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To determine whether nutritional status at hospital admission is independently associated with new-onset delirium (NOD) in elderly, orthopaedic trauma patients.Single-center, retrospective, cross-sectional study.Data from patients at a large teaching hospital in Boston, MA, were analyzed.All patients were ≥65 years and hospitalized for acute surgical management of their major fractures after trauma.None.Nutritional status was assessed at admission using the Mini Nutritional Assessment-Short Form (MNA-SF). Delirium was assessed using the Confusion Assessment Method within 24 hours of admission and daily throughout hospitalization.The incidence of delirium was 20% (94/471). Each unit decrement in MNA-SF was associated with a 14% higher risk of NOD (adjusted OR 1.14; 95% CI 1.05-1.28). Moreover, malnourished patients (MNA-SF score 0-7) were twice as likely to develop NOD (adjusted OR 2.07; 95% CI 1.01-4.35) compared with patients who were not malnourished (MNA-SF score 8-14).In hospitalized, elderly, orthopaedic trauma patients, poor nutritional status may be a modifiable risk factor for NOD. Future studies are needed to determine whether aggressive nutritional interventions can reduce the incidence of NOD and improve outcomes in this cohort of patients.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The STOP-Bang questionnaire is an established clinical screening tool to identify the risk of having mild, moderate or severe obstructive sleep apnoea using eight variables. It is unclear whether all eight variables contribute equally to the risk of clinically significant obstructive sleep apnoea. We analysed each variable for its contribution to detecting obstructive sleep apnoea; based on the results, we investigated whether the STOP-Bang questionnaire could be abbreviated to identify patients at high risk for severe obstructive sleep apnoea. We recruited patients with suspected obstructive sleep apnoea who were referred for overnight polysomnography. We used multivariable logistic regression to investigate the association of STOP-Bang parameters with severe obstructive sleep apnoea based on clinical and polysomnography data. Regression estimates were used to select variables to create the novel B-APNEIC score. We constructed receiver operating characteristic curves for the STOP-Bang questionnaire and B-APNEIC scores to identify patients with severe obstructive sleep apnoea and compared the areas under the curve using the DeLong method. Of the 275 patients enrolled, 32% (n = 88) had severe obstructive sleep apnoea. Logistic regression demonstrated that neck circumference (OR 2.20; 95%CI 1.10-4.40, p = 0.03) was the only variable independently associated with severe obstructive sleep apnoea. Observed apnoea during sleep, blood pressure and body mass index were the three next most closely trending predictors of severe obstructive sleep apnoea and were included along with neck circumference in the B-APNEIC score. Receiver operating curves demonstrated that the areas under the curve for STOP-Bang vs. B-APNEIC were comparable for identifying patients with severe obstructive sleep apnoea (OR 0.75; 95%CI 0.68-0.81 vs. OR 0.75; 95%CI 0.68-0.81: p = 0.99, respectively). Our results suggest that the B-APNEIC score is a simplified adaptation of the STOP-Bang questionnaire with equivalent effectiveness in identifying patients with severe obstructive sleep apnoea. Further studies are needed to validate and build on our findings.

Background Central nervous system complications are reported in an increasing number of patients with Coronavirus Disease 2019 (COVID-19). COVID-19-related Guillain-Barre syndrome (GBS) is of particular importance given its association with higher mortality rates and prolonged respiratory failure. Review summary We conducted a systematic review of published cases for COVID-19-related GBS, and provide a summary of clinical management strategies for these cases. Sixty-three studies, including 86 patients, were included. Seventy-six cases with reported outcome data were eligible for the outcome analysis. Ninety-nine percent of patients were diagnosed with COVID-19 before diagnosis of GBS (median: 14 d prior, interquartile range: 7 to 20). Intravenous immunotherapy (intravenous immunoglobulin: 0.4 g/kg/d for 5 d) was the most frequently used treatment approach. The review indicated that the outcome was not favorable in 26% of cases (persistent neurological deficits). A mortality rate of 3.5% was observed in patients with COVID-19-related GBS. Conclusions Although evidence to support specific treatments is lacking, clinicians should consider the benefits of immunotherapy and plasma exchange in addition to the standard antimicrobial and supportive therapies for patients who meet the diagnostic criteria for acute sensory and motor polyradiculoneuritis. Intravenous immunoglobulin treatment alone is not shown to result in improved outcomes or mortality. More extensive studies aimed at exploring the neurological manifestations and complications of COVID-19 and distinctive treatment options for COVID-19-related GBS are warranted.

BACKGROUND Nutrition is often thought to influence outcomes in critically ill patients. However, the relationship between macronutrient delivery and functional status is not well characterized. Our goal was to investigate whether caloric or protein deficit over the course of critical illness is associated with functional status at the time of intensive care unit (ICU) discharge. METHODS We performed a retrospective analysis of surgical ICU patients at a teaching hospital in Boston, MA. To investigate the association of caloric or protein deficit with Functional Status Score for the ICU (FSS-ICU), we constructed linear regression models, controlling for age, sex, race, body mass index, Nutritional Risk in the Critically Ill score, and ICU length of stay. We then dichotomized caloric as well as protein deficit, and performed logistic regressions to investigate their association with functional status, controlling for the same variables. RESULTS Linear regression models (n = 976) demonstrated a caloric deficit of 238 kcal (237.88; 95%CI 75.13-400.63) or a protein deficit of 14 g (14.23; 95%CI 4.46-24.00) was associated with each unit decrement in FSS-ICU. Logistic regression models demonstrated a 6% likelihood (1.06; 95%CI 1.01-1.14) of caloric deficit ≥6000 vs.

