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BACKGROUND: While the results of clinical research are clearly valuable in the care of critically ill patients, the limitations of such information and the role of other forms of medical knowledge for clinical decision making have not been carefully examined. METHODS: The leadership of three large professional societies representing critical care practitioners convened a diverse group representing a wide variety of views regarding the role of clinical research results in clinical practice to develop a document to serve as a basis for agreement and a framework for ongoing discussion. RESULTS: Consensus was reached on several issues. While the results of rigorous clinical research are important in arriving at the best course of action for an individual critically ill patient, other forms of medical knowledge, including clinical experience and pathophysiologic reasoning, remain essential. No single source of knowledge is sufficient to guide clinical decisions, nor does one kind of knowledge always take precedence over others. Clinicians will find clinical research compelling for a variety of reasons that go beyond study design. While clinical practice guidelines and protocols based upon clinical research may improve care and decrease variability in practice, clinicians must be able to understand and articulate the rationale as to why a particular protocol or guideline is used or why an alternative approach is taken. Making this clinical reasoning explicit is necessary to understand practice variability. CONCLUSIONS: Understanding the strengths and weaknesses of different kinds of medical knowledge for clinical decision making and factors beyond study design that make clinical research compelling to clinicians can provide a framework for understanding the role of clinical research in practice. [ABSTRACT FROM AUTHOR]

Context: Ventilator-associated pneumonia (VAP) causes substantial morbidity. A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation.Objective: To determine whether a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP.Design, Setting, and Participants: Prospective, randomized, single-blind, controlled study conducted in 54 centers in North America. A total of 9417 adult patients (> or = 18 years) were screened between 2002 and 2006. A total of 2003 patients expected to require mechanical ventilation for 24 hours or longer were randomized.Intervention: Patients were assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes, similar except for a silver coating on the experimental tube.Main Outcome Measures: Primary outcome was VAP incidence based on quantitative bronchoalveolar lavage fluid culture with 10(4) colony-forming units/mL or greater in patients intubated for 24 hours or longer. Other outcomes were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality, and adverse events.Results: Among patients intubated for 24 hours or longer, rates of microbiologically confirmed VAP were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4%-6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7%-9.7%) (P = .03) in the group receiving the uncoated tube (all intubated patients, 3.8% [37/968; 95% CI, 2.7%-5.2%] and 5.8% [56/964; 95% CI, 4.4%-7.5%] [P = .04]), with a relative risk reduction of 35.9% (95% CI, 3.6%-69.0%; all intubated patients, 34.2% [95% CI, 1.2%-67.9%]). The silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005). No statistically significant between-group differences were observed in durations of intubation, intensive care unit stay, and hospital stay; mortality; and frequency and severity of adverse events.Conclusion: Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube.Trial Registration: clinicaltrials.gov Identifier: NCT00148642. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The use of sedatives, opioids, and neuromuscular blocking agents (NMBAs) may delay weaning and prolong intensive care unit length of stay. We hypothesized that in patients on higher positive end-expiratory pressure (PEEP), sedatives, opioids, and NMBAs are used in a higher proportion of patients and in higher doses and that the use of these medications is associated with prolongation of weaning and mortality. DESIGN: Retrospective analysis. SETTING: The ALVEOLI trial. PATIENTS: Five hundred forty-nine patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) who were enrolled in the ALVEOLI trial. INTERVENTIONS: We analyzed prospectively collected data regarding the impact of sedatives, opioids, and NMBAs in ALI/ARDS patients on duration of mechanical ventilation, time to weaning landmarks, and mortality. MEASUREMENTS AND MAIN RESULTS: Sedatives and opioids were used in >80% of the patients in similar proportion in the two groups. The use of sedatives and opioids, but not the use of NMBAs, was associated with longer time on mechanical ventilation and an increased time to achieve a 2-hr spontaneous breathing trial (p < .0001). Sedatives were also associated with increased time to achieve unassisted breathing. NMBAs were used for a short period of time, in a higher proportion of patients in the lower PEEP group, and for a longer time (0.23 days). CONCLUSIONS: Sedatives and opioids use was similar in the higher and lower PEEP groups. The use of sedatives and opioids, but not NMBAs, was associated with a longer time to achieve important weaning landmarks. [ABSTRACT FROM AUTHOR]

Background Published reports consistently describe incomplete delivery of prescribed enteral nutrition. Which specific step in the process delays or interferes with the administration of a full dose of nutrients is unclear. Objectives To assess factors associated with interruptions in enteral nutrition in critically ill patients receiving mechanical ventilation. Methods An observational prospective study of 59 consecutive patients who required mechanical ventilation and were receiving enteral nutrition was done in an 18-bed medical intensive care unit of an academic center. Data were collected prospectively on standardized forms. Steps involved in the feeding process from admission to discharge were recorded, each step was timed, and delivery of nutrition was quantified. Results Patients received approximately 50% (mean, 1106.3; SD, 885.9 Cal) of the prescribed caloric needs. Enteral nutrition was interrupted 27.3% of the available time. A mean of 1.13 interruptions occurred per patient per day; enteral nutrition was interrupted a mean of 6 (SD, 0.9) hours per patient each day. Prolonged interruptions were mainly associated with problems related to small-bore feeding tubes (25.5%), increased residual volumes (13.3%), weaning (11.7%), and other reasons (22.8%). Placement and confirmation of placement of the small-bore feeding tube were significant causes of incomplete delivery of nutrients on the day of admission. Conclusions Delivery of enteral nutrition in critically ill patients receiving mechanical ventilation is interrupted by practices embedded in the care of these patients. Evaluation of the process reveals areas to improve the delivery of enteral nutrition. [ABSTRACT FROM AUTHOR]

