paul McDonagh, Michael Curran, John Kitts, J. Earl Wynands, Alison S. Carr, Elizabeth J. Hartley, Helen M. Holtby, Peter Cox, Bruce A. Macpherson, James E. Baker, Andrew J. Baker, C. David Mazer, C. Peniston, T. David, D. C. H. Cheng, J. Karski, B. Asokumar, J. Carroll, H. Nierenberg, S. Roger, A. N. Sandier, J. Tong, C. M. Feindel, J. F. Boylan, S. J. Teasdale, J. Boylan, P. Harley, Jennifer E. Froelich, David P. Archer, Alastair Ewen, Naaznin Samanani, Sheldon H. Roth, Richard I. Hall, Michael Neumeister, Gwen Dawe, Cathy Cody, Randy O’Brien, Jan Shields-Thomson, Kenneth M. LeDez, Catherine Penney, Walter Snedden, John Tucker, Nicolas Fauvel, Mladen Glavinovic, François Donati, S. B. Backman, R. D. Stein, C. Polosa, C. Abdallah, S. Gal, A. John Clark, George A. Doig, Tunde Gondocz, E. A. Peter, A. Lopez, A. Mathieu, Pierre Couture, Daniel Boudreault, Marc Derouin, Martin Allard, Gilbert Blaise, Dominique Girard, Richard L. Knill, Teresa Novick, Margaret K. Vandervoort, Frances Chung, Shantha Paramanathar, Smita Parikh, Charles Cruise, Christina Michaloliakou, Brenda Dusek, D. K. Rose, M. M. Cohen, D. DeBoer, George Shorten, Earnest Cutz, Jerrold Lerman, Myrna Dolovich, Edward T. Crosby, Robert Cirone, Dennis Reid, Joanne Lind, Melanie Armstrong, Wanda Doyle, S. Halpern, P. Glanc, T. Myhr, M -L. Ryan, K. Fong, K. Amankwah, A. Ohlsson, R. Preston, Andor Petras, Michael J. Jacka, Brian Milne, Kanji Nakatsu, S. Pancham, Graeme Smith, Kush N. Duggal, M. Joanne Douglas, Pamela M. Merrick, Philip Blew, Donald Miller, Raymond Martineau, Kathryn Hull, C. M. Baron, S. Kowalskl, R. Greengrass, T. Horan, H. Unruh, C. L. Baron, Patricia M. Cruchley, K. Nakajima, Y. Sugiura, Y. Goto, K. Takakura, J. Harada, Robert M. K. W. Lee, Angelica M. Fargas-Babjak, Jin Ni, Eva S. Werstiuk, Joseph Woo, David H. Morison, Michael D. McHugh, Hanna M. Pappius, Hironori Ishihara, Yuki Shimodate, Hiroaki Koh, Akitomo Matsuki, John W. R. Mclntyre, Pierre Bergeron, Lulz G. R. DeLima, Jean-Yves Dupuls, James Enns, J. M. Murkin, F. N. McKenzie, S. White, N. A. Shannon, Wojciech B. Dobkowski, Judy L. Kutt, Bernard J. Mezon, David R. Grant, William J. Wall, Dennis D. Doblar, Yong C. Lim, Luc Frenette, Jaime R. Ronderos, Steve Poplawski, Dinesh Ranjan, L. Dubé, L. Van Obbergh, M. Francoeur, C. Blouin, R. Carrier, D. Doblar, J. Ronderos, D. Singer, J. Cox, B. Gosdin, M. Boatwright, Charles E. Smith, Aleksandr Rovner, Carlos Botero, Curt Holbrook, Nileshkumar Patel, Alfred Pinchak, Alfred C. Pinchak, Yin James Kao, Andrew Thio, Steven J. Barker, Patrick Sullivan, Matthew Posner, C. William Cole, Patty Lindsay, Paul B. Langevin, Paul A. Gulig, N. Gravenstein, David T. Wong, Manuel Gomez, Glenn P. McGuire, Robert J. Byrick, Shared K. Sharma, Frederick J. Carmicheal, Walter J. Montanera, Sharad Sharma, D. A. Yee, Basem