Among elderly orthopedic trauma patients, the prevalence of delirium during hospitalization has been reported to be as high as 60%. Frail elderly patients have an increased risk of delirium after elective surgery; however, such an association remains underexplored among trauma patients. Our goal was to investigate whether preoperative frailty is associated with postoperative delirium (POD) in elderly orthopedic trauma patients. We conducted a single-center, retrospective, cross-sectional study. All patients were ≥ 65 years of age and were admitted to the hospital between 01/01/2017 and 08/31/2018 for surgical intervention of a significant extremity fracture. Frailty was assessed using the fatigue, resistance, ambulation, illness, and loss of weight questionnaire. Delirium was assessed using the Confusion Assessment Method. POD was defined as new-onset delirium that occurred within 24 h after surgery. To investigate whether frailty is associated with POD, we performed a multiple variable logistic regression, controlling for biologically relevant confounders. Five hundred fifty-six patients comprised the analytic cohort. Incidence of POD was 14% (n = 80). Multiple variable regression analysis demonstrated that each unit increment in FRAIL score was associated with a 33% higher likelihood of POD (OR 1.33; 95% CI 1.02–1.72, p = 0.03). Our results suggest that preoperative frailty increases the risk of POD in hospitalized, elderly, orthopedic trauma patients. Future studies are needed to determine whether perioperative interventions focused on improving frailty can reduce the risk of POD and improve outcomes in this rapidly growing cohort of patients.

BACKGROUND Recent data on the prevalence of essential trace element (ETE) deficiencies in home parenteral nutrition (HPN) patients are scarce. We investigated whether ETE deficiencies are still an important issue for HPN patients and whether the prevalence of such deficiencies may be influenced by nationwide drug shortages. METHODS We conducted a single-institution, retrospective analysis from 2006 to 2015 of hospitalized HPN patients who continued PN during and in between hospitalizations. In subgroup analysis, patients were dichotomized as those with HPN duration

Background Frailty has been associated with increased incidence of postoperative delirium and mortality. We hypothesised that postoperative delirium mediates a clinically significant (≥1%) percentage of the effect of frailty on mortality in older orthopaedic trauma patients. Methods This was a single-centre, retrospective observational study including 558 adults 65 yr and older, who presented with an extremity fracture requiring hospitalisation without initial ICU admission. We used causal statistical inference methods to estimate the relationships between frailty, postoperative delirium, and mortality. Results In the cohort, 180-day mortality rate was 6.5% (36/558). Frail and prefrail patients comprised 23% and 39%, respectively, of the study cohort. Frailty was associated with increased 180 day mortality from 1.4% to 12.2% (11% difference; 95% confidence interval [CI], 8.4–13.6), which translated statistically into an 88.7% (79.9–94.3%) direct effect and an 11.3% (5.7–20.1%) postoperative delirium mediated effect. Prefrailty was also associated with increased 180 day mortality from 1.4% to 4.4% (2.9% difference; 2.4–3.4), which was translated into a 92.5% (83.8–99.9%) direct effect and a 7.5% (0.1–16.2%) postoperative delirium mediated effect. Conclusions Frailty is associated with increased postoperative mortality, and delirium might mediate a clinically significant, but small percentage of this effect. Studies should assess whether, in patients with frailty, attempts to mitigate delirium might decrease postoperative mortality.

Background: Acute respiratory distress syndrome (ARDS) is a highly morbid condition that has limited therapeutic options. Optimal vitamin D status has been linked to immunological effects that may benefit critically ill patients. Therefore, we investigated whether admission 25-hydroxyvitamin D levels (25OHD) are associated with clinical outcomes in ARDS patients. Methods: We performed a secondary analysis of data from a randomized, controlled trial comparing oxygenation strategies in 549 patients with ARDS (NCT00000579). Baseline 25OHD was measured in stored plasma samples. We investigated the relationship between vitamin D status and ventilator-free days (VFD) as well as 90-day survival, using linear regression and Cox proportional hazard models, respectively. Analyses were adjusted for age, race, and Acute Physiology and Chronic Health Evaluation III score. Results: Baseline 25OHD was measured in 476 patients. 90% of these individuals had 25OHD 10 ng/ml. Conclusions: In patients with ARDS, vitamin D status is associated with duration of mechanical ventilation and 90-day mortality. Randomized, controlled trials are warranted to determine whether vitamin D supplementation improves clinical outcomes in ARDS patients.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, known as coronavirus disease 2019 (COVID-19) causes cytokine release syndrome (CRS), leading to acute respiratory distress syndrome (ARDS), acute kidney and cardiac injury, liver dysfunction, and multiorgan failure. Although several studies have discussed the role of 5-lipoxygenase (5-LOX) in viral infections, such as influenzae and SARS, it remains unexplored in the pathophysiology of COVID-19. 5-LOX acts on free arachidonic acid (AA) to form proinflammatory leukotrienes (LTs). Of note, numerous cells involved with COVID-19 (e.g., inflammatory and smooth muscle cells, platelets, and vascular endothelium) widely express leukotriene receptors. Moreover, 5-LOX metabolites induce the release of cytokines (e.g., tumour necrosis factor-α [TNF-α], interleukin-1α [IL-1α], and interleukin-1β [IL-1β]) and express tissue factor on cell membranes and activate plasmin. Since macrophages, monocytes, neutrophils, and eosinophils can express lipoxygenases, activation of 5-LOX and the subsequent release of LTs may contribute to the severity of COVID-19. This review sheds light on the potential implications of 5-LOX in SARS-CoV-2-mediated infection and the anticipated therapeutic role of 5-LOX inhibitors.