CONTEXT: The long-term survival of patients with cirrhosis of the liver admitted to the ICU has not been described. OBJECTIVE: The main objectives were to determine the 1-year and 5-year mortality rates of a cohort of patients admitted to a medical ICU (MICU), and to identify the risk factors that may predict long-term outcomes. DESIGN: This is a cohort study. We used a model-building (MB) and model validation (MV) procedure that has previously been described to determine the risk factors for overall mortality.Settings: An MICU in a major referral medical center. PATIENTS: Four hundred twenty consecutive patients admitted to the ICU from January 1, 1993, through October 31, 1998, met the inclusion criteria of diagnosis of liver failure, cirrhosis, chronic liver disease, variceal bleeding, hepatic encephalopathy, or hepatorenal syndrome. Patients with acute liver failure who had undergone liver transplantation, or candidates for orthotopic liver transplantation were excluded. INTERVENTION: None. RESULTS: The 1-year mortality rate was 69%, and the 5-year mortality rate was 77%. The median survival time was 1 month. The independent predictors of mortality in patients in the MB group who retained their significance in the MV group were as follows: an acute physiology, age, and chronic health evaluation (APACHE) III score of >/= 90 (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.6 to 2.8; p < 0.0001), the use of pressors (HR, 2.5; 95% CI, 1.9 to 3.2; p < 0.0001), and jaundice (HR, 1.7; 95% CI, 1.4 to 2.2; p < 0.0001). Patients with all three risk factors (ie, APACHE III score >/= 90, use of pressors, and jaundice) had a 92% 1-month mortality rate compared to 11.2% for patients with no risk factors. CONCLUSIONS: Patients admitted to an MICU with underlying cirrhosis who are not eligible for liver transplantation have a poor long-term prognosis, even if they survive the ICU admission, particularly as the number of risk factors increases. [ABSTRACT FROM AUTHOR]

When patients give no reason for refusing therapy (an enigmatic refusal), this creates the dilemma of whether or not to administer the therapy by force, especially when the therapy poses low risk and offers significant benefit. We argue that there is a duty to assess the patient's decision-making capacity, as well as attempt to understand a patient's reason(s) for refusing treatment. While some patients may not readily offer reasons for refusing treatment, this does not preclude an obligation for clinicians to inquire about such. The reasons for treatment refusal can be related to the patient's goals, values, fears, and mental state. [ABSTRACT FROM AUTHOR]

Context: The outcome of patients receiving mechanical ventilation for particular indications has been studied, but the outcome in a large number of unselected, heterogeneous patients has not been reported.Objective: To determine the survival of patients receiving mechanical ventilation and the relative importance of factors influencing survival.Design, Setting, and Subjects: Prospective cohort of consecutive adult patients admitted to 361 intensive care units who received mechanical ventilation for more than 12 hours between March 1, 1998, and March 31, 1998. Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of mechanical ventilation for up to 28 days.Main Outcome Measure: All-cause mortality during intensive care unit stay.Results: Of the 15 757 patients admitted, a total of 5183 (33%) received mechanical ventilation for a mean (SD) duration of 5.9 (7.2) days. The mean (SD) length of stay in the intensive care unit was 11.2 (13.7) days. Overall mortality rate in the intensive care unit was 30.7% (1590 patients) for the entire population, 52% (120) in patients who received ventilation because of acute respiratory distress syndrome, and 22% (115) in patients who received ventilation for an exacerbation of chronic obstructive pulmonary disease. Survival of unselected patients receiving mechanical ventilation for more than 12 hours was 69%. The main conditions independently associated with increased mortality were (1) factors present at the start of mechanical ventilation (odds ratio [OR], 2.98; 95% confidence interval [CI], 2.44-3.63; P<.001 for coma), (2) factors related to patient management (OR, 3.67; 95% CI, 2.02-6.66; P<.001 for plateau airway pressure >35 cm H(2)O), and (3) developments occurring over the course of mechanical ventilation (OR, 8.71; 95% CI, 5.44-13.94; P<.001 for ratio of PaO(2) to fraction of inspired oxygen <100).Conclusion: Survival among mechanically ventilated patients depends not only on the factors present at the start of mechanical ventilation, but also on the development of complications and patient management in the intensive care unit. [ABSTRACT FROM AUTHOR]

Objective: To determine patterns and frequency of sedative, analgesic, and neuromuscular blocker (NMB) use in a medical intensive care unit (MICU); to describe drug costs; and to describe MICU length of stay and self-extubation related to medication use following implementation of sedation guidelines. Design: Prospective cohort study. Subjects: One hundred patients requiring mechanical ventilation consecutively admitted to an MICU. Measurement: The following data were concurrently collected from medical records: demographic characteristics; clinical variables; sedative, analgesic, and NMB use; MICU length of stay; and self-extubation events. Results: The 85 patients who received a study medication were given a mean of 2.5 (+/- 1.5) medications each. Morphine was the most commonly used analgesic (n = 39), primarily as an as-needed bolus. Fentanyl exceeded morphine in acquisition cost and days of use even at equipotent doses. Lorazepam was the most commonly used (n = 71) and least expensive sedative. Only 12 patients received an NMB. Length of stay was associated with the number of drug classes received (p = 0.0002) but not with the type of drug used. Fifty-nine patients received two or more drugs, usually a benzodiazepine and an analgesic. Conclusions: Benzodiazepines were used more often than analgesics in the MICU. Most patients received lorazepam and morphine on an asneeded basis, as specified by the guidelines, at less cost than with continuous infusion. There was no evidence that as-needed use of morphine or lorazepam increased MICU length of stay or self-extubation. [ABSTRACT FROM AUTHOR]

Although numerous therapies have been used for the treatment and prevention of acute renal failure (ARF), none has been successful in reducing mortality. Agents commonly used in the management of ARF include mannitol, loop and thiazide diuretics, and dopamine. Mannitol has a role for oliguric patients with ARF, but its usefulness for anuric patients is limited. While loop diuretics effectively convert patients to nonoliguria, they fail to consistently reduce dialysis requirements and have no effect on mortality. Thiazide diuretics may be useful as an adjunct to loop diuretics if the patient's diuretic response is not maintained. Although dopamine increases urine output, it has not demonstrated an effect on biochemical markers or dialysis requirements. Given the many potential complications associated with dopamine, patients may be more appropriately managed with diuretics alone. Among the agents being investigated for prevention or treatment of ARF are atrial natriuretic peptide, calcium channel blockers, and fenoldopam. While these potential therapies have shown promise for select applications or patient populations, further controlled trials are needed before their routine use can be recommended. [ABSTRACT FROM AUTHOR]

