Publications by authors named "Robert McDermid"

41 Publications

The Influence of Geography, Religion, Religiosity and Institutional Factors on Worldwide End-of-Life Care for the Critically Ill: The WELPICUS Study.

J Palliat Care 2021 Apr 5:8258597211002308. Epub 2021 Apr 5.

Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.

Purpose: To evaluate the association between provider religion and religiosity and consensus about end-of-life care and explore if geographical and institutional factors contribute to variability in practice.

Materials And Methods: Using a modified Delphi method 22 end-of-life issues consisting of 35 definitions and 46 statements were evaluated in 32 countries in North America, South America, Eastern Europe, Western Europe, Asia, Australia and South Africa. A multidisciplinary, expert group from specialties treating patients at the end-of-life within each participating institution assessed the association between 7 key statements and geography, religion, religiosity and institutional factors likely influencing the development of consensus.

Results: Of 3049 participants, 1366 (45%) responded. Mean age of respondents was 45 ± 9 years and 55% were females. Following 2 Delphi rounds, consensus was obtained for 77 (95%) of 81 definitions and statements. There was a significant difference in responses across geographical regions. South African and North American respondents were more likely to encourage patients to write advance directives. Fewer Eastern European and Asian respondents agreed with withdrawing life-sustaining treatments without consent of patients or surrogates. While respondent's religion, years in practice or institution did not affect their agreement, religiosity, physician specialty and responsibility for end-of-life decisions did.

Conclusions: Variability in agreement with key consensus statements about end-of-life care is related primarily to differences among providers, with provider-level variations related to differences in religiosity and specialty. Geography also plays a role in influencing some end-of-life practices. This information may help understanding ethical dilemmas and developing culturally sensitive end-of-life care strategies.
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http://dx.doi.org/10.1177/08258597211002308DOI Listing
April 2021

A Computerized Frailty Assessment Tool at Points-of-Care: Development of a Standalone Electronic Comprehensive Geriatric Assessment/Frailty Index (eFI-CGA).

Front Public Health 2020 31;8:89. Epub 2020 Mar 31.

Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada.

Frailty is characterized by loss of biological reserves and is associated with an increased risk of adverse health outcomes. Frailty can be operationalized using a Frailty Index (FI) based on the accumulation of health deficits; items under health evaluation in the well-established Comprehensive Geriatric Assessment (CGA) have been used to generate an FI-CGA. Traditionally, constructing the FI-CGA has relied on paper-based recording and manual data processing. As this can be time-consuming and error-prone, it limits widespread uptake of this proven type of frailty assessment. Here, we report the development of an electronic tool, the eFI-CGA, for use on personal computers by frontline healthcare providers, to collect CGA data and automate FI-CFA calculation. The ultimate goal is to support early identification and management of frailty at points-of-care, and make uptake in Electronic Medical Records (EMR) feasible and transparent. An electronic CGA (eCGA) form was implemented to operate on Microsoft's WinForms platform and coded using C# programming language. Users complete the eCGA form, from which items under the CGA evaluation are automatically retrieved and processed to output an eFI-CGA score. A user-friendly interface and secured data saving methods were implemented. The software was debugged and tested using systematically designed simulation data, addressing different logic, syntax, and application errors, and then tested with clinical assessment. The user manual and manual scoring were used as ground truth to compare eFI-CGA input and automated eFI score calculations. Frontline health-provider user feedback was incorporated to improve the end-user experience. The Standalone eFI-CGA software tool was developed and optimized for use on personal computers. The user interface adapted the design of paper-based CGA form to facilitate familiarity for clinical users. Compared to known scores, the software tool generated eFI-CGA scores with 100% accuracy to four decimal places. The eFI-CGA allowed secure data storage and retrieval of multiple types, including user input, completed eCGA form, coded items, and calculated eFI-CGA scores. It also permitted recording of actions requiring clinical follow-up, facilitating care planning. Application bugs were identified and resolved at various stages of the implementation, resulting in efficient system performance. Accurate, robust, and reliable computerized frailty assessments are needed to promote effective frailty assessment and management, as a key tool in health care systems facing up to frailty. Our research has enabled the delivery of the standalone eFI-CGA software technology to empower effective frailty assessment and management by various healthcare providers at points-of-care, facilitating integrated care of older adults.
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http://dx.doi.org/10.3389/fpubh.2020.00089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137764PMC
March 2020

Health solutions to improve post-intensive care outcomes: a realist review protocol.

Syst Rev 2019 01 8;8(1):11. Epub 2019 Jan 8.

Fraser Health Authority, Surrey, British Columbia, Canada.