Background. Acute respiratory failure from COVID-19 pneumonia is a major cause of death after SARS-CoV-2 infection. We investigated whether PaO2/FiO2, oxygenation index (OI), SpO2/FiO2, and oxygen saturation index (OSI), commonly used to assess the severity of acute respiratory distress syndrome (ARDS), can predict mortality in mechanically ventilated COVID-19 patients. Methods. In this single-centered retrospective pilot study, we enrolled 68 critically ill mechanically ventilated adult patients with confirmed COVID-19. Physiological variables were recorded on the day of intubation (day 0) and postintubation days 3 and 7. The association between physiological parameters, PaO2/FiO2, OI, SpO2/FiO2, and OSI with mortality was assessed using multiple variable logistic regression analysis. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models. Results. The ARDS severity indices were not statistically different on the day of intubation, suggesting similar baseline conditions in nonsurviving and surviving patients. However, these indices were significantly worse in the nonsurviving as compared to surviving patients on postintubation days 3 and 7. On intubation day 3, PaO2/FiO2 was 101.0 (61.4) in nonsurviving patients vs. 140.2 (109.6) in surviving patients, p = 0.004 , and on day 7 106.3 (94.2) vs. 178.0 (69.3), p < 0.001 . OI was 135.0 (129.7) in nonsurviving vs. 84.8 (86.1) in surviving patients ( p = 0.003 ) on day 3 and 150.0 (118.4) vs. 61.5 (46.7) ( p < 0.001 ) on day 7. OSI was 12.0 (11.7) vs. 8.0 (10.0) ( p = 0.006 ) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) ( p < 0.001 ) on day 7. Similarly, SpO2/FiO2 was 130 (90) vs. 210 (90) ( p = 0.003 ) on day 3 and 130 (90) vs. 230 (50) ( p < 0.001 ) on day 7, while OSI was 12.0 (11.7) vs. 8.0 (10.0) ( p = 0.006 ) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) ( p < 0.001 ) on day 7 in the nonsurviving and surviving patients, respectively. All measures were independently associated with hospital mortality, with significantly greater odds ratios observed on day 7. The area under the receiver operating characteristic curve (AUC) for mortality prediction was greatest on intubation day 7 (AUC = 0.775, 0.808, and 0.828 for PaO2/FiO2, OI, SpO2/FiO2, and OSI, respectively). Conclusions. Decline in oxygenation indices after intubation is predictive of mortality in COVID-19 patients. This time window is critical to the outcome of these patients and a possible target for future interventions. Future large-scale studies to confirm the prognostic value of the indices in COVID-19 patients are warranted.

BACKGROUND Using nonopioid analgesics may decrease the risk of patients chronically using opioids postoperatively. The authors evaluated the relationship between paravertebral block and pain score at the time of hospital discharge. METHODS The authors performed a retrospective cohort study of 89 women with American Society of Anesthesiologists Physical Status I to III undergoing oncoplastic breast surgery with 20 to 50 percent breast tissue removal and immediate contralateral reconstruction between August of 2015 and August of 2018. The primary outcome was pain score at hospital discharge with or without paravertebral block. The secondary outcome was postoperative length of stay. Data were analyzed using the Wilcoxon rank sum test, t test, Fisher's exact test, univariable and multivariable regression, Kaplan-Meier analyses, and Cox regression. RESULTS Median pain score at hospital discharge was lower with paravertebral block [2 (interquartile range, 0 to 2) compared to 4 (interquartile range, 3 to 5); p < 0.001]. Multivariable regression revealed that pain score at the time of hospital discharge was inversely associated with paravertebral block after adjusting for age, body mass index, American Society of Anesthesiologists class, extent of lymph node surgery, and duration of surgery (p < 0.001). Pain score at hospital discharge was also associated with total opioid consumption during the first 24 hours after surgery (p = 0.001). Patients who received paravertebral blocks had median total 24-hour postoperative opioid consumption in morphine equivalents of 7 mg (interquartile range, 3 to 10 mg) compared with 13 mg (interquartile range, 7 to 18 mg) (p < 0.001), and median length of stay of 18 hours (interquartile range, 16 to 20 hours) compared with 22 hours (interquartile range, 21 to 27 hours) (p < 0.001). CONCLUSION Paravertebral blocks are associated with decreased pain score at the time of hospital discharge. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Background Poor nutritional status is linked to suboptimal outcomes following elective surgery. Trauma patients do not typically have an opportunity for preoperative nutritional optimization and may be at risk for malnutrition with its related complications. Our goal was to investigate whether nutritional status is associated with development of hospital-acquired infections (HAIs) in elderly, orthopedic trauma patients. Methods We performed a retrospective analysis of data between 01/01/2017 to 08/30/2018 from the Massachusetts General Hospital Geriatric Inpatient Fracture Trauma Service (GIFTS). Admission nutritional status was assessed using the Mini Nutritional Assessment (MNA) and HAIs were validated through the American College of Surgeons National Surgical Quality Improvement Project database. To investigate whether nutritional status is associated with HAIs, we performed a multiple variable logistic regression analysis, controlling for age, sex, Charlson Comorbidity Index, glomerular filtration rate, and type of anesthesia. Results 461 patients comprised the analytic cohort. Multiple variable regression analysis demonstrated that each unit increment in MNA score was associated with a 13% reduction in risk of HAI (OR 0.87; 95%CI 0.79-0.97). Furthermore, adjusting for timing of perioperative antibiotics, perioperative transfusions, or development of pressure injury during hospitalization results did not materially change these results. Conclusion Our results demonstrate that malnutrition is highly prevalent in elderly orthopedic trauma patients and that nutritional status may influence the risk of developing HAIs in this cohort of patients. Further studies are needed to determine whether optimizing perioperative nutritional status in elderly orthopedic trauma patients can reduce infectious complications and improve overall health outcomes. This article is protected by copyright. All rights reserved.

