RCT = randomized controlled trial; MA = metaanalisis; sr = systematic review; DX = diagnosis; inc_ = incident; w_ = with; wo_ = without; pxs = patients; EX = exclusion; IN = inclusion; ↗️ = improve; ↘️ = worsen; ↑ = increase; ↓ = decrease; 𝙄𝙌𝘾 BS = 𝙄𝙉𝘼𝘼𝙌𝘾 ᴮᴼ brief scope = year (Y), journal (J), country (C) ➖ type of study (T) ➕ number of patients/sample (N) ➕ time (t) ➖ population (P), intervention (I), comparison (C), outcome (O, OC); p = primary; s = secondary
1. A JC is an academic session where we go through a scientific article for 1 hour.
2. It takes place every Friday.
3. Its purpose is to understand and discuss relevant elements about the content taking interactive and pedagogic notes (highlighting, underlining and using other learning resources) about the content.
4. We generate further appraisal, identify the opportunities of learning and formulate some potential research questions.
5. We write down the key-points of every session and publish them on our website
6. The article for the next session is posted one week in advance the must-read JC channel of our DISCORD server.
Friday, January 26, 2024, at 18h BO
VFP, HIBN, AAQC
1. The point to understand vulnerability without risking excellence
2. Tension between once-acceptable workplace demands and well-being is hardly unique to medicine.
3. Discomfort is part of the human condition and a prerequisite for learning (Mitchell)
4. The ability to discern (oppression 🆚 violence) the difference is a form of EMOTIONAL MATURITY we should encourage
5. While most trainees were striving for excellence, a vocal minority could set the tone — and shape perceptions — for the majority.
6. Daily racism is different from being asked if you’re old enough to be a doctor OR burn-out 🆚 depression
7. Doctor posts a twitter about success and is interpreted as offense (those who work hard, are burned out).
8. Resident telling a female attendant about how difficult is to be a woman in medicine (asking her to “smile more”)
9. Does the pursuit of excellence conflict with the pursuit of wellbeing?
10. The heightened sensitivity regarding expectations of excellence impedes our ability to give candid constructive feedback.
11. “How far we’ve fallen”
12. Pretending to be someone example ➩ changing her hair… her voice… being naive… “playing a performance”
13. Invocations of harm thus often force a moral choice: Are you with the victim or the victimizer?
⏳ TIME MANAGEMENT.
Round: 9 21:29:46 Wrap-up
Round: 8 05:57:01 Questioning the narrative
Round: 7 02:30:75 Playing the game
Round: 6 11:54:78 Playing the game
Round: 5 07:38:08 Constructive criticism
Round: 4 13:46:67 Excellence as offense
Round: 3 23:38:95 New hierarchy
Round: 2 15:32:11 Intro
Round: 1 06:15:19 Selecting ART
Friday, April 19, 2024 at 17:15 BE
HIBN, GIP, AAQC
ICU LOS = ICU length of stay, MV = mechanical ventilation, H+_MM = hospital mortality, ITW = interviews, Hospital Anxiety and Depression Scale = HADS
1. Y, J, C ➖ T ➕ N ➕ t ➖ PICO:
2. 2024, ICM, FR ➖ RCT ➕ 385 pxs ➕ 2020-2023 ➖ PICO:
- P: ICU pxs families
- I: nurse facilitators communication & support
- C: standard communication by ICU clinicians
- O: pOC = family symptoms of depression ➕ sOC = HADS-anxiety, event scale-6, QUAL-E
3. Importance:
- Psychological burden = anxiety, depression & post traumatic stress
- Communication = skills, goals of care, confidence & biliefs
- Family satisfaction = influenced by hospital culture
- Previous interventions (px navigation, discharge planning, care coordination) = ↘️ re-hospitalizations
4. Methods:
- Co-designed with J. Randall Curtis
- 5 university H+
- Table 1 explored: MV same % in I + C ➕ ICU LOS = same % in I + C
- IN pxs: adults + expected LOS ≥2d + chronic life-timing illness (SS >2y + SOFA H+_MM >15%), FR speaking, visiting relatives, informed OR deferred consent
- IN families: adults + FR speaking + legal surrogates + w_informed consent
5. Procedures:
- 2-day training session for training facilitators by EXTERNAL CONSULTANTS (EC)
- EC w_expertise in clinical communication skills, use of attachment theory, and mediation.