I. Naser, G. L. Bryson, J. B. Kitts, D. R. Miller, R. J. Martineau, M. J. Curran, P. R. Bragg, Jacek M. Karski, Davy Cheng, Kevin Bailey, S. Levytam, R. Arellano, J. Katz, J. Doyle, Mitchel B. Sosis, William Blazek, G. Plourde, A. Malik, Tammy Peddle, James Au, Jeffrey Sloan, Mark Cleland, Donald E. Hancock, Nilesh Patel, Frank Costello, Louise Patterson, Masao Yamashita, Tsukasa Kondo, M. R. Graham, D. Thiessen, David F. Vener, Thomas Long, S. Marion, D. J. Steward, Berton Braverman, Mark Levine, Steve Yentis, Catherine R. Bachman, Murray Kopelow, Ann McNeill, R. Graham, Norbert Froese, Leena Patel, Heinz Reimer, Jo Swartz, Suzanne Ullyot, Harley Wong, Maria A. Markakis, Nancy Siklch, Blair D. Goranson, Scott A. Lang, Martin J. Stockwell, Bibiana Cujec, Raymond W. Yip, Lucy C. Southeriand, Tanya Duke B. Vet, Jeisane M. Gollagher, Lesley-Ann Crone, James G. Ferguson, Demetrius Litwin, Maria Bertlik, Beverley A. Orser, Lu-Wang Yang, John F. MacDonald, Gary F. Morris, Wendy L. Gore-Hickman, J. E. Zamora, O. P. Rosaeg, M. P. Lindsay, M. L. Crossan, Carol Pattee, Michael Adams, John P. Koller, Guy J. Lavoie, Wynn M. Rigal, Dylan A. Taylor, Michael G. Grace, Barry A. Flnegan, Christopher Hawkes, Harry Hopkins, Michael Tierney, David R. Drover, Gordon Whatley, J. W. Donald Knox, Jarmila Rausa, Hossam El-Beheiry, Ronald Seegobin, Georgia C. Hirst, William N. Dust, J. David Cassidy, D. Boisvert, H. Braden, M. L. Halperin, S. Cheema-Dhadli, D. J. McKnight, W. Singer, Thomas Elwood, Shirley Huchcroft, Charles MacAdams, R. Peter Farran, Gerald Goresky, Phillip LaLande, Gilles Lacroix, Martin Lessard, Claude Trépanier, Janet M. van Vlymen, Joel L. Parlow, Chikwendu Ibebunjo, Arnold H. Morscher, Gregory J. Gordon, H. P. Grocott, Susan E. Belo, Georgios Koutsoukos, Susan Belo, David Smith, Sarah Henderson, Adriene Gelb, G. Kantor, N. H. Badner, W. E. Komar, R. Bhandari, D. Cuillerier, W. Dobkowski, M. H. Smith, A. N. Vannelli, Sean Wharton, Mike Tierney, E. Redmond, E. Reddy, A. Gray, J. Flynn, R. B. Bourne, C. H. Rorabeck, S. J. MacDonald, J. A. Doyle, Peter T. Newton, Carol A. Moote, R. Joiner, M. F. X. Glynn, Vytas Zulys, M. Hennessy, T. Winton, W. Demajo, William P. S. McKay, Peter H. Gregson, Benjamin W. S. McKay, Julio Militzer, Eric Hollebone, Raymond Yee, George Klein, R. L. Garnett, J. Conway, F. E. Ralley, G. R. Robbins, James E. Brown, J. V. Frei, Edward Podufal, Norman J. Snow, Altagracia M. Chavez, Richard P. Kramer, D. Mickle, William A. Tweed, Bisharad M. Shrestha, Narendra B. Basnyat, Bhawan D. Lekhak, Susan D. O’Leary, J. K. Maryniak, John H. Tucker, Cameron B. Guest, J. Brendan Mullen, J. Colin Kay, Dan F. Wigglesworth, Mashallah Goodarzi, Nicte Ha Shier, John A. Ogden, O. R. Hung, S. Pytka, M. F. Murphy, B. Martin, and R. D. Stewart

Subjects
Anesthesiology and Pain Medicine, General Medicine
Published
1994
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