New Methods for Resolving Conflicting Requests with Examples from Medical Residency Scheduling

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138246/1/poms12728.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/138246/2/poms12728-sup-0001-SupInfo.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/138246/3/poms12728_am.pd

Renal Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT Renal dysfunction is associated with poor outcomes in critically ill children. OBJECTIVE To evaluate the current evidence for criteria defining renal dysfunction in critically ill children and association with adverse outcomes. To develop contemporary consensus criteria for renal dysfunction in critically ill children. DATA SOURCES PubMed and Embase were searched from January 1992 to January 2020. STUDY SELECTION Included studies evaluated critically ill children with renal dysfunction, performance characteristics of assessment tools for renal dysfunction, and outcomes related to mortality, functional status, or organ-specific or other patient-centered outcomes. Studies with adults or premature infants (≤36 weeks' gestational age), animal studies, reviews, case series, and studies not published in English with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were extracted from included studies into a standard data extraction form by task force members. RESULTS The systematic review supported the following criteria for renal dysfunction: (1) urine output <0.5 mL/kg per hour for ≥6 hours and serum creatinine increase of 1.5 to 1.9 times baseline or ≥0.3 mg/dL, or (2) urine output <0.5 mL/kg per hour for ≥12 hours, or (3) serum creatinine increase ≥2 times baseline, or (4) estimated glomerular filtration rate <35 mL/minute/1.73 m2, or (5) initiation of renal replacement therapy, or (6) fluid overload ≥20%. Data also support criteria for persistent renal dysfunction and for high risk of renal dysfunction. LIMITATIONS All included studies were observational and many were retrospective. CONCLUSIONS We present consensus criteria for renal dysfunction in critically ill children

Sources of variability in distortion product otoacoustic emissions

The goal of this study was to determine the extent to which the variability seen in distortion product otoacoustic emissions (DPOAEs), among ears with normal hearing, could be accounted for. Several factors were selected for investigation, including behavioral threshold, differences in middle-ear transmission characteristics either in the forward or the reverse direction, and differences in contributions from the distortion and reflection sources. These variables were assessed after optimizing stimulus parameters for individual ears at each frequency. A multiple-linear regression was performed to identify whether the selected variables, either individually or in combination, explained significant portions of variability in DPOAE responses. Behavioral threshold at the f2 frequency and behavioral threshold squared at that same frequency explained the largest amount of variability in DPOAE level, compared to the other variables. The combined model explained a small, but significant, amount of variance in DPOAE level at five frequencies. A large amount of residual variability remained, even at frequencies where the model accounted for significant amounts of variance

Do &quot;Optimal&quot; Conditions Improve Distortion Product Otoacoustic Emission Test Performance?

Objectives: To determine whether an &quot;optimal&quot; distortion product otoacoustic emission (DPOAE) protocol that (1) used optimal stimulus levels and primary-frequency ratios for each f 2 , (2) simultaneously measured 2f 2 Ϫ f 1 and 2f 1 Ϫ f 2 distortion products, (3) controlled source contribution, (4) implemented improved calibration techniques, (5) accounted for the influence of middle ear reflectance, and (6) applied multivariate analyses to DPOAE data results in improved accuracy in differentiating between normal-hearing and hearing-impaired ears, compared with a standard clinical protocol. Design: Data were collected for f 2 frequencies ranging from 0.75 to 8 kHz in 28 normal-hearing and 78 hearing-impaired subjects. The protocol included a control condition incorporating standard stimulus levels and primary-frequency ratios calibrated with a standard SPL method and three experimental conditions using optimized stimuli calibrated with an alternative forward pressure level method. The experimental conditions differed with respect to the level of the reflection-source suppressor tone and included conditions referred to as the null suppressor (i.e., no suppressor tone presented), low-level suppressor (i.e., suppressor tone presented at 58 dB SPL), and high-level suppressor (i.e., suppressor tone presented at 68 dB SPL) conditions. The area under receiver operating characteristic (A ROC ) curves and sensitivities for fixed specificities (and vice versa) were estimated to evaluate test performance in each condition. Results: A ROC analyses indicated (1) improved test performance in all conditions using multivariate analyses, (2) improved performance in the null suppressor and low suppressor experimental conditions compared with the control condition, and (3) poorer performance below 4 kHz with the high-level suppressor. As expected from A ROC , sensitivities for fixed specificities and specificities for fixed sensitivities were highest for the null suppressor and low suppressor conditions and lowest for standard clinical procedures. The influence of 2f 2 Ϫ f 1 and reflectance on test performance were negligible. Conclusions: Predictions of auditory status based on DPOAE measurements in clinical protocols may be improved by the inclusion of (1) optimized stimuli, (2) alternative calibration techniques, (3) low-level suppressors, and (4) multivariate analyses

Renal angina index predicts fluid overload in critically ill children: an observational cohort study

Abstract Background Fluid overload and acute kidney injury are common and associated with poor outcomes among critically ill children. The prodrome of renal angina stratifies patients by risk for severe acute kidney injury, but the predictive discrimination for fluid overload is unknown. Methods Post-hoc analysis of patients admitted to a tertiary care pediatric intensive care unit (PICU). The primary outcome was the performance of renal angina fulfillment on day of ICU admission to predict fluid overload ≥15% on Day 3. Results 77/139 children (55%) fulfilled renal angina (RA+). After adjusting for covariates, RA+ was associated with increased odds of fluid overload on Day 3 (adjusted odds ratio (aOR) 5.1, 95% CI 1.23–21.2, p = 0.025, versus RA-). RA- resulted in a 90% negative predictive value for fluid overload on Day 3. Median fluid overload was significantly higher in RA+ patients with severe acute kidney injury compared to RA+ patients without severe acute kidney injury (% fluid overload on Day 3: 8.8% vs. 0.73%, p = 0.002). Conclusion Among critically ill children, fulfillment of renal angina was associated with increased odds of fluid overload versus the absence of renal angina and a higher fluid overload among patients who developed acute kidney injury. Renal angina directed risk classification may identify patients at highest risk for fluid accumulation. Expanded study in larger populations is warranted.http://deepblue.lib.umich.edu/bitstream/2027.42/173576/1/12882_2021_Article_2540.pd

Distribution of standing-wave errors in real-ear sound-level measurements

Standing waves can cause measurement errors when sound-pressure level (SPL) measurements are performed in a closed ear canal, e.g., during probe-microphone system calibration for distortion-product otoacoustic emission (DPOAE) testing. Alternative calibration methods, such as forward-pressure level (FPL), minimize the influence of standing waves by calculating the forward-going sound waves separate from the reflections that cause errors. Previous research compared test performance (Burkeet al., 2010) and threshold prediction (Rogerset al., 2010) using SPL and multiple FPL calibration conditions, and surprisingly found no significant improvements when using FPL relative to SPL, except at 8 kHz. The present study examined the calibration data collected by Burkeet al. and Rogerset al. from 155 human subjects in order to describe the frequency location and magnitude of standing-wave pressure minima to see if these errors might explain trends in test performance. Results indicate that while individual results varied widely, pressure variability was larger around 4 kHz and smaller at 8 kHz, consistent with the dimensions of the adult ear canal. The present data suggest that standing-wave errors are not responsible for the historically poor (8 kHz) or good (4 kHz) performance of DPOAE measures at specific test frequencies