Showing papers by "Deborah J. Cook published in 2003"
TL;DR: This document reflects a process whereby a group of experts and opinion leaders revisited the 1992 sepsis guidelines and found that apart from expanding the list of signs and symptoms of sepsi to reflect clinical bedside experience, no evidence exists to support a change to the definitions.
Abstract: Objective: In 1991, the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) convened a "Consensus Conference", the goals of which were to provide a conceptual and a practical framework to define the systemic inflammatory response to infection, which is a progressive inju- rious process that falls under the gen- eralized term 'sepsis' and includes sepsis-associated organ dysfunction as well. The general definitions intro- duced as a result of that conference have been widely used in practice, and have served as the foundation for in- clusion criteria for numerous clinical trials of therapeutic interventions. Nevertheless, there has been an impe- tus from experts in the field to modify these definitions to reflect our current understanding of the pathophysiology of these syndromes. Design: Several North American and European inten- sive care societies agreed to revisit the definitions for sepsis and related con- ditions. This conference was spon- sored by the Society of Critical Care Medicine (SCCM), The European So-
5,298 citations
TL;DR: A hypothetical model for staging sepsis is presented, which, in the future, may better characterize the syndrome on the basis of predisposing factors and premorbid conditions, the nature of the underlying infection, the characteristics of the host response, and the extent of the resultant organ dysfunction.
Abstract: In 1991, the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) convened a "Consensus Conference," the goals of which were to "provide a conceptual and a practical framework to define the systemic inflammatory response to infection, which is a progressive injurious process that falls under the generalized term 'sepsis' and includes sepsis-associated organ dysfunction as well. The general definitions introduced as a result of that conference have been widely used in practice, and have served as the foundation for inclusion criteria for numerous clinical trials of therapeutic interventions. Nevertheless, there has been an impetus from experts in the field to modify these definitions to reflect our current understanding of the pathophysiology of these syndromes. Several North American and European intensive care societies agreed to revisit the definitions for sepsis and related conditions. This conference was sponsored by the Society of Critical Care Medicine (SCCM), The European Society of Intensive Care Medicine (ESICM), The American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Surgical Infection Society (SIS). 29 participants attended the conference from Europe and North America. In advance of the conference, subgroups were formed to evaluate the following areas: signs and symptoms of sepsis, cell markers, cytokines, microbiologic data, and coagulation parameters.. The present manuscript serves as the final report of the 2001 International Sepsis Definitions Conference. 1. Current concepts of sepsis, severe sepsis and septic shock remain useful to clinicians and researchers. 2. These definitions do not allow precise staging or prognostication of the host response to infection. 3. While SIRS remains a useful concept, the diagnostic criteria for SIRS published in 1992 are overly sensitive and non-specific. 4. An expanded list of signs and symptoms of sepsis may better reflect the clinical response to infection. 6. PIRO, a hypothetical model for staging sepsis is presented, which, in the future, may better characterize the syndrome on the basis of predisposing factors and premorbid conditions, the nature of the underlying infection, the characteristics of the host response, and the extent of the resultant organ dysfunction.
4,432 citations
TL;DR: In this article, the authors evaluated 109 survivors of the acute respiratory distress syndrome 3, 6, and 12 months after discharge from the intensive care unit, and found that muscle weakness and fatigue were the reasons for their functional limitation.
Abstract: Background As more patients survive the acute respiratory distress syndrome, an understanding of the long-term outcomes of this condition is needed. Methods We evaluated 109 survivors of the acute respiratory distress syndrome 3, 6, and 12 months after discharge from the intensive care unit. At each visit, patients were interviewed and underwent a physical examination, pulmonary-function testing, a six-minute–walk test, and a quality-of-life evaluation. Results Patients who survived the acute respiratory distress syndrome were young (median age, 45 years) and severely ill (median Acute Physiology, Age, and Chronic Health Evaluation score, 23) and had a long stay in the intensive care unit (median, 25 days). Patients had lost 18 percent of their base-line body weight by the time they were discharged from the intensive care unit and stated that muscle weakness and fatigue were the reasons for their functional limitation. Lung volume and spirometric measurements were normal by 6 months, but carbon monoxide d...