Background: Despite the variability and complexity of geriatric conditions, few COVID-19 reports of clinical characteristic prognostication provide data specific to oldest-old adults (over age 85), and instead generally report broadly as 65 and older., Objective: To examine metabolic syndrome criteria in adults across 25 hospitals with variation in chronological age., Design and Participants: This cohort study examined 39,564 hospitalizations of patients aged 18 or older with COVID-19 who received inpatient care between March 13, 2020, and February 28, 2022., Exposure: ICU admission and/or in-hospital mortality., Main Measures: Metabolic syndrome criteria and patient demographics were examined as risk factors. The main outcomes were admission to ICU and hospital mortality., Key Results: Oldest old patients (≥ 85 years) hospitalized with COVID-19 accounted for 7.0% (2758/39,564) of all adult hospitalizations. They had shorter ICU length of stay, similar overall hospitalization duration, and higher rates of discharge destinations providing healthcare services (i.e., home health, skilled nursing facility) compared to independent care. Chronic conditions varied by age group, with lower proportions of diabetes and uncontrolled diabetes in the oldest-old cohort compared with young-old (65-74 years) and middle-old (75-84 years) groups. Evaluations of the effect of metabolic syndrome and patient demographics (i.e., age, sex, race) on ICU admission demonstrate minimal change in the magnitude of effect for metabolic syndrome on ICU admission across the different models., Conclusions: Metabolic syndrome measures are important individual predictors of COVID-19 outcomes. Building on prior examinations that metabolic syndrome is associated with death and ARDS across all ages, this analysis supports that metabolic syndrome criteria may be more relevant than chronological age as risk factors for poor outcomes attributed to COVID-19., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: In previous studies, there was an increase in mortality with secondary coinfections in all COVID-19 variants. However, no prior study has explored the association of coinfection with outcomes of hospitalized patients among the COVID-19 variants (Alpha, Delta, and Omicron)., Methods: This observational cohort study involved 21,186 patients hospitalized with COVID-19 in 25 hospitals in Texas. Patients were divided into groups by surges of COVID-19: Alpha (November 1, 2020-February 10, 2021), Delta (July 10, 2021-October 14, 2021), and Omicron (December 21, 2021-March 3, 2022). Data were collected from electronic health records using methodology from the Viral Respiratory Illness Universal Study COVID-19 registry (NCT04323787) of COVID-19 hospitalizations. Multivariable Cox-proportional hazard regression model assessed the adjusted effect of different surge periods on mortality., Results: Bacterial coinfections varied among hospitalization surges associated with Alpha (8.5%), Delta (11.7%), and Omicron (11.9%) variants. Adjusted analyses showed a higher 30-day and 90-day mortality in all variants when coinfections were present compared with isolated COVID-19 infection. In particular, 30-day and 90-day mortality were significantly worse with Delta compared to Alpha and Omicron., Conclusions: All variants were associated with a higher mortality when bacterial coinfections were present. Delta was associated with a higher risk-adjusted mortality at 30 days and thereafter., (Copyright © 2024 Baylor University Medical Center.)

Background: Since publication of the 2012 Berlin definition of acute respiratory distress syndrome (ARDS), several developments have supported the need for an expansion of the definition, including the use of high-flow nasal oxygen, the expansion of the use of pulse oximetry in place of arterial blood gases, the use of ultrasound for chest imaging, and the need for applicability in resource-limited settings. Methods: A consensus conference of 32 critical care ARDS experts was convened, had six virtual meetings (June 2021 to March 2022), and subsequently obtained input from members of several critical care societies. The goal was to develop a definition that would 1 ) identify patients with the currently accepted conceptual framework for ARDS, 2 ) facilitate rapid ARDS diagnosis for clinical care and research, 3 ) be applicable in resource-limited settings, 4 ) be useful for testing specific therapies, and 5 ) be practical for communication to patients and caregivers. Results: The committee made four main recommendations: 1 ) include high-flow nasal oxygen with a minimum flow rate of ⩾30 L/min; 2 ) use Pa O 2 :Fi O 2  ⩽ 300 mm Hg or oxygen saturation as measured by pulse oximetry Sp O 2 :Fi O 2  ⩽ 315 (if oxygen saturation as measured by pulse oximetry is ⩽97%) to identify hypoxemia; 3 ) retain bilateral opacities for imaging criteria but add ultrasound as an imaging modality, especially in resource-limited areas; and 4 ) in resource-limited settings, do not require positive end-expiratory pressure, oxygen flow rate, or specific respiratory support devices. Conclusions: We propose a new global definition of ARDS that builds on the Berlin definition. The recommendations also identify areas for future research, including the need for prospective assessments of the feasibility, reliability, and prognostic validity of the proposed global definition.

Objective: The leadership team invited surgical team members to participate in educational sessions that created self and other awareness as well as gathered baseline information about these topics: communication, conflict management, emotional intelligence, and teamwork., Design: Each educational session included an inventory that was completed to help participants understand their own characteristics and the characteristics of their team members. The results from these inventories were aggregated, relationships were identified, and the intervention was evaluated., Setting: A level 1 trauma center, Baylor Scott and White Health, in central Texas; a 636-bed tertiary care main hospital and an affiliated children's hospital., Participants: An open invitation for all surgical team members yielded 551 interprofessional OR team members including anesthesia, attending physicians, nursing, physician assistants, residents, and administration., Results: Surgeons' communication styles were individual focused, while other team members were group focused. The most common conflict management mode for surgical team members on average was avoiding, and the least common was collaborating. Surgeons primarily used competing mode for conflict management, with avoiding coming in a close second. Finally, the 5 dysfunctions of a team inventory revealed low accountability scores, meaning the participants struggled with holding team members accountable., Conclusions: Helping team members understand their own and others' strengths and blind spots will help create opportunity for more purposeful and clear communication. Additionally, this knowledge should improve efficiency and safety in the high-stakes environment of the operating room., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Many COVID-19 studies are constructed to report hospitalization outcomes, with few large multi-center population-based reports on the time course of intra-hospitalization characteristics, including daily oxygenation support requirements. Comprehensive epidemiologic profiles of oxygenation methods used by day and by week during hospitalization across all severities are important to illustrate the clinical and economic burden of COVID-19 hospitalizations., Methods: This was a retrospective, multi-center observational cohort study of 15,361 consecutive hospitalizations of patients with COVID-19 at 25 adult acute care hospitals in Texas participating in the Society of Critical Care Medicine Discovery Viral Respiratory Illness Universal Study COVID-19 registry., Results: At initial hospitalization, the majority required nasal cannula (44.0%), with an increasing proportion of invasive mechanical ventilation in the first week and particularly the weeks to follow. After 4 weeks of acute illness, 69.9% of adults hospitalized with COVID-19 required intermediate (eg, high-flow nasal cannula, noninvasive ventilation) or advanced respiratory support (ie, invasive mechanical ventilation), with similar proportions that extended to hospitalizations that lasted ≥ 6 weeks., Conclusions: Data representation of intra-hospital processes of care drawn from hospitals with varied size, teaching and trauma designations is important to presenting a balanced perspective of care delivery mechanisms employed, such as daily oxygen method utilization., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2023 by Daedalus Enterprises.)