Background: While 80% of critically ill patients treated in an intensive care unit (ICU) will survive, survivors often suffer a constellation of new or worsening physical, cognitive, and psychiatric complications, termed post-intensive care syndrome. Emerging evidence paints a challenging picture of complex, long-term complications that are often untreated and culminate in substantial dependence on acute care services. Clinicians and decision-makers in the Fraser Health Authority of British Columbia are working to develop evidence-based community healthcare solutions that will be successful in the context of existing healthcare services. The objective of the proposed review is to provide the theoretical scaffolding to transform the care of survivors of critical illness by a synthesis of relevant clinical and healthcare service programs.

Methods: Realist review will be used to develop and refine a theoretical understanding of why, how, for whom, and in what circumstances post-ICU program impact ICU survivors' outcomes. This review will follow the recommended five steps of realist review which include (1) clarifying the scope of the review and articulating a preliminary program theory, (2) searching for evidence, (3) appraising primary studies and extracting data, (4) synthesizing evidence and sharing conclusions, and (5) disseminating and implementing recommendations.

Discussion: This realist review will provide a program theory, encompassing the contexts, mechanisms, and outcomes, to explain how clinical and health service interventions to improve ICU survivor outcomes operate in different contexts for different survivors, and with what effect. This review will be an evidentiary pillar for health service development and implementation by our knowledge user team members as well as advance scholarly knowledge relevant nationally and internationally.

Systematic Review Registration: PROSPERO CRD42018087795.
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http://dx.doi.org/10.1186/s13643-018-0939-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6323758PMC
January 2019

Patterns of Palliative Care Referral in Patients Admitted With Heart Failure Requiring Mechanical Ventilation.

Am J Hosp Palliat Care 2018 Apr 22;35(4):620-626. Epub 2017 Aug 22.

2 Beth Israel Deaconess Medical Center, Boston, MA, USA.

Background: Palliative care is recommended for advanced heart failure (HF) by several major societies, though prior studies indicate that it is underutilized.

Aim: To investigate patterns of palliative care referral for patients admitted with HF exacerbations, as well as to examine patient and hospital factors associated with different rates of palliative care referral.

Design: Retrospective nationwide cohort analysis utilizing the National Inpatient Sample from 2006 to 2012. Patients referred to palliative care were compared to those who were not.

Setting/participants: Patients ≥18 years of age with a primary diagnosis of HF requiring mechanical ventilation (MV) were included. A cohort of non-HF patients with metastatic cancer was created for temporal comparison.

Results: Between 2006 and 2012, 74 824 patients underwent MV for HF. A referral to palliative care was made in 2903 (3.9%) patients. The rate of referral for palliative care in HF increased from 0.8% in 2006 to 6.4% in 2012 ( P < .01). In comparison, rate of palliative care referral in patients with cancer increased from 2.9% in 2006 to 11.9% in 2012 ( P < .01). In a multivariate logistic regression model, higher socioeconomic status (SES) was associated with increased access to palliative care ( P < .01). Racial differences were also observed in rates of referral to palliative care.

Conclusion: The use of palliative care for patients with advanced HF increased during the study period; however, palliative care remains underutilized in this setting. Patient factors such as race and SES affect access to palliative care.
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http://dx.doi.org/10.1177/1049909117727455DOI Listing
April 2018

In Reply.

Obstet Gynecol 2017 07;130(1):218-219

Beth Israel Deaconess Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1097/AOG.0000000000002124DOI Listing
July 2017

Response.

Chest 2017 05;151(5):1184

Beth Israel Deaconess Medical Center, Boston, MA.

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http://dx.doi.org/10.1016/j.chest.2017.02.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026219PMC
May 2017

Association of Household Income Level and In-Hospital Mortality in Patients With Sepsis: A Nationwide Retrospective Cohort Analysis.

J Intensive Care Med 2018 Oct 7;33(10):551-556. Epub 2017 Apr 7.

3 Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, British Columbia, Canada.

Objective: Associations between low socioeconomic status (SES) and poor health outcomes have been demonstrated in a variety of conditions. However, the relationship in patients with sepsis is not well described. We investigated the association of lower household income with in-hospital mortality in patients with sepsis across the United States.

Methods: Retrospective nationwide cohort analysis utilizing the Nationwide Inpatient Sample (NIS) from 2011. Patients aged 18 years or older with sepsis were included. Socioeconomic status was approximated by the median household income of the zip code in which the patient resided. Multivariate logistic modeling incorporating a validated illness severity score for sepsis in administrative data was performed.

Results: A total of 8 023 590 admissions from the 2011 NIS were examined. A total of 671 858 patients with sepsis were included in the analysis. The lowest income residents compared to the highest were younger (66.9 years, standard deviation [SD] = 16.5 vs 71.4 years, SD = 16.1, P < .01), more likely to be female (53.5% vs 51.9%, P < .01), less likely to be white (54.6% vs 76.6%, P < .01), as well as less likely to have health insurance coverage (92.8% vs 95.9%, P < .01). After controlling for severity of sepsis, residing in the lowest income quartile compared to the highest quartile was associated with a higher risk of mortality (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 1.03-1.08, P < .01). There was no association seen between the second (OR: 1.02, 95% CI: 0.99-1.05, P = .14) and third (OR: 0.99, 95% CI: 0.97-1.01, P = .40) quartiles compared to the highest.