Neostigmine, an acetylcholinesterase inhibitor, is used to reverse the effects of non-depolarizing neuromuscular blocking agents. Inappropriate dosing of neostigmine can lead to post-operative respiratory complications. Post-operative respiratory complications are associated with major morbidity and mortality. The purpose of this case-control study was to determine neuromuscular blockade-related risk factors associated with post-operative respiratory complications (specifically, reintubation, respiratory insufficiency, hypoxia, and/or aspiration).We performed an Institutional Review Board-approved case-control study of all patients who underwent a general anesthetic requiring neuromuscular blockade at Tufts Medical Center between March 22, 2013 and June 1, 2019. Cases were patients who experienced post-operative complications. We identified 58 controls and 116 cases from a database of 130,178 patients during the 74-month study period.After adjusting for covariates, the administration of high dose neostigmine (60 mg per kg ideal body weight) was associated with increased odds of post-operative respiratory complications (odds ratio = 8.2; 95% CI: 2.5-26.6, P0.001). Rocuronium dose and the use of train-of-four peripheral nerve stimulator were not associated with post-operative respiratory complications.High dose neostigmine was identified as an independent risk factor for post-operative respiratory complications. Our study suggests that inappropriate dosing of neostigmine continues to be a problem despite growing evidence of an association with respiratory complications.

Rhabdomyolysis, the release of myoglobin and other cellular breakdown products from necrotic muscle tissue, is seen in patients with crush injuries, drug overdose, malignant hyperthermia, muscular dystrophy, and with increasing frequency in obese patients undergoing routine procedures. For the perioperative clinician, managing the resultant shock, hyperkalemia, acidosis, and myoglobinuric acute kidney injury can present a significant challenge. Prompt recognition, hydration, and correction of metabolic disturbances may reduce or eliminate the need for long-term renal replacement therapy. This article reviews the pathophysiology and discusses key issues in the perioperative diagnosis, risk stratification, and management of rhabdomyolysis.

Aim: We investigated whether sex is associated with pain scores and opioid administration after laparoscopic sleeve gastrectomy. Materials & methods: We performed a single-center, retrospective analysis of laparoscopic sleeve gastrectomy patients from December 2016–July 2018. Multivariable linear regressions were performed to investigate the association of sex with pain scores and opioid administration. Results: Baseline pain scores were similar between women and men (n = 266; 78% women). Men reported lower pain scores in all phases of care and received more opioids during their hospitalization (ß = 25.48; 95% CI: 5.77–45.20; p = 0.01), compared with women. Conclusion: Our data suggest that women self-report greater postoperative pain scores, while men received more opioids during their hospitalization. Further studies are needed to understand the reasons for such differences in postoperative pain management.

Among elderly orthopedic trauma patients, the prevalence of delirium during hospitalization has been reported to be as high as 60%. Frail elderly patients have an increased risk of delirium after elective surgery; however, such an association remains underexplored among trauma patients.Our goal was to investigate whether preoperative frailty is associated with postoperative delirium (POD) in elderly orthopedic trauma patients.We conducted a single-center, retrospective, cross-sectional study. All patients were ≥ 65 years of age and were admitted to the hospital between 01/01/2017 and 08/31/2018 for surgical intervention of a significant extremity fracture. Frailty was assessed using the fatigue, resistance, ambulation, illness, and loss of weight questionnaire. Delirium was assessed using the Confusion Assessment Method. POD was defined as new-onset delirium that occurred within 24 h after surgery. To investigate whether frailty is associated with POD, we performed a multiple variable logistic regression, controlling for biologically relevant confounders.Five hundred fifty-six patients comprised the analytic cohort. Incidence of POD was 14% (n = 80). Multiple variable regression analysis demonstrated that each unit increment in FRAIL score was associated with a 33% higher likelihood of POD (OR 1.33; 95% CI 1.02-1.72, p = 0.03).Our results suggest that preoperative frailty increases the risk of POD in hospitalized, elderly, orthopedic trauma patients. Future studies are needed to determine whether perioperative interventions focused on improving frailty can reduce the risk of POD and improve outcomes in this rapidly growing cohort of patients.

Nutrition is often thought to influence outcomes in critically ill patients. However, the relationship between macronutrient delivery and functional status is not well characterized. Our goal was to investigate whether caloric or protein deficit over the course of critical illness is associated with functional status at the time of intensive care unit (ICU) discharge.We performed a retrospective analysis of surgical ICU patients at a teaching hospital in Boston, MA. To investigate the association of caloric or protein deficit with Functional Status Score for the ICU (FSS-ICU), we constructed linear regression models, controlling for age, sex, race, body mass index, Nutritional Risk in the Critically Ill score, and ICU length of stay. We then dichotomized caloric as well as protein deficit, and performed logistic regressions to investigate their association with functional status, controlling for the same variables.Linear regression models (n = 976) demonstrated a caloric deficit of 238 kcal (237.88; 95%CI 75.13-400.63) or a protein deficit of 14 g (14.23; 95%CI 4.46-24.00) was associated with each unit decrement in FSS-ICU. Logistic regression models demonstrated a 6% likelihood (1.06; 95%CI 1.01-1.14) of caloric deficit ≥6000 vs.6000 kcal and an 8% likelihood (1.08; 95%CI 1.01-1.15) of protein deficit ≥300 vs.300 g with each unit decrement in FSS-ICU.In our cohort of patients, macronutrient deficit over the course of critical illness was associated with worse functional status at discharge. Future studies are needed to determine whether optimized macronutrient delivery can improve outcomes in ICU survivors.