Background: The RAPID [Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)] score is a validated scoring system which allows risk stratification in patients with pleural infection at presentation. Surgical intervention plays a key role in managing pleural empyema., Methods: A retrospective study of patients with complicated pleural effusions and/or empyema undergoing thoracoscopic or open decortication admitted to multiple affiliated Texas hospitals from September 1, 2014 to September 30, 2018. The primary outcome was all-cause 90-day mortality. The secondary outcomes were organ failure, length of stay and 30-day readmission rate. The outcomes were compared between early surgery (≤3 days from diagnosis) and late surgery (>3 days from diagnosis) and low [0-3] vs. high [4-7] RAPID scores., Results: We enrolled 182 patients. Late surgery was associated with increased organ failure (64.0% vs. 45.6%, P=0.0197) and longer length of stay (16 vs. 10 days, P<0.0001). High RAPID scores were associated with a higher 90-day mortality (16.3% vs. 2.3%, P=0.0014), and organ failure (81.6% vs. 49.6%, P=0.0001). High RAPID scores with early surgery were associated with higher 90-day mortality (21.4% vs. 0%, P=0.0124), organ failure (78.6% vs. 34.9%, P=0.0044), 30-day readmission (50.0% vs. 16.3%, P=0.027) and length of stay (16 vs. 9 days, P=0.0064). High vs. low RAPID scores with late surgery was associated with a higher rate of organ failure (82.9% vs. 56.7%, P=0.0062), but there was not a significant association with mortality., Conclusions: We found a significant association between RAPID scores and surgical timing with new organ failure. Patients with complicated pleural effusions who had early surgery and low RAPID scores experienced better outcomes including decreased length of stay and organ failure compared with those who had late surgery and low RAPID scores. This suggests that using the RAPID score may help identify those who would benefit from early surgery., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-747/coif). The authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Background: COVID-19 symptom reports describe varying levels of disease severity with differing periods of recovery and symptom trajectories. Thus, there are a multitude of disease and symptom characteristics clinicians must navigate and interpret to guide care., Objective: To find natural groups of patients with similar constellations of post-acute sequelae of COVID-19 (PASC) symptoms., Design: Cohort SETTING: Outpatient COVID-19 recovery clinic with patient referrals from 160 primary care clinics serving 36 counties in Texas., Patients: Adult patients seeking COVID-19 recovery clinic care between November 15, 2020, and July 31, 2021, with laboratory-confirmed mild (not hospitalized), moderate (hospitalized), or severe (hospitalized with critical care) COVID-19., Main Measures: Demographics, COVID illness onset, and duration of persistent PASC symptoms via semi-structured medical assessments., Key Results: Four hundred forty-one patients (mean age 51.5 years; 295 [66.9%] women; 99 [22%] Hispanic, and 170 [38.5%] non-White, racial minority) met inclusion criteria. Using a k-medoids algorithm, we found that PASC symptoms cluster into two distinct groups: neuropsychiatric (N = 186) (e.g., subjective cognitive dysfunction) and pulmonary (N = 255) (e.g., dyspnea, cough). The neuropsychiatric cluster had significantly higher incidences of otolaryngologic (X 2 = 14.3, p < 0.001), gastrointestinal (X 2 = 6.90, p = 0.009), neurologic (X 2 = 441, p < 0.001), and psychiatric sequelae (X 2 = 40.6, p < 0.001) with more female (X 2 = 5.44, p = 0.020) and younger age (t = 2.39, p = 0.017) patients experiencing longer durations of PASC symptoms before seeking care (t = 2.44, p = 0.015). Patients in the pulmonary cluster were more often hospitalized for COVID-19 (X 2 = 3.98, p = 0.046) and had significantly higher comorbidity burden (U = 20800, p = 0.019) and pulmonary sequelae (X 2 = 13.2, p < 0.001)., Conclusions: Health services clinic data from a large integrated health system offers insights into the post-COVID symptoms associated with care seeking for sequelae that are not adequately managed by usual care pathways (self-management and primary care clinic visits). These findings can inform machine learning algorithms, primary care management, and selection of patients for earlier COVID-19 recovery referral., Trial Registration: N/A., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Competing Interests: The authors report no funding or conflicts of interest.

