IntroductionThe purpose of this study was to evaluate if ultrasound derived measures of diaphragm thickening, rather than diaphragm motion, can be used to predict extubation success or failure. Methods Sixty-three mechanically ventilated patients were prospectively recruited. Diaphragm thickness (tdi) was measured in the zone of apposition of the diaphragm to the rib cage using a 7-10 MHz ultrasound transducer. The percent change in tdi between end-expiration and end-inspiration (Δtdi%) was calculated during either spontaneous breathing (SB) or pressure support (PS) weaning trials. A successful extubation was defined as SB for >48 h following endotracheal tube removal. Results Of the 63 subjects studied, 27 patients were weaned with SB and 36 were weaned with PS. The combined sensitivity and specificity of Δtdi%≥30% for extubation success was 88% and 71%, respectively. The positive predictive value and negative predictive value were 91% and 63%, respectively. The area under the receiver operating characteristic curve was 0.79 for Δtdi%. Conclusions Ultrasound measures of diaphragm thickening in the zone of apposition may be useful to predict extubation success or failure during SB or PS trials.

Sepsis and severe sepsis in particular remain a major health problem worldwide. Their cost to society extends well beyond lives lost, as the impact of survivorship is increasingly felt. A review of the medical literature was completed in MEDLINE using the search phrases "severe sepsis" and "septic shock" and the MeSH terms "epidemiology", "statistics", "mortality", "economics", and "quality of life". Results were limited to human trials that were published in English from 2002 to 2014. Articles were classified by dominant themes to address epidemiology and outcomes, including quality of life of both patient and family caregivers, as well as societal costs. The severity of sepsis is determined by the number of organ failures and the presence of shock. In most developed countries, severe sepsis and septic shock account for disproportionate mortality and resource utilization. Although mortality rates have decreased, overall mortality continues to increase and is projected to accelerate as people live longer with more chronic illness. Among those who do survive, impaired quality of life, increased dependence, and rehospitalization increase healthcare consumption and, along with increased mortality, all contribute to the humanistic burden of severe sepsis. A large part of the economic burden of severe sepsis occurs after discharge. Initial inpatient costs represent only 30 % of the total cost and are related to severity and length of stay, whereas lost productivity and other indirect medical costs following hospitalization account for the majority of the economic burden of sepsis. Timeliness of treatment as well as avoidance of intensive care unit (ICU)-acquired illness/morbidity lead to important differences in both cost and outcome of treatment for severe sepsis and represent areas where improvement in care is possible. The degree of sophistication of a health system from a national perspective results in significant differences in resource use and outcomes for patients with serious infections. Comprehensive understanding of the cost and humanistic burden of severe sepsis provides an initial practical framework for health policy development and resource use.

Tetraalkyl and dialkyl derivatives, where alkyl=ethyl and propyl, of the organic electron donor molecule bis(ethylenedithio)tetrathiafulvalene, BEDT-TTF or ET, have been synthesized via the Diels-Alder approach. Several cation-radical salts of these new donors have been prepared and structurally characterized, and found to contain donor molecules in nominally higher oxidation states (+1, +1.5 and +2) than the typically observed oxidation state of +0.5 in BEDT-TTF salts. The higher solubility of the tetraalkyl and dialkyl derivatives in solvents used for crystal growth is proposed as the principal reason for this finding. Surprisingly, X-ray crystallographic studies reveal that the alkyl groups in the neutral tetraethyl-ET as well as the oxidized tetraethyl-ET and diethyl-ET molecules in their cation-radical salts adopt axial configurations, rather than the expected equatorial configurations. Electrical properties of the cation-radical salts have been found to be either insulating or semiconducting, consistent with the higher oxidation states of the donor molecules in the salts and the crystal structures.

BACKGROUND Red blood cell (RBC) transfusion is an important treatment modality during severe sickle cell crisis (SCC). SCC patients who refuse, or cannot accept, RBCs present a unique challenge. Acellular hemoglobin (Hb)‐based oxygen carriers (HBOCs) might be an alternative for critically ill patients in SCC with multiorgan failure due to life‐threatening anemia. HBOC‐201 (HbO2 Therapeutics) has been administered to more than 800 anemic patients in 22 clinical trials, but use of any HBOCs in critically ill sickle cell patients with organ failure is exceedingly rare. In the United States, HBOC‐201 is currently only available for expanded access. CASE REPORT We report three cases of HBOC‐201 administered to critically ill sickle cell disease patients in SCC with multiorgan failure, either who refused RBCs (Jehovah's Witnesses) or for whom compatible RBCs were not available. RESULTS Two patients received more than 20 units of HBOC‐201, while the other received 6. The 27 units used in the third case equals the largest volume a patient has successfully received to date. All three patients survived to hospital discharge. CONCLUSION These reports suggest that blood substitutes such as HBOC‐201 can provide an oxygen bridge in SCC with multiorgan failure, until corpuscular Hb levels recover to meet metabolic demand, and highlight the compelling biochemical properties that warrant further investigation.