Introduction Pressure recovery (PR) in aortic stenosis (AS) occurrence has been studied since the late 1980’s as specific cases applicable only to small or low-normal ranges aortas. [1] Interest regarding PR has increased significantly in recent years. [2-3] The aim of our study is to determine the impact of PR adjustment on disease severity in patients with severe AS by traditional grading methods. We hypothesize that accounting for PR will result in a reclassification of aortic stenosis severity in a significant number of patients. Methods After institutional board approval, we performed a retrospective single center study on patients who underwent TAVR at Tufts Medical center between October 2012 to February 2021. Standard measurements and mean transaortic gradients were obtained by pre-procedure transthoracic echocardiograms. Aortic valve areas (AVA) were calculated using the continuity equation. PR and PR adjusted AVA were calculated using previously validated equations. [4-5] Sinotubular junction (STJ) size was obtained from pre-procedural computerized tomography (CT) scans. Results Patient characteristics are shown in Table 1. A total of 544 patients were evaluated after excluding patients greater than mild mitral or aortic regurgitation. The absolute value of pressure PR recovery was significantly different between the reclassified groups. (p-value = 0.02) Using PR adjusted AVA resulted in the reclassification of 109 patients (25.05%) from severe to moderate aortic stenosis (AVA >1 cm2). Of the 109 patients who were reclassified, 36 patients (33.02%) had STJ diameters >3.0 cm. (Table 1) Discussion Adjusting calculated AVA for PR resulted in a reclassification of a significant number of adult patients from severe to moderate aortic stenosis. PR was significantly larger in patients who reclassified from severe to moderate aortic stenosis after adjusting for PR. There was no difference in STJ diameter between the PR adjusted groups. Our data suggests that those patients most vulnerable to reclassification with PR adjustment are those with the largest calculated “severe” aortic valve areas, rather than those with particular aortic root dimensions.

Supplemental Digital Content is available in the text., Respiratory failure in coronavirus disease 2019 (COVID-19) patients with prolonged endotracheal intubation may require a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement to facilitate recovery. Both techniques are considered high-risk aerosol-generating procedures and present a heightened risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for operating room personnel. We designed, simulated, and implemented a portable, continuous negative pressure, operative field barrier system using standard equipment available in hospitals to enhance health care provider safety during high-risk aerosol-generating procedures.

Objectives Low psoas muscle mass previously has been associated with mortality after transcatheter aortic valve replacement (TAVR). Evidence from other clinical disciplines suggests that psoas density (PD) may be a better predictor than psoas muscle cross-sectional area indexed to body surface area (PI). The authors hypothesized that PD would be more strongly correlated with patient discharge disposition and survival after TAVR than PI. Design The authors performed a single-center, retrospective study of TAVR patients from 2013 to 2016. PI and PD were assessed at the third lumbar spine level using computed tomography imaging. Propensity-score matching was used to investigate the association of PI and PD with discharge disposition and mortality. Setting Tertiary university hospital Participants Cohort of 245 TAVR patients. Interventions None Measurements and Main Results A total of 245 patients met inclusion criteria. Following propensity score matching, patients with PI 25 HU. After repeating the propensity score matching with PI as a covariable, PD remained associated with mortality (90 days: odds ratio [OR] 4.59; 95% confidence interval [CI] 2.96-10.31, p Conclusions PD may be more relevant than PI in risk stratification for TAVR patients.

Patients with COVID-19 often need therapeutic interventions that are considered high aerosol-generating procedures. These are either being performed by healthcare providers with potentially inadequate personal protective equipment or the procedures are being delayed until patients clear their viral load. Both scenarios are suboptimal. We present a simple, cost-effective method of creating a portable negative pressure environment using equipment that is found in most hospitals to better protect healthcare providers and to facilitate more timely care for patients with COVID-19.

Oral and maxillofacial surgery in patients with suspected or confirmed COVID-19, presents a high risk of exposure and cross contamination to the operative room personnel. We designed, simulated and implemented a continue negative pressure operative field barrier to provide an additional layer of protection, using standard equipment readily available in most operative rooms during oral and maxillofacial procedures., Highlights • Salivary and mucosal secretions act as a reservoir for high concentrations of COVID-19. • Oral and maxillofacial procedures are known to generate aerosols (High speed drilling, Irrigation). • Continuous negative pressure operative barrier may decrease the exposure of COVID-19 during oral maxillofacial surgery.

Background Vitamin D status is associated with length of stay (LOS) and discharge destination in critically ill patients. To further understand this relationship, we investigated whether admission 25-hydroxyvitaminD (25OHD) levels are associated with discharge functional status in the intensive care unit (ICU). Methods In this retrospective study, data from 2 surgical ICUs at a large teaching hospital were analyzed. 25OHD levels were measured within 24 hours of ICU admission and Functional Status Score for the ICU (FSS-ICU) was calculated within 24 hours of ICU discharge for all patients. To investigate the association of vitamin D status with FSS-ICU, we constructed linear and logistic regression models, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU LOS, and cumulative protein or caloric deficit during ICU admission. Results Mean 25OHD level and FSS-ICU was 19 (SD 8) ng/mL and 17 (SD 4), respectively, in the analytic cohort (n = 300). Each unit increase in 25OHD level was associated with a 0.2 increment in FSS-ICU (β = .20; 95% CI 0.14-0.25). Patients with 25OHD levels 3-fold risk of low FSS-ICU ( 20 ng/mL (OR 3.45; 95% CI 1.96-6.08). Conclusions Our results suggest that vitamin D status at admission is associated with discharge FSS-ICU in critically ill surgical patients. Future studies are needed to validate our results, to build upon our findings, and to determine whether optimizing 25OHD levels can improve functional status and other important clinical outcomes in ICU patients.

BACKGROUND The Patient- And Nutrition-Derived Outcome Risk Assessment (PANDORA) was recently validated for predicting mortality in hospitalized patients; however, its utility in the intensive care unit (ICU) remains unknown. METHODS We investigated whether PANDORA is associated with 30, 90, and 180 day mortality in critically ill surgical patients by performing logistic regressions, controlling for age, sex, race, body mass index, macronutrient deficit, and length of stay. The area under the receiver operating characteristic curves (AUC) of PANDORA vs Acute Physiology and Chronic Health Evaluation (APACHE) II scores for mortality at each time point were also compared. RESULTS 312 patients comprised the analytic cohort. PANDORA was associated with mortality at 30 (OR 1.08; 95% CI 1.04-1.13; P < .001), 90 (OR 1.09; 95% CI 1.03-1.12; P < .001), and 180 days (OR 1.10; 95% CI 1.06-1.15; P < .001). PANDORA and APACHE II were comparable for mortality prediction at 30 (AUC: 0.69, 95% CI 0.62-0.76 vs 0.74, 95% CI 0.67-0.81; P = .29), 90 (AUC: 0.71, 95% CI 0.63-0.77 vs 0.74, 95% CI 0.67-0.80; P = .52), and 180 days (AUC: 0.73, 95% CI 0.67-0.79 vs 0.75, 95% CI 0.69-0.81; P = .66). CONCLUSION In surgical ICU patients, PANDORA was associated with mortality and was comparable with APACHE II for mortality prediction at 30, 90, and 180 days after initiation of care. Prospective studies are needed to assess whether nutrition support, stratified by PANDORA scores, can improve outcomes in surgical ICU patients.

