Impact of Fluconazole Prophylaxis on Cortisol Levels in Critically Ill Surgical Patients

Fluconazole is widely used in the intensive care unit for prevention and treatment of fungal infections. Case reports have described an association between fluconazole and adrenal dysfunction, an important cause of morbidity and mortality in critically ill patients. We sought to determine whether 400 mg of fluconazole per day administered to critically ill surgical patients was associated with a reduction in cortisol levels. Cortisol levels were measured in stored plasma specimens drawn from 154 critically ill surgical patients randomized in 1998-1999 to receive fluconazole or placebo for the prevention of candidiasis. The primary outcome measure was the median plasma cortisol level ≥1 day after study drug initiation (MPCL). Secondary outcomes were adrenal dysfunction, defined as an MPCL of <15 μg/dl, changes in cortisol levels over time, and mortality. The median MPCL was 15.75 μg/dl (interquartile range [IQR], 11.65 to 21.33 μg/dl) in 79 patients randomized to fluconazole and 16.71 μg/dl (IQR, 11.67 to 23.00 μg/dl) in 75 patients randomized to placebo (P = 0.52). Patients randomized to fluconazole did not have significantly increased odds of adrenal dysfunction compared to patients randomized to placebo (odds ratio, 0.98; 95% confidence interval, 0.48 to 2.01). Randomization to fluconazole was not associated with a significant difference in cortisol level changes over time. Mortality was not different between patients with and without adrenal dysfunction, nor was it different between patients with adrenal dysfunction who were randomized to fluconazole and those randomized to placebo. Fluconazole prophylaxis in this population of critically ill surgical patients did not result in significant adrenal dysfunction

Effective Clinical Practice Intensive Care Unit Nurse Staffing and the Risk for Complications after Abdominal Aortic Surgery

Context. We previously found that length of stay in the intensive care unit (ICU) after abdominal aortic surgery increased when fewer ICU nurses were available per patient. We hypothesized that having fewer nurses increases the risk for medical complications. Objective. To evaluate the association between nurse-to-patient ratio in the ICU and risk for medical and surgical complications after abdominal aortic surgery. Design. Observational study. Setting. All nonfederal acute care hospitals in Maryland. Data Sources. Information about patients came from hospital discharge data on all patients in Maryland with a principal procedure code for abdominal aortic surgery from 1994 through 1996 (n = 2606). The organizational characteristics of ICUs were obtained by surveying ICU medical and nursing directors in 1996 at the 46 Maryland hospitals that performed abdominal aortic surgery. Thirty-nine of the ICU directors (85%) completed the survey. Exposure. Surgery in hospitals with fewer ICU nurses (in which each nurse cared for three or four patients) compared with hospitals with more ICU nurses (in which each nurse cared for one or two patients). Outcome. Proportion of patients who developed postoperative complications. Results. Seven hospitals with 478 patients had fewer ICU nurses, and 31 hospitals with 212

Changing surgical culture through surgical education: Introduction to the PACTS trial

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients\u27 needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)\u27s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes

Association of unconscious race and social class bias with vignette-based clinical assessments by medical students

Context: Studies involving physicians suggest that unconscious bias may be related to clinical decision making and may predict poor patient-physician interaction. The presence of unconscious race and social class bias and its association with clinical assessments or decision making among medical students is unknown.Objective: To estimate unconscious race and social class bias among first-year medical students and investigate its relationship with assessments made during clinical vignettes.Design, setting, and participants: A secure Web-based survey was administered to 211 medical students entering classes at Johns Hopkins School of Medicine, Baltimore, Maryland, in August 2009 and August 2010. The survey included the Implicit Association Test (IAT) to assess unconscious preferences, direct questions regarding students\u27 explicit race and social class preferences, and 8 clinical assessment vignettes focused on pain assessment, informed consent, patient reliability, and patient trust. Adjusting for student demographics, multiple logistic regression was used to determine whether responses to the vignettes were associated with unconscious race or social class preferences.Main outcome measures: Association of scores on an established IAT for race and a novel IAT for social class with vignette responses.Results: Among the 202 students who completed the survey, IAT responses were consistent with an implicit preference toward white persons among 140 students (69%, 95% CI, 61%-75%). Responses were consistent with a preference toward those in the upper class among 174 students (86%, 95% CI, 80%-90%). Assessments generally did not vary by patient race or occupation, and multivariable analyses for all vignettes found no significant relationship between implicit biases and clinical assessments. Regression coefficient for the association between pain assessment and race IAT scores was -0.49 (95% CI, -1.00 to 0.03) and for social class, the coefficient was -0.04 (95% CI, -0.50 to 0.41). Adjusted odds ratios for other vignettes ranged from 0.69 to 3.03 per unit change in IAT score, but none were statistically significant. Analysis stratified by vignette patient race or class status yielded similarly negative results. Tests for interactions between patient race or class status and student IAT D scores in predicting clinical assessments were not statistically significant.Conclusions: The majority of first-year medical students at a single school had IAT scores consistent with implicit preference for white persons and possibly for those in the upper class. However, overall vignette-based clinical assessments were not associated with patient race or occupation, and no association existed between implicit preferences and the assessments