Conclusion: After adjustment for severity of illness, patients with sepsis who live in the lowest median income quartile had a higher risk of mortality compared to residents of the highest income quartile. The association between SES and mortality in sepsis warrants further investigation with more comprehensive measures of SES.
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http://dx.doi.org/10.1177/0885066617703338DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5680141PMC
October 2018

Association between chronic exposure to air pollution and mortality in the acute respiratory distress syndrome.

Environ Pollut 2017 May 13;224:352-356. Epub 2017 Feb 13.

Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, Canada. Electronic address:

The impact of chronic exposure to air pollution and outcomes in the acute respiratory distress syndrome (ARDS) is unknown. The Nationwide Inpatient Sample (NIS) from 2011 was utilized for this analysis. The NIS is a national database that captures 20% of all US in-patient hospitalizations from 47 states. Patients with ARDS who underwent mechanical ventilation from the highest 15 ozone pollution cities were compared with the rest of the country. Secondary analyses assessed outcomes of ARDS patients for ozone pollution and particulate matter pollution on a continuous scale by county of residence. A total of 8,023,590 hospital admissions from the 2011 NIS sample were analyzed. There were 93,950 patients who underwent mechanical ventilation for ARDS included in the study. Patients treated in high ozone regions had significantly higher unadjusted hospital mortality (34.9% versus 30.8%, p < 0.01) than patients in cities with control levels of ozone. After controlling for all variables in the model, treatment in a hospital located in a high ozone pollution area was associated with an increased odds of in-hospital mortality (OR 1.11, 95% CI 1.08-1.15, p < 0.01). After adjustment for all variables in the model, for each increase in ozone exposure by 0.01 ppm the OR for death was 1.07 (95% CI 1.06-1.08, p < 0.01). Similarly, for each increase in particulate matter exposure by 10 μg/m, the OR for death was 1.08 (95% CI 1.02-1.16, p < 0.01). Chronic exposure to both ozone and particulate matter pollution is associated with higher rates of mortality in ARDS. These preliminary findings need to be confirmed by further detailed studies.
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http://dx.doi.org/10.1016/j.envpol.2017.02.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683074PMC
May 2017

Acute Respiratory Distress Syndrome in Pregnant Women.

Obstet Gynecol 2017 03;129(3):530-535

Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, and the Departments of Anesthesia, Pharmacology and Therapeutics and Orthopaedic Surgery, the Centre for Heart Lung Innovation, and the Division of Critical Care Medicine, St Paul's Hospital, University of British Columbia, Vancouver, and the Department of Critical Care Medicine, Surrey Memorial Hospital, Surrey, British Columbia, Canada; and Harvard T. H. Chan School of Public Health, Harvard University, and Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Objective: To estimate the rate of acute respiratory distress syndrome (ARDS) in pregnant patients as well as to investigate clinical conditions associated with mortality.

Methods: We used the Nationwide Inpatient Sample from 2006 to 2012 to identify a cohort of pregnant patients who underwent mechanical ventilation for ARDS. A multivariate model predicting in-hospital mortality was created.

Results: A total of 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Samples were analyzed. There were 2,808 pregnant patients with ARDS who underwent mechanical ventilation included in the cohort. The overall mortality rate for the cohort was 9%. The rate of ARDS requiring mechanical ventilation increased from 36.5 cases (95% confidence interval [CI] 33.1-39.8) per 100,000 live births in 2006 to 59.6 cases (95% CI 57.7-61.4) per 100,000 live births in 2012. Factors associated with a higher risk of death were prolonged mechanical ventilation (adjusted odds ratio [OR] 1.69, 95% CI 1.25-2.28), renal failure requiring hemodialysis (adjusted OR 3.40, 95% CI 2.11-5.47), liver failure (adjusted OR 1.71, 95% CI 1.09-2.68), amniotic fluid embolism (adjusted OR 2.31, 95% CI 1.16-4.59), influenza infection (OR 2.26, 95% CI 1.28-4.00), septic obstetric emboli (adjusted OR 2.15, 95% CI 1.17-3.96), and puerperal infection (adjusted OR 1.86, 95% CI 1.28-2.70). Factors associated with a lower risk of death were: insurance coverage (adjusted OR 0.56, 95% CI 0.37-0.85), tobacco use (adjusted OR 0.53, 95% CI 0.31-0.90), and pneumonia (adjusted OR 0.70, 95% CI 0.50-0.98).