BACKGROUND Understanding the severity of patients' dyspnea is critical to avoid under‐ or overtreatment of patients with acute cardiopulmonary conditions. OBJECTIVE To evaluate the agreement between dyspnea assessment by patients and healthcare providers and to explore which factors contribute to discordance in assessment. DESIGN, SETTINGS AND PARTICIPANTS Prospective study of patients hospitalized for acute cardiopulmonary diseases at an urban teaching hospital. INTERVENTION AND MEASUREMENTS A numerical rating scale (0–10) was used to assess dyspnea severity as perceived by patients and assessed by providers. Agreement was defined as a score within ±1 between patient and healthcare provider; differences of ≥2 points were considered over‐ or underestimations. The relationship between patient self‐perceived dyspnea severity and provider rating was assessed using a weighted kappa coefficient. RESULTS Of the 138 patients enrolled, 33% had a diagnosis of heart failure, 30% chronic obstructive pulmonary disease, and 13% pneumonia; median age was 72 years, and 57% were women. In all, 96 patient‐physician and 138 patient‐nurses pairs were included in the study. The kappa coefficient for agreement was 0.11 (95% confidence interval [CI]: 0.01 to 0.21) between patients and physicians and 0.18 (95% CI: 0.12 to 0.24) between patients and nurses. Physicians underestimated patients' dyspnea 37.9% of the time and overestimated it 25.8% of the time, whereas nurses underestimated it 43.5% of the time and overestimated it 12.4% of the time. Admitting diagnosis was the only patient factor associated with discordance. CONCLUSIONS Agreement between patient perception of dyspnea and healthcare providers' assessment is low. Future studies should prospectively test whether routine assessment of dyspnea results in better patient outcomes. Journal of Hospital Medicine 2016;11:701–707. © 2016 Society of Hospital Medicine

We evaluated the diagnostic accuracy of a virtual microscopy setup using surgical pathology specimens commonly encountered in a university hospital setting. The high quality images, Internet sharing and collaborative capability, interactivity, and ease of use suggested to us that this might have applications in countries with developing economies. We discuss the development process and its potential applications in medical education and telemedicine in countries with developing economies. Published in Proceedings of the 38th Hawaii International Conference on System Sciences, 2005

Context The trajectory of dyspnea for patients hospitalized with acute cardiopulmonary disease, who are not terminally ill, is poorly characterized. Objectives To investigate the natural history of dyspnea during hospitalization, and examine the role that admission diagnosis, and patient factors play in altering symptom resolution. Methods Prospective cohort study of patients hospitalized for an acute cardiopulmonary condition at a large tertiary care center. Dyspnea levels and change in dyspnea score were the main outcomes of interest and were assessed at admission, 24 and 48 hours and at discharge using the verbal 0 - 10 numeric scale. Results Among 295 patients enrolled, the median age was 68 years, and the most common admitting diagnoses were heart failure (32%), chronic obstructive pulmonary disease (COPD) (39%), and pneumonia (13%). The median dyspnea score at admission was 9 (interquartile range [IQR] 7, 10); decreased to 4 (IQR 2, 7) within the first 24 hours; and subsequently plateaued at 48 hours. At discharge, the median score had decreased to 2.75 (IQR 1, 4). Compared to patients with heart failure, patients with COPD had higher median dyspnea score at baseline and admission, and experienced a slower resolution of dyspnea symptoms. After adjusting for patient characteristics, the change in dyspnea score from admission to discharge was not significantly different between patients hospitalized with congestive heart failure, COPD or pneumonia. Conclusion Most patients admitted with acute cardiopulmonary conditions have severe dyspnea on presentation, and their symptoms improve rapidly after admission. The trajectory of dyspnea is associated with the underlying disease process. These findings may help set expectations for the resolution of dyspnea symptoms in hospitalized patients with acute cardiopulmonary diseases.

Our prospective study suggests that patients with a significant sGaw decline alone during MCT are a clinically and physiologically important hyper-reactivity phenotype--whose hyper-reactivity independently was confirmed to be nearly identical to those with an FEV(1) decline. By failing to assess airways conductance/resistance, asthma may be inappropriately "ruled out" in ∼20% of the patients referred for MCT. Based on this, standardized incorporation of body plethysmography and/or IOS to MCT protocols should be considered.