A Comparison of the Effect of Journal Club through New and Traditional Methods on the Attitudes of Anesthesiology Residents of Shiraz University of Medical Sciences, Iran

Background & Objective: Journal club is one of the classical methods of medical education dating back to 100 years ago. This method can be used for teaching critical evaluation, evidence-based medicine, research design, statistics, and educational concepts to medical residents. The purpose of this study was to investigate the anesthesiology residents’ attitude toward a new method of presenting journal club (with the presence of specialists in community medicine and/or statistics). Methods: This was a cross-sectional, interventional study performed in the adult intensive care unit of Namazi Hospital, Shiraz, Iran. From among 50 faculty members and second year anesthesiology residents participating in the journal club through both the new and traditional methods, 36 returned their viewpoints. A questionnaire with 19 items was designed by the researcher with the collaboration of the Medical Education Development Office and the Anesthesiology Department of Shiraz University of Medical Sciences, Iran. The validity of the questionnaire was confirmed by educational experts and its reliability was reported as over 90% using Cronbach's alpha coefficient. Results: The intervention group (journal club sessions with the presence of community medicine or statistics professionals) scored significantly higher than the control group on all items of the questionnaire. The participants in the experimental group reported that the most important effects of the new approach was their better understanding of statistical terms and research methodology, a positive attitude toward the usefulness of interdisciplinary communication, article reviews and the application of results in clinical practice, development of article assessment skills, creating motivation for further research, causing desire to participate in other journal clubs, and recommending colleagues to participate in such clubs. Moreover, Spearman's rank correlation coefficient showed that with the increase in the number of journal club sessions participated in, the rate of knowledge and desire to participate in more sessions also increased. Conclusion: Participants admitted that they had improved academically and were generally satisfied with this new approach. Regarding the generalizability and implementation in other training centers, this new approach can be exploited in other departments of specialized medical fields. In case of achieving valid and reliable results, the approach can be proposed as a national model.Keywords Journal club Attitude New approach Medical residents Critical Car

Prophylactic effect of ephedrine to reduce hemodynamic changes associated with anesthesia induction with propofol and remifentanil

Background: One of the complications of anesthesia induction with propofol is a substantial decrease in arterial blood pressure and heart rate (HR), which can be intensified by adding remifentanil. This study aimed to assess the prophylactic effects of two doses of ephedrine to control the hypotension and bradycardia caused by anesthesia induced with propofol and remifentanil. Materials and Methods: A total of 150 patients candidate for short-term minor elective orthopedic and ophthalmic surgery under general anesthesia were randomized to three groups receiving normal saline, low dose ephedrine (0.07 mg/kg) or high dose ephedrine (0.15 mg/kg). Anesthesia was induced in all groups with propofol 2.5 mg/kg and remifentanil 3 μg/kg. No neuromuscular blocking agent was used. Patients′ hemodynamic status was assessed in the following four steps: Immediately before, 2 min after induction of anesthesia, as well as 1 and 5 min after intubation. Results: A total of 143 patients consisting of 46 patients in the low dose ephedrine (0.07 mg/kg) group, 49 patients in the high dose ephedrine (0.15 mg/kg) group and 48 controls completed the trial. In all three groups, after induction of anesthesia, significant decreases occurred in the mean systolic, diastolic and mean arterial pressures, as well as in the mean HR. This decline was highest in the control group and lowest in the high dose ephedrine (0.15 mg/kg) group. Conclusion: Our findings suggest that the administration of high dose ephedrine (0.15 mg/kg) may have a significant effect in preventing hypotension and bradycardia after anesthesia induction with propofol and remifentanil

The association of diameter and depth of internal jugular and subclavian veins with hand dominancy

Background: The central veins’ catheterization, required in critically ill patients, is more successful in larger veins. Some researchers hypothesized that hand preference might be associated with larger ipsi/contra central veins. Objective: To determine the diameter and depth of internal jugular and subclavian veins on both sides and its association with left- or right-handedness. Methods: This cross-sectional study, was conducted on patients referring for elective breast or thyroid check-up to Shahid Faghihi Hospital ultrasound unit, Shiraz, Iran, from September 2014 to May 2015. Inclusion criteria consisted of adult normotensive patients with American Society of Anesthesiology (ASA) class I without underlying diseases. The patients’ demographics were recorded and the diameter and depth of the internal jugular and subclavian veins were measured by ultrasound. The results of measurements were compared between patients’ hand preference by SPSS version 19, using paired-samples t-test and independent-samples t-test. Results: Of 65 patients, 86% were women and 19 were left-handed (29%) with the only significant difference between the right and left subclavian diameter in right-handed individuals (p=0.007) and no significant difference between the left and right internal jugular vein diameter and depth and subclavian vein depth between the left- and right-handed patients. The subclavian diameter of the right and left side was also not different in left-handed patients. Conclusion: The right or left central veins are not superior to each other with respect to diameter and depth in right- or left-handed patient

Gastrotracheal Fistula as a Result of Transhiatal Esophagectomy for Esophageal Cancer: An Unusual Complication