1,914 citations
TL;DR: The strongest determinants of the withdrawal of ventilation in critically ill patients were the physician's perception that the patient preferred not to use life support, the physicians' predictions of a low likelihood of survival in the intensive care unit and a high likelihood of poor cognitive function, and the use of inotropes or vasopressors.
Abstract: Background In critically ill patients who are receiving mechanical ventilation, the factors associated with physicians' decisions to withdraw ventilation in anticipation of death are unclear. The objective of this study was to examine the clinical determinants that were associated with the withdrawal of mechanical ventilation. Methods We studied adults who were receiving mechanical ventilation in 15 intensive care units, recording base-line physiological characteristics, daily Multiple Organ Dysfunction Scores, the patient's decision-making ability, the type of life support administered, the use of do-not-resuscitate orders, the physician's prediction of the patient's status, and the physician's perceptions of the patient's preferences about the use of life support. We examined the relation between these factors and withdrawal of mechanical ventilation, using Cox proportional-hazards regression analysis. Results Of 851 patients who were receiving mechanical ventilation, 539 (63.3 percent) were successfully weaned, 146 (17.2 percent) died while receiving mechanical ventilation, and 166 (19.5 percent) had mechanical ventilation withdrawn. The need for inotropes or vasopressors was associated with withdrawal of the ventilator (hazard ratio, 1.78; 95 percent confidence interval, 1.20 to 2.66; P=0.004), as were the physician's prediction that the patient's likelihood of survival in the intensive care unit was less than 10 percent (hazard ratio, 3.49; 95 percent confidence interval, 1.39 to 8.79; P=0.002), the physician's prediction that future cognitive function would be severely impaired (hazard ratio, 2.51; 95 percent confidence interval, 1.28 to 4.94; P=0.04), and the physician's perception that the patient did not want life support used (hazard ratio, 4.19; 95 percent confidence interval, 2.57 to 6.81; P Conclusions Rather than age or the severity of the illness and organ dysfunction, the strongest determinants of the withdrawal of ventilation in critically ill patients were the physician's perception that the patient preferred not to use life support, the physician's predictions of a low likelihood of survival in the intensive care unit and a high likelihood of poor cognitive function, and the use of inotropes or vasopressors.
404 citations
TL;DR: A meta-analysis of 15 trials found that adding NPPV to standard care reduced rates of endotracheal intubation, length of hospital stay, and in-hospital mortality rates in patients with severe exacerbations but not in those with milder exacerbations.
Abstract: Background: Over the past decade, noninvasive positive-pressure ventilation (NPPV) in the setting of acute exacerbations of chronic obstructive pulmonary disease (COPD) has increased in popularity. Although several trials have been published on the relative effectiveness of this treatment, apparent inconsistencies in study results remain. Purpose: To assess the effect of NPPV on rate of endotracheal intubation, length of hospital stay, and in-hospital mortality rate in patients with an acute exacerbation of COPD and to determine the effect of exacerbation severity on these outcomes. Data Sources: MEDLINE (1966 to 2002) and EMBASE (1990 to 2002). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. There were no language restrictions. Study Selection: The researchers selected randomized, controlled trials that 1) examined patients with acute exacerbation of COPD; 2) compared noninvasive ventilation and standard therapy with standard therapy alone; and 3) included need for endotracheal intubation, length of hospital stay, or hospital survival as an outcome. Data Extraction: Methodologic quality and results were abstracted independently and in duplicate. Data Synthesis: The addition of NPPV to standard care in patients with an acute exacerbation of COPD decreased the rate of endotracheal intubation (risk reduction, 28% [95% CI, 15% to 40%]), length of hospital stay (absolute reduction, 4.57 days [CI, 2.30 to 6.83 days]), and in-hospital mortality rate (risk reduction, 10% [CI, 5% to 15%]). However, subgroup analysis showed that these beneficial effects occurred only in patients with severe exacerbations, not in those with milder exacerbations. Conclusions: Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations.
376 citations
TL;DR: In this multicenter observational study, it was found that most substitute decision-makers for ICU patients wanted to share decision-making responsibility with physicians and that, overall, they were satisfied with their decision- making experience.