6. The facilitators’ role = help families prepare for ITW w_docto, considering:
- what information did they want to share
- what questions did they want to ask
- what difficulties were they experiencing
- what were their specific needs
- once these were identified, the facilitator would strive to help families express these questions/difficulties/needs.
7. The control:
- open visitation policies
- multidisciplinary D3 meeting to review (DX, TTO, PROG)
- Meetings when deemed necessary - The possibility to meet with a psychologist ± a social worker.
8. Results: - pOC ➩ HADS at 6m - sOC ➩ anxiety, PTS, goal-concordant care, QOL9. Limitations: … to continue…
Friday, May 10, 2024 at 17h15 at BE
HIBN, AAQC
2024 ICM - Systemic inflammation and delirium during critical illness (brummel) [R].pdf
Glossary: oDYS = dysfunction; CI = cognitive impairment
1. 2024, ICM, USA ➖ prospective cohort ➕ 991 (5 centers)➕ 3y (Jan 2007 - Dec 2010) ➖ PICO:
- P: BRAIN-ICU + MIND-ICU. 🫁 failure + SHOCK (>18y)
- I: samples (CRP, IFN-∂, IL-1ß, MMP-9, TNF-alfa, TNFR1, prot C) + mental status (RASS, CAM-ICU) ➩ association delirium ⌄ coma
- C: normal mental status (next day)
- O: “association”
2. Importance + background:
- Delirium affects 1/2 pxs w_Critical Illness.
- Duration predicts: ↗️ MM + in survivors “CI + daily activity disability”
- Acute inflammation + ↓ endogenous anticoagulant activity = oDYS
3. Justification:
- Small sample size previous studies
- Limited number of markers
- Inconsistent associations
4. Methods
- IN. ✔︎
- EX. Acute oDYS for>72 h ➕ a recent ICU stay>5 d ➕ s_preexisting CI ➕ inability to communicate in English.
- Taken from PARENT STUDIES
5. Results. The following day: - Delirium = ↑ concentrations of IL-6 (OR 1.8), IL-8 (1.3), IL-10 (1.5), TNF-α (1.2), and TNFR1 (1.3) and lower concentrations of protein C (0.7)
- Coma = ↑ concentrations of CRP (1.4), IFN-γ (1.3), IL-6 (2.3 ), IL-8 (1.8), and IL-10 (1.5) and lower concentrations of protein C (0.6) - IL-1β, IL-12, MMP-9 ➩ NOT associated w_mental status.
Friday, Nov 29, 2024 at 18h30 at BO - 23h30 at BE
RCH, RICH, HIBN, AAQC
⏳ TIME MANAGEMENT.
01:02:41
Round: 2 22:12:52 Wrap-up
Round: 1 40:28:71 Article 1
Codified by AAQC
Glossary: w_MV = with mechanical ventilation; ICU MM = ICU mortality; in_H MM = in hospital mortality; in_H stay = in hospital stay; nf_MV = need for mechanical ventilation; 𝙄𝙉𝘼𝘼𝙌𝘾 ᴮᴼ brief scope = year (Y), journal (J), country (C) ➖ type of study (T) ➕ number of patients/sample (N) ➕ time (t) ➖ population (P), intervention (I), comparison (C), outcome (O).
1. Y, J, C ➖ T ➕ N ➕ t ➖ PICO: ➩ 2024, NCC, EGYPT ➖ RCT ➕ 100/344 ➕ 4m ➖ PICO:
- P: adults in ICU w_MV
- I: quetiapina
- C: haloperidol
- O:
* primary ➩ DRS-R-98 w_↓ ≥50% and ↓ to ≤12
* Secondary (6)➩ ICU MM + in_H MM + in_H stay + nf_MV + ICU stay + sleeping hours
2. Traditional use for DELIRIUM = haloperidol – new evidence towards atypical antipsychotics (quetiapine and risperidone)
3. RESULTS:
- Response in 92%
- sOC = NO DIFF
- INT ↓ ICU stay + ↑ sleeping hours per night ….
4. Written informed consent was obtained from the patient’s legal guardian in a private room beside the ICU following approval by the research ethics committee, the Department of Critical Care Medicine of the Faculty of Medicine at Alexandria University, and after thorough explanation of the benefits and risks of the study interventions. This study’s protocol was registered on ClinicalTrials.gov (identifier: NCT05690698).