Importance: Hypotension is common during tracheal intubation of critically ill adults and increases the risk of cardiac arrest and death. Whether administering an intravenous fluid bolus to critically ill adults undergoing tracheal intubation prevents severe hypotension, cardiac arrest, or death remains uncertain., Objective: To determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death., Design, Setting, and Participants: This randomized clinical trial enrolled 1067 critically ill adults undergoing tracheal intubation with sedation and positive pressure ventilation at 11 intensive care units in the US between February 1, 2019, and May 24, 2021. The date of final follow-up was June 21, 2021., Interventions: Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527)., Main Outcomes and Measures: The primary outcome was cardiovascular collapse (defined as new or increased receipt of vasopressors or a systolic blood pressure <65 mm Hg between induction of anesthesia and 2 minutes after tracheal intubation, or cardiac arrest or death between induction of anesthesia and 1 hour after tracheal intubation). The secondary outcome was the incidence of death prior to day 28, which was censored at hospital discharge., Results: Among 1067 patients randomized, 1065 (99.8%) completed the trial and were included in the primary analysis (median age, 62 years [IQR, 51-70 years]; 42.1% were women). Cardiovascular collapse occurred in 113 patients (21.0%) in the fluid bolus group and in 96 patients (18.2%) in the no fluid bolus group (absolute difference, 2.8% [95% CI, -2.2% to 7.7%]; P = .25). New or increased receipt of vasopressors occurred in 20.6% of patients in the fluid bolus group compared with 17.6% of patients in the no fluid bolus group, a systolic blood pressure of less than 65 mm Hg occurred in 3.9% vs 4.2%, respectively, cardiac arrest occurred in 1.7% vs 1.5%, and death occurred in 0.7% vs 0.6%. Death prior to day 28 (censored at hospital discharge) occurred in 218 patients (40.5%) in the fluid bolus group compared with 223 patients (42.3%) in the no fluid bolus group (absolute difference, -1.8% [95% CI, -7.9% to 4.3%]; P = .55)., Conclusions and Relevance: Among critically ill adults undergoing tracheal intubation, administration of an intravenous fluid bolus compared with no fluid bolus did not significantly decrease the incidence of cardiovascular collapse., Trial Registration: ClinicalTrials.gov Identifier: NCT03787732.

In December 2019, China witnessed the emergence of a novel coronavirus, SARS-CoV-2. Its ability to spread quickly made it a global pandemic. The United States has been greatly affected, with more than 980,000 lives lost so far. Diagnosis is made primarily through nasopharyngeal swab for polymerase chain reaction. Point-of-care testing by antigen is less sensitive and specific and may require polymerase chain reaction confirmation. Management of the COVID-19 patient remains largely supportive. Steroids are now a therapy mainstay if the patient is hypoxic. Direct antivirals, such as nirmatrelvir/ritonavir, remdesivir, or molnupirivir, can be used if certain criteria are met. SARS-CoV-2 is transmitted primarily by inhalation of large droplets, though transmission by aerosolization may occur, particularly via certain procedures. In the hospital setting, use of personal protective equipment for the care of COVID-19 patients has largely remained the same, with full use of gowns, gloves, respirators, and eye protection. Inadequate supply at the start of the pandemic required innovative ways to reprocess and extend the use of personal protective equipment. Three vaccines are now available in the US, all with excellent efficacy against severe disease and hospitalization, though booster doses are needed to bolster waning antibody levels. The possibility of emerging variants continues to remain a threat to control of the pandemic. The leader of the World Health Organization, Dr. Tedros, has stated, "The pandemic will not be over anywhere until it's over everywhere.", (Copyright © 2022 Baylor University Medical Center.)

Background: Evidence for vaccine effectiveness (VE) against influenza-associated pneumonia has varied by season, location, and strain. We estimate VE against hospitalization for radiographically identified influenza-associated pneumonia during 2015-2016 to 2017-2018 seasons in the US Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN)., Methods: Among adults aged ≥18 years admitted to 10 US hospitals for acute respiratory illness (ARI), clinician-investigators used keywords from reports of chest imaging performed during 3 days around hospital admission to assign a diagnosis of "definite/probable pneumonia." We used a test-negative design to estimate VE against hospitalization for radiographically identified laboratory-confirmed influenza-associated pneumonia, comparing reverse transcriptase-polymerase chain reaction-confirmed influenza cases with test-negative subjects. Influenza vaccination status was documented in immunization records or self-reported, including date and location. Multivariable logistic regression models were used to adjust for age, site, season, calendar-time, and other factors., Results: Of 4843 adults hospitalized with ARI included in the primary analysis, 266 (5.5%) had "definite/probable pneumonia" and confirmed influenza. Adjusted VE against hospitalization for any radiographically confirmed influenza-associated pneumonia was 38% (95% confidence interval [CI], 17-53%); by type/subtype, it was 74% (95% CI, 52-87%) influenza A (H1N1)pdm09, 25% (95% CI, -15% to 50%) A (H3N2), and 23% (95% CI, -32% to 54%) influenza B. Adjusted VE against intensive care for any influenza was 57% (95% CI, 19-77%)., Conclusions: Influenza vaccination was modestly effective among adults in preventing hospitalizations and the need for intensive care associated with influenza pneumonia. VE was significantly higher against A (H1N1)pdm09 and was low against A (H3N2) and B., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States., Design: Cross-sectional survey., Setting: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated., Patients: None., Interventions: None., Measurement and Main Results: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing ( n = 20, 77%), volunteer staff support ( n = 15, 58%), institutional staff/space support ( n = 13, 46%), and grant or foundation funding ( n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%)., Conclusions: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

As surges in the COVID-19 pandemic have continued worldwide, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has mutated, spawning several new variants, and impacting, to various degrees, transmission, disease severity, diagnostics, therapeutics, and natural and vaccine-induced immunity. Baylor Scott & White Health has implemented, along with laboratory diagnosis, SARS-CoV-2 sequencing to identify variants in its geographical service area. We analyzed virus sequencing results of specimens collected across Central Texas and found dramatic changes in variant distribution in the first half of 2021. The alpha variant (B 1.1.7) became predominant at week 13 and continued dominance until week 25. A growth rate of 1.20 (R 2  = 0.92) for the first 15 weeks was noted and this growth gradually declined to -0.55 (R 2  = 0.99) for the final 13 weeks. Currently, B.1.1.7 is being displaced with B.1.617.2 at a 0.58 growth rate (R 2  = 0.97). We also investigated vaccine breakthrough cases (VBCs) within our healthcare system and present clinical data on 28 symptomatic patients., (© 2021 Wiley Periodicals LLC.)