Abstract:
Objective. To describe the substitute decision-makers' perspectives related to decision-making in the intensive care unit (ICU) and to determine those variables associated with their overall satisfaction with decision-making.
Design. Prospective, multicenter, cohort study.
Setting. Six Canadian university-affiliated ICUs.
Patients and participants. We distributed a validated, self-administered questionnaire assessing 21 key aspects of communication and decision-making to substitute decision-makers of ICU patients who were mechanically ventilated for more than 48 h.
Intervention. None.
Measurements and results. A group consisting of 1,123 substitute decision-makers received questionnaires; 789 were returned (70.3% response rate). Respondents were most satisfied with the frequency of communication with nurses and least satisfied with the frequency of communication with physicians. In terms of overall satisfaction with decision-making, 560 (70.9%) of the respondents were either completely or very satisfied. The majority (81.2%) of respondents preferred some form of shared decision-making process. Factors contributing the most to satisfaction with decision-making included: complete satisfaction with level of health care the patient received, completeness of information received, and feeling supported through the decision-making process. Satisfaction with decision-making varied significantly across sites.
Conclusions. In this multicenter observational study, we found that most substitute decision-makers for ICU patients wanted to share decision-making responsibility with physicians and that, overall, they were satisfied with their decision-making experience. Adequate communication, feeling supported, and achieving the appropriate level of care for their family member were key determinants of satisfaction with decision-making in the ICU.
287 citations
TL;DR: A candidate framework for such a system, based on the infection, the host response, and the extent of organ dysfunction (the IRO system) is described.
Abstract: Background Sepsis is not a single disease but a complex and heterogeneous process. Its expression is variable, and its severity is influenced by the nature of the infection, the genetic background of the patient, the time to clinical intervention, the supportive care provided by the clinician, and a number of factors as yet unknown. The evaluation of effective therapies has been hampered by limitations in our ability to characterize the process and to stratify patients into more homogeneous groups with respect to pathogenesis. Objectives To develop a taxonomy of markers relevant to clinical research in sepsis and to propose a testable candidate system for stratifying patients into more therapeutically homogeneous groups. Data source An expert roundtable discussion and a MEDLINE review using search terms "marker" and "sepsis." Results Markers provide information in one or more of three domains: diagnosis, prognosis, and response to therapy. More than 80 putative markers of sepsis have been described. All correlate with the risk of mortality (prognosis), yet none has shown utility in stratifying patients with respect to therapy (diagnosis) or in titrating that therapy (response). Their limitations arise from the challenges of establishing causality in a complex disease process such as sepsis and of stratifying patients into more homogeneous populations. The former limitation may be addressed through a modification of Koch's postulates to differentiate causality from simple association. The latter suggests the need for a staging system analogous to those used in other complex disease processes such as cancer. A candidate framework for such a system, based on the infection, the host response, and the extent of organ dysfunction (the IRO system) is described. Conclusions Advances in the understanding and management of patients with sepsis will necessitate more rigorous approaches to disease description and stratification. Models should be developed, tested, and modified through clinical studies rather than through consensus.
270 citations
TL;DR: In a survey of investigators who had not had a full-text article published after presenting the abstract at a national meeting, it was found that the failure to publish was due to one of three main reasons: they did not have enough time to prepare a manuscript for publication, relationships with co-authors sometimes presented a barrier to final publication.
Abstract: Background: Oral presentations at national and international meetings offer an excellent forum for the dissemination of current research findings. However, publication rates of full-text articles after presentation of abstracts at international meetings have ranged from 11% to 78%, which suggests that at least 32% of the abstracts presented are never published as complete articles in peer-reviewed journals. In an effort to identify the reasons that surgeons had not had a paper published following presentation of their work at an international orthopaedic meeting, we conducted a survey of a cross section of authors of orthopaedic papers presented at a national meeting.
Methods: We retrieved all abstracts from the 1996 scientific program of the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons. A computerized Medline and PubMed search established whether the abstract had been subsequently published as a full-text article. The authors of the abstracts that had not been subsequently published were surveyed to identify the reasons for the failure to publish.