Gastrotracheal fistula following open transhiatal esophagectomy (Orringer’s technique) for esophageal cancer is an unusual but lethal complication. Surgical intervention with resection of the fistula tract and primary interrupted suturing of gastric and tracheal orifices using a muscle flap interposition has proved to be a successful method. We report the case of a 73-year-old male with an adenocarcinoma of the distal part of the esophagus, who underwent open transhiatal esophagectomy (Orringer’s technique) with gastric tube reconstruction and cervical anastomosis. The patient did not receive induction chemoradiotherapy before the esophagectomy. Two attempts of surgical repair of fistula failed and the patient died. Being aware of warning signs such as dyspnea and respiratory distress accompanied by bilious content in the tracheal tube is helpful in the early detection and treatment of this type of fistula

Absenteeism from Theory Classes: Perspective of Medical Students

Introduction: Absenteeism is one of the most important and increasing educational problems of universities in recent years whose consequences have a negative impact on many academic aspects of students. The purpose of this study was to identify and prioritize the factors affecting absenteeism from theory classes from the perspective of basic sciences medical students at Shiraz University of Medical Sciences in 2015. Methods: This descriptive cross-sectional study was conducted on 209 basic science medical students who were selected through convenience sampling (census) from October and February semester students in 2012-13 academic year. Data collection tool was a researcher-made questionnaire. The face validity of the questionnaire was confirmed by educational experts and its reliability was measured through Cronbach’s alpha coefficient (α = 0.8). It included 26 items in five-point Likert scale (1 to 5) that were divided into 4 domains as recommended by medical education experts. The data were analyzed using descriptive statistics. Results: The mean scores of the domains related to students’ views about absenteeism from theory classes were classroom management (4±0.59), individual conditions of class engagement (4±0.48), instructor’s academic ability and teaching method (3±0.58) and time and place of classes (2. 8±0.68). Students agreed with the effect of class management and class engagement on absenteeism, while disagreed with the effect of time and place of class on absenteeism. Conclusion: Results showed that from the viewpoints of students, class management and individual conditions for class engagement could affect medical students’ absenteeism from theory classes. Prioritization of these factors could easily eliminate the weaknesses and enhance instructor-learner communication

Does red blood cell transfusion affect clinical outcomes in critically ill patients? A report from a large teaching hospital in south Iran

BACKGROUND: Despite the beneficial effects, RBC transfusion can be associated with infectious and non-infectious complications in critically ill patients. OBJECTIVES: Investigate current RBC transfusion practices and their effect on the clinical outcomes of patients in intensive care units (ICUs). DESIGN: Retrospective observational study SETTING: Three mixed medical-surgical adult ICUs of a large academic tertiary hospital PATIENTS AND METHODS: From March 2018 to February 2020, all adult patients admitted to medical or surgical ICU. Patients who received one or more RBC transfusions during the first month of ICU admission were included in the “transfusion” group, while the remaining patients were assigned to the “non-transfusion” group. MAIN OUTCOME MEASURES: Mortality and length of ICU and hospital stay. SAMPLE SIZE: 2159 patients RESULTS: Of 594 patients who recieved transfusions, 27% of patients received red blood cell (RBC) products. The mean pre-transfusion hemoglobin (Hb) level was 8.05 (1.46) g/dL. There was a significant relationship between higher APACHE II scores and ICU mortality in patients with Hb levels of 7–9 g/dL (OR adjusted=1.05). Also, ICU mortality was associated with age (OR adjusted=1.03), APACHE II score (OR adjusted=1.08), and RBC transfusion (OR adjusted=2.01) in those whose Hb levels were >9 (g/dL). CONCLUSION: RBC transfusion was associated with an approximately doubled risk of ICU mortality in patients with Hb>9 g/dL. High APACHE II score and age increase the chance of death in the ICU by 8% and 3%, respectively. Hence, ICU physicians should consider a lower Hb threshold for RBC transfusion, and efforts must be made to optimize RBC transfusion practices. LIMITATIONS: Single-center and retrospective study

Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure: the DIANA study

Purpose: The DIANA study aimed to evaluate how often antimicrobial de-escalation (ADE) of empirical treatment is performed in the intensive care unit (ICU) and to estimate the effect of ADE on clinical cure on day 7 following treatment initiation. Methods: Adult ICU patients receiving empirical antimicrobial therapy for bacterial infection were studied in a prospective observational study from October 2016 until May 2018. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of an antimicrobial with the intention to narrow the antimicrobial spectrum, within the first 3 days of therapy. Inverse probability (IP) weighting was used to account for time-varying confounding when estimating the effect of ADE on clinical cure. Results: Overall, 1495 patients from 152 ICUs in 28 countries were studied. Combination therapy was prescribed in 50%, and carbapenems were prescribed in 26% of patients. Empirical therapy underwent ADE, no change and change other than ADE within the first 3 days in 16%, 63% and 22%, respectively. Unadjusted mortality at day 28 was 15.8% in the ADE cohort and 19.4% in patients with no change [p = 0.27; RR 0.83 (95% CI 0.60-1.14)]. The IP-weighted relative risk estimate for clinical cure comparing ADE with no-ADE patients (no change or change other than ADE) was 1.37 (95% CI 1.14-1.64). Conclusion: ADE was infrequently applied in critically ill-infected patients. The observational effect estimate on clinical cure suggested no deleterious impact of ADE compared to no-ADE. However, residual confounding is likely

Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study

Purpose: In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials. Methods: We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021. Results: 2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28. Conclusions: HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.</p