Purpose: We sought to examine changes in acute respiratory distress syndrome (ARDS) management over a 12-year period of two successive randomized trials., Methods: Analyses included baseline data, from eligible patients, prior to influence of trial protocols, and daily study data, from randomized patients, of variables not determined by trial protocols. Mixed linear regressions examined changes in practice year-on-year., Results: A total of 2376 patients met the inclusion criteria. Over the 12-year period, baseline tidal volume index decreased (9.0 to 7.0 ml/kg, p < 0.001), plateau pressures decreased (30.8 to 29.0 cmH 2 O, p < 0.05), and baseline positive end-expiratory pressures increased (10.8 to 13.2 cmH 2 O, p < 0.001). Volume-controlled ventilation declined from 29.4 to 14.0% (p < 0.01). Use of corticosteroids increased (baseline: 7.7 to 30.3%; on study: 32.6 to 61.2%; both p < 0.001), as did neuromuscular blockade (baseline: 12.3 to 24.5%; on study: 55.5 to 70.0%; both p < 0.01). Inhaled nitric oxide use increased (24.9 to 65.8%, p < 0.05). We observed no significant change in prone positioning (16.2 to 18.9%, p = 0.70)., Conclusions: Clear trends were apparent in tidal volume, airway pressures, ventilator modes, adjuncts and rescue therapies. With the exception of prone positioning, and outside the context of rescue therapy, these trends appear consistent with the evolving literature on ARDS management., Competing Interests: Declaration of Competing Interest All the other authors declare no conflicts of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The epidemiology and organ-specific sequelae following acute illness due to COVID-19 and prompting patients to seek COVID recovery care are not yet well characterized. This cross-sectional study reviewed data on 200 adult patients with prolonged symptoms of COVID-19 (>14 days after symptom onset) not resolved by usual primary care or specialist care who were referred for COVID-specific follow-up. Most patients sought COVID recovery clinic visits within the first 2 months of initial onset of symptoms (median 37 days), with some seeking care for sequelae persisting up to 10 months (median 82 days). At the time of telehealth evaluation, 13% of patients were using home oxygen, and 10% of patients had been unable to return to work due to persistent fatigue and/or subjective cognitive dysfunction ("brain fog"). The prominent specific symptom sequelae prompting patients to seek COVID-specific evaluation beyond usual primary care and specialist referrals were dyspnea, fatigue/weakness, and subjective cognitive dysfunction, irrespective of whether patients had required hospitalization or time since COVID-19 symptom onset., (Copyright © 2021 Baylor University Medical Center.)

Background: Adverse reactions, including anaphylaxis, to messenger RNA coronavirus disease 2019 (COVID-19) vaccines rarely occur. Because of the need to administer a timely second dose in subjects who reported a reaction to their first dose, a panel of health-care professionals developed a safe triage of the employees and health care providers (EHCP) at a large health-care system to consider administration of future dosing. Methods: There were 28,544 EHCPs who received their first dose of COVID-19 vaccines between December 15, 2020, and March 8, 2021. The EHCPs self-reported adverse reactions to a centralized COVID-19 command center (CCC). The CCC screened and collected information on the quality of reaction, symptoms, and timing of the onset of the reaction. Results: Of 1253 calls to the CCC, 113 were identified as requiring consideration by a panel of three (American Board of Allergy and Immunology) ABAI-certified allergists for future dosing or formal in-person assessment. Of the 113 EHCPs, 94 (83.2%) were recommended to get their second dose. Eighty of 94 received their second planned dose without a severe or immediate reaction. Of the 14 of 113 identified as needing further evaluation, 6 were evaluated by a physician and subsequently received their second dose without a serious adverse reaction. Eight of 14 did not receive their second dose. Only 5 of the 113 EHCPs reported reactions (4.4%) were recommended to not take the second dose: 3 (2.6%) because of symptoms consistent with anaphylaxis, and 2 because of neurologic complications (seizure, stroke). Conclusion: The panel demonstrated that, by consideration of reaction history alone, the ECHPs could be appropriately triaged to receive scheduled second dosing of COVID-19 vaccines without delays for in-person evaluation and allergy testing.

The shifting health care landscape in the United States has surfaced challenges related to increased accountability, interprofessional health care teams, and changes in federal policy-all of which compel physicians to adopt roles beyond clinician such as clinical investigator, team leader, and manager. To address these challenges, leadership development programs across the continuum of medical education aim to develop critical leadership skills and competencies, such as emotional intelligence. Such skills and competencies are largely taught through didactic approaches (e.g., classroom). These approaches often neglect the context of learning. From medical residency to a hospital or clinic, the contextual lived experience is habitually overlooked as a vehicle for developing emotional intelligence. This article highlights lived experience, such as medical residency, as an approach to develop emotional intelligence. First, we address the need for developing emotional intelligence as a leadership skill as well as the suitability of medical residency for such development. Next, we discuss the background of lived experience and emotional intelligence. Lastly, we identify future directions for leveraging lived experiences of medical residency to develop emotional intelligence., (Copyright © 2021 Baylor University Medical Center.)

Aims: The primary aim of the Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS) peer mentor training trial is to determine the feasibility for peer mentor training to connect new ICU survivors with survivors who have made successful recoveries. Secondary aims are to also examine peer mentor eligibility, recruitment and retention rates and assess changes in participant knowledge of Post Intensive Care Syndrome (PICS), reported symptoms and health-related quality of life., Design: Prospective clinical feasibility trial., Methods: This study received funding from the National Institutes of Health funded P30 Center for Excellence (2014-2020). Up to 20 adult patients who have had an ICU stay of 3 days or longer more than 3 months ago will be enrolled into the study. Participants will undergo a 6-week peer mentor training program to learn how to promote healthy self-management behaviours, social connections, and well-being using motivational interviewing (MI). Participants will complete surveys about their recovery at 3 points during the study: prior to training, 6 weeks post-training and 3 months post-training. Survey questions will be used to assess trends in participant social isolation, depression, functional status, and self-management behaviours., Discussion: Enrollment closes by December 2020. As a feasibility trial, power sufficient for hypothesis testing will not be available. However, study operations and intervention fidelity contribute to future research knowledge and participant characteristics and longitudinal outcomes will yield data on intervention feasibility. This study is the first use of embedding peer-led motivational interviewing training into a peer support intervention for ICU survivors., Impact: Current self-management interventions are limited for ICU survivors and do not sufficiently address barriers to promoting self-management behaviours or improving their health status, well-being and cost of health. This study will provide data to develop and implement interventions for the self-management of PICS-related symptoms and sequelae., (© 2021 John Wiley & Sons Ltd.)