Rhabdomyolysis, the release of myoglobin and other cellular breakdown products from necrotic muscle tissue, is seen in patients with crush injuries, drug overdose, malignant hyperthermia, muscular dystrophy, and with increasing frequency in obese patients undergoing routine procedures. For the perioperative clinician, managing the resultant shock, hyperkalemia, acidosis, and myoglobinuric acute kidney injury can present a significant challenge. Prompt recognition, hydration, and correction of metabolic disturbances may reduce or eliminate the need for long-term renal replacement therapy. This article reviews the pathophysiology and discusses key issues in the perioperative diagnosis, risk stratification, and management of rhabdomyolysis.

Purpose To explore whether psoas cross sectional area (CSA) and density (Hounsfield Units, HU) are associated with nutritional adequacy and clinical outcomes in surgical intensive care unit patients. Materials and methods Subjects with at least one CT scan within 72 h of ICU admission were included. Demographic, nutritional, radiographic, and outcomes data were collected. Psoas muscle CSA and HU were assessed at the L4–L5 intervertebral disk level. Change (Δ) in CSA and HU overall and per day were calculated. Results 140 patients were included. There was no significant correlation between baseline CSA and HU and clinical outcomes. Patients with at least two CT scans (n = 65), had a median decrease in CSA of − 15% [IQR: − 20%, − 8%] and decrease in HU of − 2% [IQR: − 30%, + 24%]. Patients with the greatest daily %HU decline received significantly fewer calories/kg and proteins/kg and accumulated greater protein deficits at day 7 and overall. Patients with daily %HU increase had the shortest ICU and hospital LOS and more ventilator-free days in univariate and multivariable analyses. Conclusions In this exploratory study, early nutritional deficits were correlated with muscle quality deterioration. Inpatient gain in psoas density, compared to maintenance or loss, is associated with shorter hospital stay.

Introduction 80,000 hip fractures are admitted to UK hospitals annually (Royal College of Physicians, 2016). Little is known about 12-month post-operative re-admission, unplanned clinic attendance and mortality. We aimed to determine if there is a role for routine follow-up for certain strata of our hip fracture population treated by Dynamic Hip Screw (DHS) Fixation based on unplanned attendance to clinics and whether it is possible to stratify risk of re-admission, re-operation and mortality within the first 12 months post-operatively. Methods A prospectively collated single centre database of patients >65 years old undergoing DHS fixation for traumatic hip fractures between August 2007 and February 2011 was retrospectively analysed. Pre-operative data regarding patient demographics, mobility, residence and co-morbidities were collected. Post-operative (1, 4, 12 months) place of residence, mobility status, unplanned attendance to an orthopaedic clinic with symptoms relating to the respective limb, re-admission to hospital and mortality was collated. Regression analysis was performed (SPSS, IBM Corporation, version 24). P Results 648 consecutive patients were identified. Increasing age (p = 0.006) and presence of pressure sores during initial admission (p = 0.0019) increased the frequency of unplanned clinic attendance. No significant predictors of re-admission to hospital were found. Overall mortality was related to increasing age (p = 0.042), male gender (p = 0.004) and ASA grade (p = 0.009). Conclusion There is no current vogue to follow-up such patients in this post-operative period. We have identified variables that should be sought prior to discharge in this population. 22% of our population had at least one unplanned clinic attendance with a cost implication of approximately £50,132 (£151 per appointment) over the study period and potentially over £1.6 million pounds annually in the U.K. Implications Formal follow-up/rehabilitation programs could be offered for those at risk of unplanned clinic attendance. Post-operative orthogeriatric and/or general practitioner follow-up may reduce 12-month mortality in those at risk but validated scoring and risk stratification systems are required to fully justify this.

Elevated red cell distribution width (RDW) is associated with morbidity and mortality in community-dwelling individuals. Although RDW is traditionally used to diagnose anemia, it may also be a marker of systemic inflammation. Since vitamin D is a potent modulator of inflammatory cytokines our goal was to investigate whether 25-hydroxyvitamin D levels (25OHD) are associated with RDW in non-hospitalized adults. To investigate this association, we conducted a cross-sectional study. Stepwise multivariable linear and logistic regression models were used to assess the independent association of 25OHD with RDW. Elevated RDW was defined as >14.5%. Nationwide sample of non-hospitalized adults within the United States. Individuals from the National Health and Nutrition Examination Survey from 2001-2006. 15,162 individuals comprised the analytic cohort. Mean 25OHD was 24.9 ng/mL (SE 0.4) and the prevalence of elevated RDW was 6.3%. Linear regression analysis, controlling for age, sex, race, mean corpuscular volume, albumin, and neutropenia, demonstrated that 25OHD was inversely associated with RDW (β=-0.01; 95%CI -0.01 to -0.01). Logistic regression analysis, controlling for the same covariates, also demonstrated an inverse association of 25OHD with elevated RDW (OR 0.96; 95%CI 0.94-0.99). Individuals with 25OHD