Results: A total of 465 abstracts were presented at the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons in 1996. We surveyed the authors of 306 abstracts for which we were unable to locate a subsequent full-text publication on Medline. One hundred and ninety-nine investigators (65%) responded to the questionnaire. At the time of the survey, seventy-two manuscripts had been published, thirty-two had been submitted and rejected, fourteen were under consideration by journals, seven had been accepted for publication or were in press, and three were not recalled by the investigator. In addition, seventy-one abstracts (35.7%) of the 199 had not been submitted for publication. The authors of those abstracts were asked to indicate one or more reasons why they had not submitted a manuscript for publication. Thirty-three investigators (46.5%) indicated that they lacked sufficient time for research activities, twenty-two (31.0%) reported that the study presented at the meeting in 1996 was still in progress, fourteen (19.7%) believed that the responsibility for writing the manuscript belonged to someone else, and twelve (16.9%) reported that difficulties with co-authors who would not participate had impeded the completion of the manuscript. Nine investigators (12.7%) responded that the pursuit of publication was a low priority.
Conclusions: In a survey of investigators who had not had a full-text article published after presenting the abstract at a national meeting, we found that the failure to publish was due to one of three main reasons: (1) they did not have enough time to prepare a manuscript for publication (the reason most frequently given); (2) almost one-third of the studies that had not been submitted for publication were ongoing; and (3) relationships with co-authors sometimes presented a barrier to final publication. Thorough preparation before the study and the establishment of stricter guidelines to limit the presentation of preliminary data at national and international meetings may improve publication rates.
256 citations
TL;DR: Overall satisfaction with end-of-life care was significantly associated with completeness of information received by the family member, respect and compassion shown to patient and family members, and satisfaction with amount or level of health care received.
204 citations
TL;DR: The ATICE measures the adaptation of mechanically ventilated patients to the ICU environment and demonstrates high reliability, validity, and responsiveness of this instrument.
Abstract: ObjectiveTo develop a valid, reliable, and responsive bedside instrument assessing Adaptation to the Intensive Care Environment (ATICE) in mechanically ventilated adult intensive care unit (ICU) patients.DesignInstrument development and prospective clinimetric evaluation.SettingUniversity-affiliated
179 citations
TL;DR: It is concluded that positive MPS are useful in identifying patients with significantly increased risk of future myocardial infarction and cardiac death in both diabetic and nondiabetic ESRD patients.
Abstract: The prognostic utility of myocardial perfusion studies (MPS) such as thallium scintigraphy and dobutamine stress echocardiography (DSE) for stratifying cardiac risk among candidates for kidney or kidney-pancreas transplantation is uncertain. This study is a meta-analysis to determine the prognostic significance of MPS results on future myocardial infarction (MI) and cardiac death (CD) in patients with end-stage renal disease (ESRD) assessed for kidney or kidney-pancreas transplantation. MEDLINE was searched using combinations of MeSH headings and text words for transplantation, coronary artery disease, prognosis, end-stage renal disease, and noninvasive cardiac testing (nuclear scintigraphy and DSE) for primary studies. Studies were included if they reported MPS results and cardiac events in patients assessed for kidney or kidney-pancreas transplantation. Methodologic study quality and outcome data were independently abstracted in duplicate by two researchers. The relative risks (RR) of MI and CD were calculated using a random effects model. Twelve articles met all inclusion criteria; 12 studies reported CD, and 9 reported MI. In eight studies, thallium scintigraphy was used (four with pharmacologic stress, four with exercise stress), whereas four used DSE. When compared with negative tests, positive tests had a significantly increased RR of MI (2.73 [95% CI, 1.25 to 5.97]; P = 0.01) and CD (2.92 [95% CI, 1.66 to 5.12]; P < 0.001). Subgroup analyses of studies of diabetic patients indicated that positive tests were associated with a RR of CD 3.95 (95% CI, 1.48 to 10.5; P = 0.006) and a RR of MI 2.68 (95% CI, 0.95 to 7.57; P = 0.06) when compared with negative tests. In studies evaluating mixed populations of diabetic and nondiabetic patients, positive tests were associated with a RR of CD 2.52 (95% CI, 1.25 to 5.08; P = 0.01) and with a RR of MI 2.79 (95% CI, 0.85 to 9.21; P = 0.09) when compared with a negative test. The presence of reversible defects was associated with an increased risk of MI in diabetic patients and of CD in both subgroups; fixed defects were associated with an increased risk of CD but not MI. It is concluded that positive MPS are useful in identifying patients with significantly increased risk of future MI and CD in both diabetic and nondiabetic ESRD patients.