Background: Conflicts in medical settings affect both team function and patient care, yet a standardized curriculum for conflict management in clinical teams does not exist., Objectives: To evaluate the effects of an educational intervention for conflict management on knowledge and perceptions and to identify trends in preferred conflict management style among intensive care unit workers., Methods: A conflict management education intervention was created for an intensive care team. The intervention was 1 hour long and incorporated the Thomas-Kilmann Conflict Mode Instrument as well as conflict management concepts, self-reflection, and active learning through discussion and reviewing clinical cases. Descriptive statistics were prepared on the participants' preferred conflict management modes. A pretest/posttest was analyzed to evaluate knowledge and perceptions of conflict before and after the intervention, and 3 open-ended questions on the posttest were reviewed for categories., Results: Forty-nine intensive care providers participated in the intervention. The largest portion of participants had an avoiding conflict management mode (32%), followed by compromising (30%), accommodating (25%), collaborating (9%), and competing (5%). Pretest/posttest data were collected for 31 participants and showed that knowledge (P < .001) and perception (P = .004) scores increased significantly after the conflict management intervention., Conclusions: The conflict management educational intervention improved the participants' knowledge and affected perceptions. Categorization of open-ended questions suggested that intensive care providers are interested in concrete information that will help with conflict resolution, and some participants understood that mindfulness and awareness would improve professional interactions or reduce conflict., (©2020 American Association of Critical-Care Nurses.)

Public health emergency of SARS-CoV-2 has facilitated diagnostic testing as a related medical countermeasure against COVID-19 outbreak. Numerous serologic antibody tests have become available through an expedited federal emergency use only process. This paper highlights the analytical characteristic of an ELISA based assay by AnshLabs and three random access immunoassay (RAIA) by DiaSorin, Roche, and Abbott that have been approved for emergency use authorization (EUA), at a tertiary academic center in a low disease-prevalence area. The AnshLabs gave higher estimates of sero-prevalence, over the three RAIA methods. For positive results, AnshLabs had 93.3% and 100% agreement with DiaSorin or Abbott and Roche respectively. For negative results, AnshLabs had 74.3% and 78.3% agreement with DiaSorin and Roche or Abbott respectively. All discrepant samples that were positive by AnshLabs and negative by RAIA tested positive by all-in-one step SARS-CoV-2 Total (COV2T) assay performed on the automated Siemens Advia Centaur XPT analyzer. None of these methods, however, are useful in early diagnosis of SARS-CoV-2., Competing Interests: Baylor Scott and White Health provided support for the study in the form of salaries for all authors. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare. All authors have no other potential competing financial, non-financial, professional, or personal interests.

Rapid diagnosis and isolation are key to containing the quick spread of a pandemic agent like severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), which has spread globally since its initial outbreak in Wuhan province in China. SARS-CoV-2 is novel and the effect on typically prevalent seasonal viruses is just becoming apparent. We present our initial data on the prevalence of respiratory viruses in the month of March 2020. This is a retrospective cohort study post launching of SARS-CoV-2 testing at Baylor Scott and White Hospital (BSWH), Temple, Texas. Testing for SARS-CoV-2 was performed by real-time reverse transcription polymerase chain reaction assay and results were shared with State public health officials for immediate interventions. More than 3500 tests were performed during the first 2 weeks of testing for SARS-CoV-2 and identified 168 (4.7%) positive patients. Sixty-two (3.2%) of the 1912 ambulatory patients and 106 (6.3%) of the 1659 emergency department/inpatients tested were positive. The highest rate of infection (6.9%) was seen in patients aged 25 to 34 years, while the lowest rate of infection was seen among patients aged <25 years old (2%). County-specific patient demographic information was shared with respective public health departments for epidemiological interventions. Incidentally, this study showed that there was a significant decrease in the occurrence of seasonal respiratory virus infections, perhaps due to increased epidemiological awareness about SARS-CoV-2 among the general public, as well as the social distancing measures implemented in response to SARS-CoV-2. Data extracted for BSWH from the Centers for Disease Control and Prevention's National Respiratory and Enteric Virus Surveillance System site revealed that Influenza incidence was 8.7% in March 2020, compared with 25% in March 2019. This study was intended to provide an initial experience of dealing with a pandemic and the role of laboratories in crisis management. This study provided SARS-CoV-2 testing data from ambulatory and inpatient population. Epidemiological interventions depend on timely availability of accurate diagnostic tests and throughput capacity of such systems during large outbreaks like SARS-CoV-2., (© 2020 Wiley Periodicals LLC.)

The pandemic has required creative and agile teamwork and leadership. Creativity was especially necessary when employing the social distancing requirements for this disease. To ensure compliance while also meeting the needs of our system and community, a huge telemedicine initiative was deployed. Administrative leadership utilized ad hoc teams to overcome challenges and ensured success with a shared vision, clarity, communication, and a positive culture. This article outlines how the team was developed, what challenges the team faced, and how they were successful in the unchartered waters of a COVID-19 response. Finally, best practices are shared for inconsistent teams in an inconsistent setting, ensuring success within an ad hoc team residing in a fluid environment., (Copyright © 2020 Baylor University Medical Center.)