Friday, Nov 22, 2024 at 18h30 at BO - 23h30 at BE
RCH, RICH, ABFL, HIBN, AAQC
Codified by MAAT
Glossary: CH = Switzerland; HF = heart failure; GL = guidelines; TMA = Translational Medicine Academy; HIC = high-income country; LMIC = low-middle income countries; OC = outcome; pxs = patients; 𝙄𝙉𝘼𝘼𝙌𝘾 ᴮᴼ brief scope = year (Y), journal (J), country (C) ➖ type of study (T) ➕ number of patients/sample (N) ➕ time (t) ➖ population (P), intervention (I), comparison (C), outcome (O).
1. Bsss ➩ 2024, EJHF, CH ➖ int, internet-based survey ➕ >2.5k clinicians ➕ Oct - Nov 2023 ➖PICO:
- P: clinicians HIC and LMIC
- I: survey (email)
- C: NA
- O: applicability view of HF GL
2. METHODS
- 1 original, 4 reminders (emails)
- TMA database ➩ non-profit medical education organization in Basel, CH. ➩ OBJ = enhance Px care + ↑ OC ➩ develop + disseminate research & education programs (conferences, website, webinars)
- Variables: demographics, experience, views of HF GL
- QuestionPro® ➩ for dissemination + data accumulation
- All multiple choice - one not analyzed (nature of responses)
3. STATS
- Fisher exact + chi-square➩ categorical
- Unpaired t-test ➩ continuous
- HIC 🆚 other counties compared
- Continuous ➩ mean (SE)
- Categorical ➩ number (%)
4. RESULTS
- LMIC regarded HF GL to be ↓ applicable 🆚 HIC (p = 0.0002).
- From all, >75% = somewhat or mostly true (mostly applicable to HIC)
- Those from LMIC (not HIC) ➩ the greatest implementation obstacle was that the guidelines were for HIC (51.3% vs. 43.1%; p = 0.0387).
- A significantly higher proportion ➩ resources were the problem
5. QUOTE: “While it is not the intention that they be directed for clinicians and patients solely in the higher socio-economic environments, by the nature of the data and experts’ experience, and with appropriate attention to newer pharmaceuticals, devices, and interventions, the result is that they are perceived in that manner.”
6. RESULTS.
- ↓ d_ATBs
* PCT 🆚 SOC ➩ ✔
* CRP 🆚 SOC ➩ ✖ (no difference)
- MM28
* PCT 🆚 SOC ➩ ✖ (noninferior)
7. RATIONALE.
- Suspected sepsis = a_OD ↔ suspected INF
- We did not mandate a definition for acute organ dysfunction.
⏳ TIME MANAGEMENT.
01:02:41
Round: 6 02:27:50 Comments
Round: 5 13:37:72 Comments
Round: 4 49:15:51 Evidence
Round: 3 19:40:68 Scope
Round: 2 01:46:38 ART selection
Round: 1 04:57:22 Past JC
Friday, Dec 13, 2024 at 18h30 at BO - 23h30 at BE
RICH, OQC, JCAU, HIBN, GMC, DFM, AHO, AAQC
Codified by
Glossary: 🫁 = lungs; ARDS = acute respiratory distress syndrome; SS = Survival; ii = investigator initiated; mc = multicentric; int_ = international; SOC = standard of care; ICU LOS = ICU length of stay; H+ LOS = Hospital length of stay; MV = mechanical ventilation; MM = mortality; MM28 = mortality at 28 days; MM90 = mortality at 90 days; ATB = antibiotics; d_ = duration; TTO = treatment; RES = resistance; bioM = biomarkers; SSC = surviving sepsis campaign; ENG = England; SCO = Scotland; p = primary; s = secondary; toci = tocilizumab; sari= sarilumab; RANDOM = randomization; INTERV = interventions; SX = surgery; ⛔ = stop;
1. 𝙄𝙌𝘾 BS ➩ Y, J, C ➖ T ➕ N ➕ t ➖ P I C O:
2. 𝙄𝙌𝘾 BS ➩ 2024, JAMA, ENG + SCO ➖ ii_mc_int_RCT ➕ >2.5k (41 ICUs) ➕ 2018-2024 (lockdown 2020)➖ P I C O:
- P: adults, > ♂, suspected sepsis
- I: CRP + PCT
- C: standard
- O: p ➩ duration ATB + MM28 ➖ s ➩ LOS H+ …ICU + MM90
3. EVIDENCE.
- Timely + appropriate ATB ➩↗️ OC
- Optimal d_ATB ➩ uncertain ➖ decisions guided to stop ATB by clinical progress + bioM
(CRP and PCT) [ICM 2015, Albrich et al - Pros and cons of bioM 🆚 clinical decisions…].