Conclusion: In this nationwide study, the overall mortality rate for pregnant patients mechanically ventilated for ARDS was 9%. The rate of ARDS requiring mechanical ventilation increased from 36.5 cases (95% CI 33.5-41.8) per 100,000 live births in 2006 to 59.6 cases (95% CI 54.3-65.3) per 100,000 live births in 2012.
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http://dx.doi.org/10.1097/AOG.0000000000001907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5695219PMC
March 2017

Impact of hospital case-volume on subarachnoid hemorrhage outcomes: A nationwide analysis adjusting for hemorrhage severity.

J Crit Care 2017 02 14;37:240-243. Epub 2016 Sep 14.

Beth Israel Deaconess Medical Center, Boston, MA, USA. Electronic address:

Objective: There have been suggestions that patients with subarachnoid hemorrhage (SAH) have a better outcome when treated in high-volume centers. Much of the published literature on the subject is limited by an inability to control for severity of SAH.

Methods: This is a nationwide retrospective cohort analysis using the Nationwide Inpatient Sample (NIS). The NIS Subarachnoid Severity Scale was used to adjust for severity of SAH in multivariate logistic regression modeling.

Results: The records of 47 911 414 hospital admissions from the 2006-2011 NIS samples were examined. There were 11 607 patients who met inclusion criteria for the study. Of these, 7787 (67.0%) were treated at a high-volume center compared with 3820 (32.9%) treated at a low-volume center. Patients treated at high-volume centers compared with low-volume centers were more likely to receive endovascular aneurysm control (58.5% vs 51.2%, P=.04), be transferred from another hospital (35.4% vs 19.7%, P<.01), be treated in a teaching facility (97.3% vs 72.9%, P<.01), and have a longer length of stay (14.9 days [interquartile range 10.3-21.7] vs 13.9 days [interquartile range, 8.9-20.1], P<.01). After adjustment for all baseline covariates, including severity of SAH, treatment in a high-volume center was associated with an odds ratio for death of 0.82 (95% confidence interval, 0.72-0.95; P<.01) and a higher odds of a good functional outcome (odds ratio, 1.16; 95% confidence interval, 1.04-1.28; P<.01).

Conclusion: After adjustment for severity of SAH, treatment in a high-volume center was associated with a lower risk of in-hospital mortality and a higher odds of a good functional outcome.
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http://dx.doi.org/10.1016/j.jcrc.2016.09.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679218PMC
February 2017

Erratum to: A prospective multicenter cohort study of frailty in younger critically ill patients.

Crit Care 2016 Jul 19;20(1):223. Epub 2016 Jul 19.

Department of Critical Care Medicine, Faculty of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1 N4, Canada.

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http://dx.doi.org/10.1186/s13054-016-1393-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4952065PMC
July 2016

Use of Palliative Care in Patients With End-Stage COPD and Receiving Home Oxygen: National Trends and Barriers to Care in the United States.

Chest 2017 Jan 4;151(1):41-46. Epub 2016 Jul 4.

Beth Israel Deaconess Medical Center, Boston, MA.

Background: To investigate the use of palliative care (PC) in patients with end-stage COPD receiving home oxygen hospitalized for an exacerbation.

Methods: A retrospective nationwide cohort analysis was performed, using the Nationwide Inpatient Sample. All patients ≥ 18 years of age with a diagnosis of COPD, receiving home oxygen, and admitted for an exacerbation were included.

Results: A total of 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Sample were examined. There were 181,689 patients with COPD, receiving home oxygen, and admitted for an exacerbation; 3,145 patients (1.7%) also had a PC contact. There was a 4.5-fold relative increase in PC referral from 2006 (0.45%) to 2012 (2.56%) (P < .01). Patients receiving PC consultations compared with those who did not were older (75.0 years [SD 10.9] vs 70.6 years [SD 9.7]; P < .01), had longer hospitalizations (4.9 days [interquartile range, 2.6-8.2] vs 3.5 days [interquartile range, 2.1-5.6]), and more likely to die in hospital (32.1% vs 1.5%; P < .01). Race was significantly associated with referral to palliative care, with white patients referred more often than minorities (P < .01). Factors associated with PC referral included age (OR, 1.03; 95% CI, 1.02-1.04; P < .01), metastatic cancer (OR, 2.40; 95% CI, 2.02-2.87; P < .01), nonmetastatic cancer (OR, 2.75; 95% CI, 2.43-3.11; P < .01), invasive mechanical ventilation (OR, 4.89; 95% CI, 4.31-5.55; P < .01), noninvasive mechanical ventilation (OR, 2.84; 95% CI, 2.58-3.12; P < .01), and Do Not Resuscitate status (OR, 7.95; 95% CI, 7.29-8.67; P < .01).