Background: Vancomycin-resistant Enterococcus (VRE) bacteremia has significant morbidity and mortality. Empiric antibiotic regimens for treating patients with risk factors for multidrug-resistant organisms may not have medications directed at treating VRE., Study Question: To evaluate the impact of antibiotic therapy (and other risk factors) on mortality in VRE bacteremia., Study Design: We identified 146 patients with VRE bacteremia, admitted at our institution over an 11 years period (2004-2014). All inpatients with an initial positive VRE blood culture were included only once in the analysis. Eighteen patients were excluded from the study because of inability to retrieve medical information regarding one or more important study variables. The retrospectively collected data from electronic medical records of 128 patients were analyzed., Results: The inpatient, 30-day, and 1-year mortality rates from VRE bacteremia were 23%, 31%, and 59%, respectively. Only 19% patients were discharged home. Inappropriate antibiotics were prescribed in 19% patients. Appropriate antibiotics were prescribed in 81% patients (62% daptomycin and 37% linezolid); however, only 58% patients received appropriate antibiotics within 24 hours of the reported positive blood cultures. The 30-day and 1-year mortality rates for patients treated with inappropriate antibiotics were 54% and 67% compared with 26% and 50%, respectively, for those treated with appropriate antibiotics. The median survival rate for patients treated with inappropriate antibiotics was 1 month (95% confidence interval: 0.0-1.0) compared with 11 months (95% confidence interval: 4.0-13.0) for those treated with appropriate antibiotics. The advanced patient age (median age 75 years vs. 63 years) was a significant risk factor for inappropriate antibiotic therapy (P value = 0.02). The multivariate Cox regression model revealed inappropriate antibiotic therapy (P value = 0.003), septic shock (P value = 0.0004), albumin (P value = 0.04), and dementia (P value = 0.003) to be associated with 30-day mortality., Conclusions: Our study highlights the detrimental effect of inappropriate antibiotic therapy and other risk factors on morbidity and mortality associated with VRE bacteremia., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Our hypothesis was that patients managed with noninvasive ventilation (NIV) on the wards could be risk-stratified with initial pulse oximetry/fraction of inspired oxygen (SpO 2 /FiO 2 ) ratios and tidal volumes (Vte). A prospective study of consecutive patients with acute respiratory failure requiring NIV on the wards was conducted. A multivariate logistic regression model and a negative binomial regression model were used. A total of 403 patients (55.8% women) had a mean age of 65.0 ± 14.9 years with a mean body mass index of 32.1 ± 11.1 kg/m 2 . The 28-day mortality was 14.1%, and the intubation rate was 16.1%. Pneumonia was associated with the highest 28-day mortality (22.5%) and rate of intubation (36.7%) when compared with chronic obstructive pulmonary disease (4.4% and 7.3%) or congestive heart failure (22.2% and 13.4%). The SpO 2 /FiO 2 groups were <214 (26.6%), 214 -357 (66.0%), and ≥357 (7.4%). Those in the SpO 2 /FiO 2  < 214 group had a higher 28-day mortality rate (odds ratio [OR] = 8.19; 95% confidence interval [CI] 1.02 -65.7), intubation rate (OR = 3.7; 95% CI 1.1 -12.1), intensive care unit admission rate (OR = 2.9; 95% CI 1.2 -7.4), and length of stay (relative risk = 2.0; 95% CI 1.3 -3.0). A Vte/predicted body weight <7.7 mL/kg was associated with increased intubations (OR = 3.1; 95% CI 1.3 -7.4), intensive care unit admissions (OR = 2.5; 95% CI 1.3 -4.6), and 30-day readmissions (OR = 2.9; 95% CI 1.2 -6.8). In conclusion, in patients without acute respiratory distress syndrome who had acute respiratory failure managed with noninvasive ventilation on the wards, severe hypoxemia as assessed by a simple SpO 2 /FiO 2  ≤ 214 was associated with poor outcomes., (Copyright © 2020 Baylor University Medical Center.)

The coronavirus (CoV) epidemic that began in China in December 2019 follows earlier epidemics of severe acute respiratory syndrome CoV in China and Middle East respiratory syndrome CoV in Saudi Arabia. The full genome of the 2019 novel coronavirus (2019-nCoV) has now been shared, and data have been gathered from several case series. As of February 11, 2020, there have been 45,182 laboratory-confirmed cases, the vast majority in China, with 1115 deaths, for an overall case-fatality rate of 2.5%. Cases have been confirmed in 27 countries. On average, each patient infects 2.2 other people. Symptomatic infection appears to predominantly affect adults, with a 5-day estimated incubation period between infection and symptom onset. The most common presenting symptoms are fever, cough, dyspnea, and myalgias and/or fatigue. All cases reported to date have shown radiographic evidence of pneumonia. 2019-nCoV is diagnosed by real-time reverse transcriptase polymerase chain reaction. Treatment is largely supportive, with regimens including antiviral therapy. Corticosteroids are not routinely recommended. Hand hygiene, prompt identification and isolation of suspect patients, and appropriate use of personal protective equipment are the most reliable methods to contain the epidemic., (Copyright © 2020 Baylor University Medical Center.)

Background : Despite recommendations from survey scientists, surveys appear to be utilized in medical education without the critical step of pretesting prior to survey launch. Pretesting helps ensure respondents understand questions as survey developers intended and that items and response options are relevant to respondents and adequately address constructs, topics, issues or problems. While psychometric testing is important in assessing aspects of question quality and item performance, it cannot discern how respondents, based upon their lived experiences, interpret the questions we pose. Aim : This audit study explored whether authors of medical education journal articles within audited journals reported pretesting survey instruments during survey development, as recommended by survey scientists and established guidelines/standards for survey instrument development. Methods : Five national and international medical education journals publishing survey articles from Jan. 2014 - Dec. 2015 were audited to determine whether authors reported pretesting during survey development. All abstracts within all issues of these journals were initially reviewed. Two hundred fifty-one articles met inclusion criteria using a protocol piloted and revised prior to use. Results : The number of survey articles published per journal ranged from 11 to 106. Of 251 audited articles, 181 (72.11%) described using a new instrument without pretesting, while 17 (6.77%) described using a new instrument where items were pretested. Fifty-three (21.12%) articles described using pre-existing instruments; of these, no articles (0%) reported pretesting existing survey instruments prior to use. Conclusions : Findings from this audit study indicate that reported survey pretesting appears to be lower than that reported in healthcare journals. This is concerning, as results of survey studies and evaluation projects are used to inform educational practices, guide future research, and influence policy and program development. Findings apply to both survey developers and faculty across a range of fields, including evaluation and medical education research.

Duty-hours policies continue to be debated. Most know the pro and con arguments, but many may not be aware of background information preceding and intertwining the development and implementation of these policies. Interestingly, several aspects of law were involved or potentially correlated with policies enacted. This review updates new generations of physicians and scholars on the historical trajectory of duty-hour policies and highlights policy implications and the current state of evidence. In reviewing the historical and legal trajectory of duty-hours, many updates seemed to be a reaction to potential federal entanglement. Additionally, the review of the postimplementation literature revealed minimal empirical evidence. Instead, the majority of the positive findings were perception based. These summaries demonstrate a need for further outcomes evidence to validate policies.