Background Although theophylline has been shown to have anti-inflammatory effects, the therapeutic use of theophylline before sepsis is unknown. The aim of our study was to determine the effect of theophylline on COPD patients presenting with sepsis. Methods This nationwide, population-based, propensity score-matched analysis used data from the linked administrative databases of Taiwan's National Health Insurance program. Patients with COPD who were hospitalized for sepsis between 2000 and 2011 were divided into theophylline users and non-users. The primary outcome was 30-day mortality. The secondary outcome was in-hospital death, intensive care unit admission, and need for mechanical ventilation. Cox proportional hazard model and conditional logistic regression were used to calculate the risk between groups. Results A propensity score-matched cohort of 51,801 theophylline users and 51,801 non-users was included. Compared with non-users, the 30-day (HR 0.931, 95% CI 0.910–0.953), 180-day (HR 0.930, 95% CI 0.914–0.946), 365-day (HR 0.944, 95% CI 0.929–0.960) and overall mortality (HR 0.965, 95% CI 0.952–0.979) were all significantly lower in theophylline users. Additionally, the theophylline users also had lower risk of in-hospital death (OR 0.895, 95% CI 0.873–0.918) and need for mechanical ventilation (OR 0.972, 95% CI 0.949–0.997). Conclusions Theophylline use is associated with a lower risk of sepsis-related mortality in COPD patients. Pre-hospital theophylline use may be protective to COPD patients with sepsis.

Background Mortality after smoke inhalation–associated acute lung injury (SI-ALI) remains substantial. Age and burn surface area are risk factors of mortality, whereas the impact of patient- and center-level variables and treatments on survival are unknown. Methods We performed a retrospective cohort study of burn and non-burn centers at 68 US academic medical centers between 2011 and 2014. Adult inpatients with SI-ALI were identified using an algorithm based on a billing code for respiratory conditions from smoke inhalation who were mechanically ventilated by hospital day 4, with either a length-of-stay ≥ 5 days or death within 4 days of hospitalization. Predictors of in-hospital mortality were identified using logistic regression. The primary outcome was the odds ratio for in-hospital mortality. Results A total of 769 patients (52.9 ± 18.1 years) with SI-ALI were analyzed. In-hospital mortality was 26% in the SI-ALI cohort and 50% in patients with ≥ 20% surface burns. In addition to age > 60 years (OR 5.1, 95% CI 2.53-10.26) and ≥ 20% burns (OR 8.7, 95% CI 4.55-16.75), additional risk factors of in-hospital mortality included initial vasopressor use (OR 5.0, 95% CI 3.16-7.91), higher diagnostic-related group–based risk-of-mortality assignment and lower hospital bed capacity (OR 2.3, 95% CI 1.23-4.15). Initial empiric antibiotics (OR 0.93, 95% CI 0.58-1.49) did not impact survival. These new risk factors improved mortality prediction by 9.9% (P Conclusions In addition to older age and major surface burns, mortality in SI-ALI is predicted by initial vasopressor use, higher diagnostic-related group–based risk-of-mortality assignment, and care at centers with

Introduction: Elevated red cell distribution width (RDW) is associated with mortality in a variety of respiratory conditions. Recent data also suggest that RDW is associated with mortality in intensive care unit (ICU) patients. Although respiratory failure is common in the ICU, the relationship between RDW and pulmonary outcomes in the ICU has not been previously explored. Therefore, our goal was to investigate the association of admission RDW with 30-day ventilator-free days (VFDs) in ICU patients. Methods: We performed a retrospective analysis from an ongoing prospective, observational study. Patients were recruited from medical and surgical ICUs of a large teaching hospital in Boston, Massachusetts. The RDW was assessed within 1 hour of ICU admission. Poisson regression analysis was used to investigate the association of RDW (normal: 11.5%-14.5% vs elevated: >14.5%) with 30-day VFD, while controlling for age, sex, race, body mass index, Nutrition Risk in the Critically Ill score, the presence of chronic lung disease, Pao2/Fio2 ratio, and admission levels of hemoglobin, mean corpuscular volume, phosphate, albumin, C-reactive protein, and creatinine. Results: A total of 637 patients comprised the analytic cohort. Mean RDW was 15 (standard deviation 4%), with 53% of patients in the normal range and 47% with elevated levels. Median VFD was 16 (interquartile range: 6-25) days. Poisson regression analysis demonstrated that ICU patients with elevated admission RDW were likely to have 32% lower 30-day VFDs compared to their counterparts with RDW in the normal range (incidence rate ratio: 0.68; 95% confidence interval: 0.55-0.83: P < .001). Conclusions: We observed an inverse association of RDW and 30-day VFD, despite controlling for demographics, nutritional factors, and severity of illness. This supports the need for future studies to validate our findings, understand the physiologic processes that lead to elevated RDW in patients with respiratory failure, and determine whether changes in RDW may be used to support clinical decision-making.

The link between seasonal variation and viral outbreaks is a topic of much debate.1 It is postulated that cold temperatures increase viral half-lives and that low relative humidity (RH) adversely influences natural processes that otherwise lead to viral inactivation.2 3 As such, there is a growing interest in whether indoor temperature and RH may be modifiable risk factors for aerial transmission of viruses. Indeed, preclinical studies and observational data suggest that high temperature as well as RH in the 40%–60% range may reduce transmission of the novel coronavirus (COVID-19).4 5 And although high humidity has been shown to reduce transmission of various other aerosolised …

Necessary procedures during the COVID-19 pandemic include electroconvulsive therapy (ECT). Providing ECT has been considered an essential service during COVID-19 in the Singapore healthcare system, not least to contribute to disease control within a society in part due to the nature of the ECT patient population. There is limited evidence-based scientific information available regarding a procedural framework for ECT during a respiratory pandemic, when much attention in the healthcare system is focused on different areas of clinical care. This article attempts to describe such a framework for ECT procedures acknowledging limited solid scientific evidence at this time and being mindful of future changes to these suggestions as testing, immunization, and treatment options develop. This approach can be adopted in whole or in part to assist practitioners to protect the patient and themselves during the procedure.