Conclusions: The use of PC increased dramatically during the study period; however, PC contact occurs only in a minority of patients with end-stage COPD admitted with an exacerbation.
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http://dx.doi.org/10.1016/j.chest.2016.06.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026227PMC
January 2017

Mechanical Ventilation Outcomes in Patients With Pulmonary Hypertension in the United States: A National Retrospective Cohort Analysis.

J Intensive Care Med 2017 Dec 8;32(10):588-592. Epub 2016 Jun 8.

1 Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

Objective: The outcome of patients with pulmonary arterial hypertension (PAH) who undergo mechanical ventilation is not well known.

Methods: The Nationwide Inpatient Sample for 2006 to 2012 was used to isolate patients with a diagnosis of PAH who also underwent invasive (MV) and noninvasive (NIMV) mechanical ventilation. The primary outcome was in-hospital mortality.

Results: The hospital records of 55 208 382 patients were studied, and there were 21 070 patients with PAH, of whom 1646 (7.8%) received MV and 834 (4.0%) received NIMV. Those receiving MV had higher mortality (39.1% vs 12.6%, P < .001) and longer hospital stays (11.9 days, interquartile range [IQR] 6.1-22.2 vs 6.7 days, IQR 3.4-11.9, P < .001) than those undergoing NIMV. Of the patients treated with MV, 4.4% also used home oxygen therapy and had similar overall mortality to those who did not use home oxygen (35.3% vs 39.1%, P = .46). Similarly, there was no relationship between home oxygen use and mortality in patients treated with NIMV (10.6% vs 12.6%, P = .48). Notably, more patients treated with NIMV used home oxygen than those treated with MV (14.4% vs 4.4%, P < .001).

Conclusion: Patients with PAH who undergo invasive mechanical ventilation have an in-hospital mortality of 39.1%. Future work may help identify the types of patients who benefit most from advanced respiratory support in a critical care setting.
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http://dx.doi.org/10.1177/0885066616653926DOI Listing
December 2017

A prospective multicenter cohort study of frailty in younger critically ill patients.

Crit Care 2016 06 6;20(1):175. Epub 2016 Jun 6.

Department of Critical Care Medicine, Faculty of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.

Background: Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserve that heightens vulnerability. Frailty has been well described among elderly patients (i.e., 65 years of age or older), but few studies have evaluated frailty in nonelderly patients with critical illness. We aimed to describe the prevalence, correlates, and outcomes associated with frailty among younger critically ill patients.

Methods: We conducted a prospective cohort study of 197 consecutive critically ill patients aged 50-64.9 years admitted to intensive care units (ICUs) at six hospitals across Alberta, Canada. Frailty was defined as a score ≥5 on the Clinical Frailty Scale before hospitalization. Multivariable analyses were used to evaluate factors independently associated with frailty before ICU admission and the independent association between frailty and outcome.

Results: In the 197 patients in the study, mean (SD) age was 58.5 (4.1) years, 37 % were female, 73 % had three or more comorbid illnesses, and 28 % (n = 55; 95 % CI 22-35) were frail. Factors independently associated with frailty included not being completely independent (adjusted OR [aOR] 4.4, 95 % CI 1.8-11.1), connective tissue disease (aOR 6.0, 95 % CI 2.1-17.0), and hospitalization within the preceding year (aOR 3.3, 95 % CI 1.3-8.1). There were no significant differences between frail and nonfrail patients in reason for admission, Acute Physiology and Chronic Health Evaluation II score, preference for life support, or treatment intensity. Younger frail patients did not have significantly longer (median [interquartile range]) hospital stay (26 [9-68] days vs. 19 [10-43] days; p = 0.4), but they had greater 1-year rehospitalization rates (61 % vs. 40 %; p = 0.02) and higher 1-year mortality (33 % vs. 20 %; adjusted HR 1.8, 95 % CI 1.0-3.3; p = 0.039).

Conclusions: Prehospital frailty is common among younger critically ill patients, and in this study it was associated with higher rates of mortality at 1 year and with rehospitalization. Our data suggest that frailty should be considered in younger adults admitted to the ICU, not just in the elderly. Additional research is needed to further characterize frailty in younger critically ill patients, along with the ideal instruments for identification.
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http://dx.doi.org/10.1186/s13054-016-1338-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893838PMC
June 2016

The complexity of bipolar and borderline personality: an expression of 'emotional frailty'?

Curr Opin Psychiatry 2016 Jan;29(1):84-8

aDepartment of PsychiatrybDepartment of Medicine, Division of Critical Care, University of British Columbia, Vancouver, Canada.

Purpose Of Review: The purpose of this article is to review recent findings regarding the comorbidity of bipolar disorder with borderline personality disorder (BPD). The conceptualization of the comorbid condition is explored in the context of complexity theory.