- Optimized d_ATB ➩ a. ↓ overTTO, b. ⛔ unwanted effects, c. Preserves ATB effectiveness
by ↓ RES.
- PCT use shows safe ↓ of ATB d_ [CC 2018, Wirz et al - PCT-guided ATB on clinical OC] ▶
clinical trial evidence judged as “low quality” [Evans et al, ICM 2021 - SSC]
- No consensus guidance for CRP [Evans et al, ICM 2021 - SSC]
4. METHODS.
- IN ➠ 24h window bioM baseline
- EX ➠ required prolonged ATB (ie,>21days) ➖ severely immunocompromised (not due to
sepsis, neutrophils <500) ➖ expected to receive IL-6 receptor ⊖ (toci, sari) d_acute phase
➖S TTOs likely to ⛔ within_24h (futility) ➖ declined consent + previousl enrolled
- RANDOM ➠ assignation (1:1:1) ➖ stratification (severity, recruitment site, rec_SX) ➖
allocation (web-based)
- INTERV ➠ Blood (random to ATB ⛔, taken daily, )➖ standardized written advice (REF 10 & 11 for cuts-offs of PCT, CRP)➖ follow-up (when blood sampling ⛔) ➖ IF ATB
reintroduced within 28d, NO need to resume/restart blood sampling ➖ IF discharged with
ATB for home, the study ⛔
Friday, Dec 06, 2024 at 18h30 at BO - 23h30 at BE
RICH, OQC, GMC, DFM, AHO, HIBN, AAQC
Codified by HIBN
Glossary: RBCT = red blood cell transfusion; HH = hemorrhage; ACS = acute coronary syndrome; wo_ = without; EX = exclusion; IN = inclusion; pxs = patients; MM90 = mortality at 90 days; ↗ = improve; ↘ = worsen; ↑ = increase; 💨 = perfusion; 𝙄𝙉𝘼𝘼𝙌𝘾 ᴮᴼ brief scope = year (Y), journal (J), country (C) ➖ type of study (T) ➕ number of patients/sample (N) ➕ time (t) ➖ population (P), intervention (I), comparison (C), outcome (O).
1. 𝙄𝙌𝘾 BS ➩ Y, J, C ➖ T ➕ N ➕ t ➖ PICO: ➩ 2024, BMJ, IT + BE ➖ ol_mc(3)_int(2)_RCT ➕ >324 (162 Per arm) ➕ X ➖ PICO:
- P: CI pxs + non-HH
- I: RBCT (Hb ≤9 + O2ER≥30%)
- C: RBCT (ESICM GL)
- O: MM + AKI
2. RBCT thresholds
- ACS <9
- 🫀 surgery OR major vascular <7.5
- Malignancy <7 (ok <9)
- Elderly (>80yo) <7 (<9)
3. Troponin I will be measured at inclusion + 24h later
4. O2ER will be validated as a physiological indicator to guide RBCT
5. IN
- Labs mentioned
- Arterial line + central venous line
6. EX
- <18yo + pregnancy
- Bleeding
- Malignancy
- Sick cell disease
- Coagulation disorders
- AKI S1 or CKD G3a (GFR <60)
7.
8. Transfusing with <O2ER was associated with ↑ mortality ➩ SOOOO, RBCT might be deleterious when the cells use O2 adequately
9. O2ER showed good performance to identify the correct timing ➩ implications in MM90. Fogagnolo (CC 2020)
10. O2ER based RCCT may ↓ inc_AKI (↗ DO2 + organ 💨)
⏳ TIME MANAGEMENT.