Background Neutrophil-lymphocyte ratio (NLR) is a measure of host inflammatory response; a higher NLR is associated with worse clinical outcomes. Enteral nutrition (EN) may mitigate inflammation through interaction with gut-associated lymphoid tissue. We hypothesized that early EN adequacy in critically ill surgical patients is associated with lower NLR and better clinical outcomes. Methods In this retrospective study, we analyzed data from adult surgical intensive care unit (ICU) patients receiving EN. NLR at baseline ICU admission (NLR-B), NLR after 3-5 days of EN (F-NLR), nutrition adequacy, caloric deficit (CD), protein deficit (PD), hospital length of stay (LOS), ICU LOS, 28-day ventilator-free days (28-VFD), and in-hospital mortality were collected. Tertiles groups were created for NLR, F-NLR, CD, and PD; the highest (H) and lowest (L) tertiles were compared. Regression analyses were performed to control for effect of age, gender, APACHE II, and NLR. Results Subjects in the L-CD group had lower median F-NLR (7 [range, 5-11] vs 10 [7-22], P = 0.005) and shorter ICU LOS (9 [6-16]) vs 16 [9-32] days; P = 0.006). The L-NLR group had shorter hospital LOS (18 [10-31] vs 22 [15-38] days, P = 0.023), greater 28-VFD (23 [18-25] vs 19 [11-22] days, P = 0.005), and lower in-hospital mortality (13% vs 41%, P = 0.002). Conclusion In critically ill surgical patients, early enteral caloric adequacy is associated with less inflammation and improved clinical outcomes.

Background Hospital-acquired pressure injuries (HAPIs) typically develop following critical illness due to immobility and suboptimal perfusion. Vitamin D helps to maintain epithelial cell integrity, particularly at barrier sites such as skin. It is unclear whether vitamin D status is a modifiable risk factor for HAPIs in critically ill patients. Our goal was to investigate the relationship between admission 25-hydroxyvitamin D (25OHD) levels with the development of HAPIs in surgical intensive care unit (ICU) patients. Methods We performed a retrospective cohort study of patients admitted to surgical ICUs at a major teaching hospital in Boston, Massachusetts. To investigate the association of 25OHD levels with subsequent development of HAPIs, we performed logistic regression analyses, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU length of stay, and cumulative ICU caloric or protein deficit. Results A total of 402 patients comprised our analytic cohort. Each unit increment in 25OHD was associated with 11% decreased odds of HAPIs (odds ratio [OR] 0.89; 95% CI 0.840.95). When vitamin D status was dichotomized, patients with 25OHD 2 times as likely to develop HAPIs (OR 2.51; 95% CI 1.065.97) compared with patients with 25OHD >20 ng/mL. Conclusion In our cohort of critically ill surgical patients, vitamin D status at ICU admission was linked to subsequent development of HAPIs. Randomized, controlled trials are needed to assess whether optimizing 25OHD levels in the ICU can reduce the incidence of HAPIs and improve other clinically relevant outcomes in critically ill patients.

Background Malnutrition is a significant problem for hospitalized patients in the United States. Nutrition assessment is an important step in recognizing malnutrition; however, it is not always performed using consistent parameters. Methods A survey among U.S. American Society for Parenteral and Enteral Nutrition (ASPEN) members was conducted to collect data on nutrition assessment parameters used in hospitals and to establish how facilities use their electronic health record (EHR) to permit data retrieval and outcome reporting. Results The survey was developed by the ASPEN Malnutrition Committee and was sent to 5487 U.S. ASPEN members, with 489 responding for a 9% response rate. Ninety-eight percent of adult and 93% of pediatric respondents indicated a registered dietitian completed the nutrition assessment following a positive nutrition screen. Variables most frequently used among adult respondents included usual body weight, ideal body weight, and body mass index. Among pediatric respondents, weight-for-age and height-for-age percentiles and length/height-for-age percentile were most frequently used. Both adult and pediatric respondents indicated use of physical assessment parameters, including muscle and fat loss and skin assessment. Eighty-seven percent of adult and 77% of pediatric respondents indicated they are using the Academy of Nutrition and Dietetics (Academy) and ASPEN Consensus Malnutrition Characteristics for Adult and Pediatric Malnutrition, respectively. Overall, 97% of respondents indicated nutrition assessment documentation was completed via an EHR. Of all respondents, 61% indicated lack of clinical decision support within their EHR. Conclusion This survey demonstrated significant use of the Academy/ASPEN malnutrition consensus characteristics.

Hypophosphatemia has been associated with refeeding malnourished patients, but its clinical significance is unclear. We investigated the incidence of refeeding hypophosphatemia (RH) in the surgical intensive care unit (SICU) and its association with early enteral nutrition (EN) administration and clinical outcomes.We performed a retrospective review of a 2-year database of patients receiving EN in the SICU. RH was defined as a post-EN phosphorus (PHOS) level decrement of0.5 mg/dL to a nadir2.0 mg/dL within 8 days from EN initiation. We investigated the risk factors for RH and examined its association with clinical outcomes using multivariable regression analyses.In total, 213 patients comprised our analytic cohort. Eighty-three of 213 (39%) individuals experienced RH and 43 of 130 (33%) of the remaining patients experienced non-RH hypophosphatemia (nadir PHOS level2.0 mg/dL). Overall, there was a total 59% incidence of hypophosphatemia of any cause (N = 126). Nutrition parameters did not differ between groups; most patients were initiated on EN within 48 hours of SICU admission, and timing of EN initiation was not a significant predictor for the development of RH. The median hospital length of stay (LOS) was 21 and 24 days for those with and without RH, respectively (P = .79); RH remained a nonsignificant predictor for hospital LOS in the multivariable analysis.RH is common in the SICU but is not related to timing or amount of EN. Hypophosphatemia is also common in the critically ill, but regardless of etiology, it was not found to be a predictor of worse clinical outcomes.