Recent Findings: Recent studies highlight distinguishing features between the two disorders. The course of illness of the comorbid condition is generally considered to be more debilitating than bipolar disorder alone.

Summary: Some of the differentiating features of bipolar disorder and BPD are highlighted. It is also crucial to consider a co-morbid diagnosis as worse outcomes may be anticipated than for bipolar disorder alone. The concept of 'emotional frailty' is introduced and the comorbid bipolar disorder-BPD condition is considered an expression of this syndrome.
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http://dx.doi.org/10.1097/YCO.0000000000000214DOI Listing
January 2016

Reply: The Worldwide End-of-Life Practice for Patients in Intensive Care Units Study: Adding Africa.

Am J Respir Crit Care Med 2015 Sep;192(6):769-70

1 Hadassah Hebrew University Medical Center Jerusalem, Israel.

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http://dx.doi.org/10.1164/rccm.201506-1213LEDOI Listing
September 2015

A Survey of Mechanical Ventilator Practices Across Burn Centers in North America.

J Burn Care Res 2016 Mar-Apr;37(2):e131-9

From the *United States Army Institute of Surgical Research, Fort Sam Houston, Texas; †Uniformed Services University of the Health Sciences, Bethesda, Maryland; ‡Sunnybrook Health Sciences Centre, Toronto, Canada; §Massachusetts General Hospital, Boston; ¶Arizona Burn Center, Phoenix; ‖University of California Irvine Regional Burn Center, Orange; #University of Wisconsin Hospital, Madison; **University of Alberta, Edmonton, Canada; ††Shriners Hospital for Children, Galveston, Texas; ††Memphis Burn Center, Memphis, Tennessee; and §§Mount Sinai Beth Israel Medical Center, New York, New York.

Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The χ, Fisher's exact, and Cochran-Mantel-Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association-supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.
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http://dx.doi.org/10.1097/BCR.0000000000000270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5312724PMC
December 2016

Long-term association between frailty and health-related quality of life among survivors of critical illness: a prospective multicenter cohort study.

Crit Care Med 2015 May;43(5):973-82

1Division of Critical Care Medicine (University of Alberta Hospital), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. 2Department of Critical Care Medicine, Faculty of Medicine, University of Calgary, Calgary, Canada. 3School of Public Health, University of Alberta, Edmonton, Canada. 4Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. 5Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. 6EPICORE Centre, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.

Objective: Frailty is a multidimensional syndrome characterized by loss of physiologic reserve that gives rise to vulnerability to poor outcomes. We aimed to examine the association between frailty and long-term health-related quality of life among survivors of critical illness.

Design: Prospective multicenter observational cohort study.

Setting: ICUs in six hospitals from across Alberta, Canada.

Patients: Four hundred twenty-one critically ill patients who were 50 years or older.

Interventions: None.

Measurements And Main Results: Frailty was operationalized by a score of more than 4 on the Clinical Frailty Scale. Health-related quality of life was measured by the EuroQol Health Questionnaire and Short-Form 12 Physical and Mental Component Scores at 6 and 12 months. Multiple logistic and linear regression with generalized estimating equations was used to explore the association between frailty and health-related quality of life. In total, frailty was diagnosed in 33% (95% CI, 28-38). Frail patients were older, had more comorbidities, and higher illness severity. EuroQol-visual analogue scale scores were lower for frail compared with not frail patients at 6 months (52.2 ± 22.5 vs 64.6 ± 19.4; p < 0.001) and 12 months (54.4 ± 23.1 vs 68.0 ± 17.8; p < 0.001). Frail patients reported greater problems with mobility (71% vs 45%; odds ratio, 3.1 [1.6-6.1]; p = 0.001), self-care (49% vs 15%; odds ratio, 5.8 [2.9-11.7]; p < 0.001), usual activities (80% vs 52%; odds ratio, 3.9 [1.8-8.2]; p < 0.001), pain/discomfort (68% vs 47%; odds ratio, 2.0 [1.1-3.8]; p = 0.03), and anxiety/depression (51% vs 27%; odds ratio, 2.8 [1.5-5.3]; p = 0.001) compared with not frail patients. Frail patients described lower health-related quality of life on both physical component score (34.7 ± 7.8 vs 37.8 ± 6.7; p = 0.012) and mental component score (33.8 ± 7.0 vs 38.6 ± 7.7; p < 0.001) at 12 months.

Conclusions: Frail survivors of critical illness experienced greater impairment in health-related quality of life, functional dependence, and disability compared with those not frail. The systematic assessment of frailty may assist in better informing patients and families on the complexities of survivorship and recovery.
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http://dx.doi.org/10.1097/CCM.0000000000000860DOI Listing
May 2015

Canadian recommendations for critical care ultrasound training and competency.