TL;DR: It is concluded that a localizing vascular injury (CVC use) and a systemic hypercoagulability disorder (HIT) interact to explain upper-extremity DVT complicating HIT.
TL;DR: Familiarity with how to do a systematic review and meta-analysis will lead to greater skill in using this type of article, which is useful sources of evidence for clinicians, teachers, and investigators.
Abstract: Systematic reviews of original research are increasing in number Systematic reviews are distinct from narrative reviews because they address a specific clinical question, require a comprehensive literature search, use explicit selection criteria to identify relevant studies, assess the methodologic quality of included studies, explore differences among study results, and either qualitatively or quantitatively synthesize study results Systematic reviews that quantitatively pool results of more than one study are called meta-analyses Several organizations are collaboratively involved in producing high quality systematic reviews and meta-analyses Familiarity with how to do a systematic review and meta-analysis will lead to greater skill in using this type of article For clinicians, teachers, and investigators, systematic reviews and meta-analyses are useful sources of evidence
TL;DR: It is found that a multidisciplinary guideline for the use of NPPVs for the treatment of patients with ARF was associated with changes in the process of care, with greater NPPV utilization in the ICU, and with increased pulmonary consultation, without any significant changes to the outcomes of care.
TL;DR: In this binational cross-sectional observational study of medical ICU patients, it was found that 92% of eligible patients received either UFH or LWMH for VTE prophylaxis, and differences in prescribing between countries include significantly greater use of LMWH in France, but use of lower doses than in Canada, and greater use in Canada.
TL;DR: The published evidence does not support a general claim that PCT is a useful decision support tool for diagnosing sepsis in patients who have SIRS, and procalcitonin has a slightly better ability to exclude the diagnosis of sepsi.
TL;DR: A priori documentation and subsequent availability of ADs at the point of care increases the probability that diagnostic, therapeutic and palliative interventions will be administered to patients within the framework of these preferences.
Abstract: Advance directives (AD) in the form of cardiopulmonary resuscitation orders are a specific set of interventions in response to a cardiopulmonary arrest. A priori documentation and subsequent availability of ADs at the point of care increases the probability that diagnostic, therapeutic and palliative interventions will be administered to patients within the framework of these preferences.
TL;DR: The strongest evidence to date supports the use of NPPV in patients with ARF caused by exacerbations of chronic obstructive pulmonary disease (COPD); the benefit for patients with acute nonhypercarbic, hypoxemic respiratory failure is less clear.
TL;DR: The chorioamnionitis as a risk factor for cerebral palsy: a meta-analysis and enhancement of developmentally regulated endogenous protection open a door for prevention are suggested.
Abstract: ment and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214-223. 16. Wu YW, Escobar GJ, Grether JK, Croen LA, Greene JD, Newman TB. Chorioamnionitis and cerebral palsy in term and near-term infants. JAMA. 2003;290: 2677-2684. 17. Grether JK, Nelson KB. Maternal infection and cerebral palsy in infants of normal birth weight. JAMA. 1997;278:207-211. 18. Wu YW, Colford JM. Chorioamnionitis as a risk factor for cerebral palsy: a meta-analysis. JAMA. 2000;284:1417-1424. 19. Dammann O, Leviton A. Brain damage in preterm newborns: might enhancement of developmentally regulated endogenous protection open a door for prevention? Pediatrics. 1999;104(3 pt 1):541-550. 20. Leviton A, Dammann O, O’Shea TM, Paneth N. Adult stroke and perinatal brain damage: like grandparent, like grandchild? Neuropediatrics. 2002;33:281287.