01:02:41
Round: 5 00:01:73 Final words
Round: 4 16:04:42 Wrap-up
Round: 3 01:27:41 ART
Round: 2 07:08:47 ART selection
Round: 1 04:18:24 Past JC
Codified by RICH
Glossary: 🪲 = infection; ADE = antibiotic de-escalation; ATB = antibiotic; ICU = intensive care unit; IPW = inverse probability weighting; MDR = multidrug resistance; MM28 = mortality at 28 days; OBS = observational; pros_ = prospective; RCT = randomized controlled trial;
1. 𝙄𝙌𝘾 BS ➩ Y, J, C ➖ T ➕ N ➕ t ➖ P I C O:
2. 𝙄𝙌𝘾 BS 🟰 2020, ICM, BE ➖ pros_OBS ➕ <1500 (152 ICU), 28 countries➕ 2y (2016 - 2018) ➖ P I C O:
- P: adults, ICU w_ATB
- I: ADE 🆚 no change 🆚 changes other than ADE
- C: NA
- O: a. how often ADE is used. b. Estimate effect on clinical cure on D7
3. EVIDENCE:
- The aim of ADE is ↓ use of broad - spectrum ATB use (a. ↓ spectrum b. Stopping) to
CONTAIN MDR
- ADE = INTERNATIONALLY RECOGNIZED as a key component of antimicrobial
stewardship
- Lack of info on MAPPING COMPLETE ATB TTO
- ADE 🟰OBS (↓ MM) 🆚 RCT (lack of convincing evidence of safety)
4. METHODS.
- ADE ➠ (1) discontinuation of ATB if empirical combination therapy or (2) replacement of an ATB with the intention to narrow the spectrum (first 3 days of therapy).
- INTERV ➠
- DEF. Empirical = UNIDENTIFED pathogen and susceptibility pattern at start of ATB.
- IN. adults ➕ ICU ➕ at least 48h (anticipated need of ICU) ➕ (community, healthcare,
H+, ICU) bacterial INF
- DEF presence. MDR on ICU admission of before D2
- DEF emergence. MDR ↔ D2 and D28.
- DEF. MDR = ESBL or carbapenemase OR Stenotrophomonas maltophilia OR methicillin-
resistant Staphylococcus aureus OR vancomycin-resistant Enterococcus sp. OR pathogen
resistant to ≥3 antimicrobial classes.
- DEF Clinical cure = as SS and resolution of all signs and symptoms related to the INF under study
6. RESULTS
- Combination ➩ 50%
- Carbapenems ➩ 26%
- Frequency of… In the first 3 days:
* ADE = 16%
* No change = 63%
* Change other than ADE = 22%
- MM28 ➩ ADE 16% 🆚 no change 19% (p=0.27)
- Clinical cure ➩ [IP-weighted relative risk estimate] ➩ ADE 🆚 no-ADE = 1.37
Friday, Dec 27, 2024 at 18h30 at BO - 23h30 at BE
MAAT, RICH, HIBN, GMC, AHO, AAQC
⏳ TIME MANAGEMENT.
59:04:93
Round: 3 00:34:58 Comments
Round: 2 54:56:36 JC
Round: 1 03:33:98 Past JC
Codified by RICH
Glossary: 💚= infection; IPW = inverse probability weighting; MM28 = mortality at 28 days; OBS = observational; pros_ = prospective; RCT = randomized controlled trial; ADE = antibiotic de-escalation; ICU = intensive care unit;
1. 𝙄𝙌𝘾 BS ➩ Y, J, C ➖ T ➕ N ➕ t ➖ P I C O:
2. 𝙄𝙌𝘾 BS 🟰 2020, ICM, BE ➖ pros_OBS ➕ <1500 ➕ 2y (2016 - 2018) ➖ P I C O:
- P: adults, ICU w_ATB
- I: ADE 🆚 no change 🆚 changes other than ADE
- C: NA
- O: a. how often ADE is used. b. Estimate effect on clinical cure on D7
3. EVIDENCE: …waiting for JCAU and AHO…
4. METHODS.
- ADE ➠ (1) discontinuation of ATB if empirical combination therapy or (2) replacement of an
ATB with the intention to narrow the spectrum (first 3 days of therapy).
- INTERV ➠ to continue...
6. RESULTS
7. RATIONALE
8. LIMITATIONS
Friday, Dec 20, 2024 at 18h30 at BO - 23h30 at BE
MAAT, RICH, JCAU, HIBN, GMC, DFM, AHO, AAQC
⏳ TIME MANAGEMENT.
01:13:17
Round: 3 11:42:67 Comments
Round: 2 50:57:40 ART + wrap-up
Round: 1 10:36:93 Past JC