Can Respir J 2014 November/December;21(6):341-345. Epub 2014 Sep 25.

Objective: To achieve national consensus on standards of training, quality assurance and maintenance of competence for critical care ultrasound for intensivists and critical care trainees in Canada using recently published international training statements.

Data Sources: Existing internationally endorsed guidelines and expert opinion.

Data Synthesis: In November 2013, a day-long consensus meeting was held with 15 Canadian experts in critical care ultrasound in which essential topics relevant to training ultrasound were discussed.

Conclusions: Consensus was achieved to direct training curriculum, oversight, quality assurance and maintenance of competence for critical care ultrasound. In providing the first national guideline of its kind, these Canadian recommendations may also serve as a model of critical care ultrasound dissemination for other countries.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4266152PMC
http://dx.doi.org/10.1155/2014/216591DOI Listing
September 2014

Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) study.

Am J Respir Crit Care Med 2014 Oct;190(8):855-66

1 Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.

Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as >80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had >90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.
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http://dx.doi.org/10.1164/rccm.201403-0593CCDOI Listing
October 2014

Controversies in fluid therapy: Type, dose and toxicity.

World J Crit Care Med 2014 Feb 4;3(1):24-33. Epub 2014 Feb 4.

Robert C McDermid, Adam Romanovsky, Sean M Bagshaw, Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G2B7, Canada.

Fluid therapy is perhaps the most common intervention received by acutely ill hospitalized patients; however, a number of critical questions on the efficacy and safety of the type and dose remain. In this review, recent insights derived from randomized trials in terms of fluid type, dose and toxicity are discussed. We contend that the prescription of fluid therapy is context-specific and that any fluid can be harmful if administered inappropriately. When contrasting ''crystalloid vs colloid'', differences in efficacy are modest but differences in safety are significant. Differences in chloride load and strong ion difference across solutions appear to be clinically important. Phases of fluid therapy in acutely ill patients are recognized, including acute resuscitation, maintaining homeostasis, and recovery phases. Quantitative toxicity (fluid overload) is associated with adverse outcomes and can be mitigated when fluid therapy based on functional hemodynamic parameters that predict volume responsiveness and minimization of non-essential fluid. Qualitative toxicity (fluid type), in particular for iatrogenic acute kidney injury and metabolic acidosis, remain a concern for synthetic colloids and isotonic saline, respectively. Physiologically balanced crystalloids may be the ''default'' fluid for acutely ill patients and the role for colloids, in particular hydroxyethyl starch, is increasingly unclear. We contend the prescription of fluid therapy is analogous to the prescription of any drug used in critically ill patients.
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http://dx.doi.org/10.5492/wjccm.v3.i1.24DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4021151PMC
February 2014

Scratching the surface: the burden of frailty in critical care.

Intensive Care Med 2014 May 21;40(5):740-2. Epub 2014 Mar 21.

Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building, 8440-122 Street NW, Edmonton, AB, T6G 2B7, Canada.

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http://dx.doi.org/10.1007/s00134-014-3246-3DOI Listing
May 2014

Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study.

CMAJ 2014 Feb 25;186(2):E95-102. Epub 2013 Nov 25.

Background: Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability to adverse outcomes. We determined the prevalence, correlates and outcomes associated with frailty among adults admitted to intensive care.

Methods: We prospectively enrolled 421 critically ill adults aged 50 or more at 6 hospitals across the province of Alberta. The primary exposure was frailty, defined by a score greater than 4 on the Clinical Frailty Scale. The primary outcome measure was in-hospital mortality. Secondary outcome measures included adverse events, 1-year mortality and quality of life.

Results: The prevalence of frailty was 32.8% (95% confidence interval [CI] 28.3%-37.5%). Frail patients were older, were more likely to be female, and had more comorbidities and greater functional dependence than those who were not frail. In-hospital mortality was higher among frail patients than among non-frail patients (32% v. 16%; adjusted odds ratio [OR] 1.81, 95% CI 1.09-3.01) and remained higher at 1 year (48% v. 25%; adjusted hazard ratio 1.82, 95% CI 1.28-2.60). Major adverse events were more common among frail patients (39% v. 29%; OR 1.54, 95% CI 1.01-2.37). Compared with nonfrail survivors, frail survivors were more likely to become functionally dependent (71% v. 52%; OR 2.25, 95% CI 1.03-4.89), had significantly lower quality of life and were more often readmitted to hospital (56% v. 39%; OR 1.98, 95% CI 1.22-3.23) in the 12 months following enrolment.

Interpretation: Frailty was common among critically ill adults aged 50 and older and identified a population at increased risk of adverse events, morbidity and mortality. Diagnosis of frailty could improve prognostication and identify a vulnerable population that might benefit from follow-up and intervention.
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http://dx.doi.org/10.1503/cmaj.130639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3903764PMC
February 2014

The role of frailty in outcomes from critical illness.