TL;DR: The quality of the growing number of practice guidelines in critical care is important to assess and several useful instruments are available for this purpose.
TL;DR: Clinicians and administrators are readily able to identify shortcomings in the seasonal bed closure process in the ICU and these shortcomings should be targeted for improvement so that intensive care health services delivery is legitimate and fair.
Journal Article•
TL;DR: In this article, patients receiving standard therapy for severe exacerbations of chronic obstructive pulmonary disease (COPD) benefit from noninvasive positive pressure ventilation (NPPV).
Abstract: Patients receiving standard therapy for severe exacerbations of chronic obstructive pulmonary disease (COPD) benefit from noninvasive positive-pressure ventilation (NPPV). However, hospitalized pat...
TL;DR: Functional status impairment perceived by the ICU team is associated clearly with do-not-resuscitate directives in patients unable to participate in decision making, but the association appears much weaker in patients able to participateIn decision making.
Journal Article•
TL;DR: The authors must rigorously and critically analyze study results to understand their strengths, limitations, and generalizability, and bear in mind that their knowledge will evolve and thereby change their practice.
Abstract: “Evidence-based practice” involves applying the best available evidence to the care of individuals. Explicit, systematic methods have developed for determining what is the best available evidence. However, often even the highest-level evidence is not thoroughly or effectively used in practice, even if it is widely known. We must rigorously and critically analyze study results to understand their strengths, limitations, and generalizability, and bear in mind that our knowledge will evolve and thereby change our practice. The clinical question is not always how to apply the evidence but whether the available evidence applies to a particular patient. We should always ask whether the right provider is doing the right thing for the right patient at the right time in the right setting with the right resources.
Journal Article•
TL;DR: This disease management program for patients with acid-related disorders led to improved processes of care and the effectiveness of such a program in other settings requires further study.
Abstract: †; Objective: To study the effectiveness of a disease management program for patients with acid-related disorders. Study Design: A cluster-randomized clinical trial of 406 patients comparing a disease management program with “usual practice.” Patients and Methods: Enrolled patients included those presenting with new dyspepsia and chronic users of antisecretory drugs in 8 geographically separate physician offices associated with the Orlando Health Care Group. There were 35 providers in the intervention group and 48 in the control group. The disease management program included evidence-based practice guidelines implemented by using physician champions, academic detailing, and multidisciplinary teams. Processes of care, patient symptoms, quality of life, costs, and work days lost were measured 6 months after patient enrollment. Results: Compared with usual practice, disease management was associated with improvements in Helicobacter pylori testing (61% vs 9%; P = .001), use of recommended H pylori treatment regimens (96% vs 10%; P = .001), and discontinuation rates of proton pump therapy after treatment (70% vs 36%; P = .04). There were few differences in patient quality of life or symptoms between the 2 study groups. Disease management resulted in fewer days of antisecretory therapy (71.7 vs 88.1 days; P = .02) but no difference in total costs. Conclusion: This disease management program for patients with acid-related disorders led to improved processes of care. The effectiveness of such a program in other settings requires further study. (Am J Manag Care. 2003;9:425-433)
TL;DR: Low-molecular-weight heparin treatment may confer economic advantages over unfractionated Heparin therapy because it does not require anticoagulant monitoring and it facilitates outpatient therapy.
Journal Article•
TL;DR: Familiarity with how to do a systematic review and meta-analysis will lead to greater skill in using this type of article, which is useful sources of evidence for clinicians, teachers, and investigators.
Abstract: Systematic reviews of original research are increasing in number. Systematic reviews are distinct from narrative reviews because they address a specific clinical question, require a comprehensive literature search, use explicit selection criteria to identify relevant studies, assess the methodologic quality of included studies, explore differences among study results, and either qualitatively or quantitatively synthesize study results. Systematic reviews that quantitatively pool results of more than one study are called meta-analyses. Several organizations are collaboratively involved in producing high quality systematic reviews and meta-analyses. Familiarity with how to do a systematic review and meta-analysis will lead to greater skill in using this type of article. For clinicians, teachers, and investigators, systematic reviews and meta-analyses are useful sources of evidence.