Curr Opin Crit Care 2013 Oct;19(5):496-503

Faculty of Medicine and Dentistry, Division of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.

Purpose Of Review: Frailty is a multidimensional syndrome characterized by loss of physiologic reserves that gives rise to vulnerability to adverse events.

Recent Findings: Frailty has been described in older patients undergoing geriatric assessment and in noncardiac and cardiac surgical settings, in which it closely correlates with heightened risk for major morbidity including functional decline, postoperative complications, institutionalization, and short-term and long-term mortality. Critically ill patients may represent a population with similar vulnerabilities to older frail patients. Prior data have described the association with less favorable outcomes and poor premorbid functional status (i.e., activities of daily living, cognitive impairment, body mass index), used perhaps as a surrogate for frailty. Preliminary epidemiologic data suggest the prevalence of frailty (and intermediate frail states) among critically ill patients is high and likely to increase with the greater demand placed on ICU resources associated with population demographic transition.

Summary: The concept of frailty, as a marker of biologic age and physiologic reserve, may have direct relevance to critical care, and clearly identifies a population at greater risk of adverse events, morbidity, and mortality. Its recognition in critical care settings may enable improved prognostication and shared decision-making and identify vulnerable subgroups with specific needs who might benefit from targeted follow-up.
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http://dx.doi.org/10.1097/MCC.0b013e328364d570DOI Listing
October 2013

High-frequency oscillation for ARDS.

N Engl J Med 2013 06;368(23):2231-2

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http://dx.doi.org/10.1056/NEJMc1304344DOI Listing
June 2013

What's new in critical illness and injury science? The costs of having a fall in Qatar!

Int J Crit Illn Inj Sci 2013 Jan;3(1):1-2

Division of Critical Care Medicine, University of Alberta, Edmonton AB, Canada.

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http://dx.doi.org/10.4103/2229-5151.109405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665111PMC
January 2013

Restricting resident work hours: the learner/employee tension.

Crit Care Med 2012 Sep;40(9):2739; author reply 2739-40

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http://dx.doi.org/10.1097/CCM.0b013e318258ebd8DOI Listing
September 2012

Orthostatic convulsive syncope in a burn patient.

J Burn Care Res 2012 Jan-Feb;33(1):e14-6

University of Alberta, Edmonton, Canada.

Orthostatic convulsive syncope is defined as a decrease in cerebral blood supply resulting in convulsive, seizure-like symptoms. The authors present the first case report of orthostatic convulsive syncope in a burn patient. There are many causes of transient loss of consciousness in patients. An algorithm is presented to aid in the workup and management strategies for this diagnosis. This approach in conjunction with a neurology consult should add in the assessment and treatment of transient loss of consciousness and orthostatic convulsive syncope in a burn patient.
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http://dx.doi.org/10.1097/BCR.0b013e318233b60dDOI Listing
May 2012

ICU and critical care outreach for the elderly.

Best Pract Res Clin Anaesthesiol 2011 Sep;25(3):439-49

Division of Critical Care Medicine, University of Alberta, 3C1.16 Walter C. Mackenzie Centre, 8440-122 Street, Edmonton, Alberta T6G2B7, Canada.

Average life expectancy has increased over the past century resulting in a shift in world population demographics. There are more elderly people alive now than throughout all of human history. The burden of comorbid disease and dependency rises with age and has been shown to independently predict need for hospitalization, institutionalization and mortality. Accordingly, there are more elderly persons living longer in more tenuous states of health. The relative proportion of patients admitted to hospital and intensive care who are elderly is considerable and recent data have suggested an increasing trend. There is likely significant selection bias amongst elderly patients triaged for access to finite critical care services. In fact, data have shown that elderly patients often receive less intensive therapy and have greater support limitations when admitted to an intensive care environment. "Chronologic" age has been an inconsistent predictor of prognosis in elderly patients who present with critical illness. However, surrogate measures of "physiologic" age are likely more relevant, such as an assessment of frailty, to aid in prognostication and informed decision-making and that ultimately correlate not only with short-term survival but additional outcomes such as functional status, institutionalization and quality of life after an episode of critical illness. There is a paucity of literature on the specific interaction of rapid response systems (RRS) and hospitalized "at-risk" elderly patients; however, the RRS may have particular application for this cohort. In particular, data have emerged to suggest mature ICU-based RRS respond commonly to elderly patients and are increasingly participating in end-of-life care discussions. In addition, another aspect of the RRS, critical care outreach (CCO), may facilitate the identification of elderly patients for timely goal-oriented advanced care planning prior to clinical deterioration.
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http://dx.doi.org/10.1016/j.bpa.2011.06.001DOI Listing
September 2011