Adherence to Established Blood Pressure Targets and Associated Complications in Patients Presenting with Acute Intracerebral Hemorrhage.

BACKGROUND: Conflicting evidence exists surrounding systolic blood pressure (SBP) control in patients with acute intracerebral hemorrhage (ICH). The 2022 American Heart Association and American Stroke Association guidelines recommend targeting a SBP of 140 mm Hg while maintaining the range of 130-150 mm Hg. The current practice at our health system is to titrate antihypertensives to a SBP goal of < 160 mm Hg, which aligns with previous recommendations. We hypothesized that the prior lack of guidance to a specific SBP target range predisposed patients to hypotension leading to an increased risk of brain and renal adverse events. METHODS: This retrospective, multicenter, single health system cohort study included adults admitted to the neurointensive care unit or intermediate unit with acute ICH from June 2019 to June 2021. The primary objective evaluated the frequency of time within SBP range (140-160 mm Hg) in the first 48 h. Secondary and safety end points included the frequency of time above and below the established SBP range, episodes of hypotension (defined as a decrease in SBP < 140 mm Hg prompting discontinuation in antihypertensive[s] or the initiation of vasopressor[s]), the incidence of new brain or renal adverse events within 7 days, and modified Rankin Scale at discharge. RESULTS: A total of 80 patients (59% men; median age 62 years) were included. The majority of ICHs in this cohort were intraparenchymal (70%). Nearly one third were attributed to systemic hypertension (31%). During the first 48 h of admission, the frequency of time spent above, within, and below the target SBP range were 6 h (12%), 16 h (34%), and 26 h (54%), respectively. Hypotension was associated with renal adverse events (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.10-11.44, p = 0.023). A relative SBP reduction > 20% in the first 48 h was associated with renal adverse events (OR 8.99, 95% CI 2.57-35.25, p < 0.001), brain ischemia (OR 22.5, 95% CI 1.92-300.11, p = 0.005), and an increased odd of a modified Rankin Scale of 4-6 at discharge (OR 11.79, 95% CI 2.79-57.02, p < 0.001). CONCLUSIONS: In individuals with nontraumatic/nonaneurysmal ICH, SBP measurements were observed to be < 140 mm Hg for > 50% of the initial 48 h following admission. Hypotension and relative SBP reduction > 20% were also independent predictors of renal adverse events. SBP reduction > 20% was also an independent predictor of brain ischemia. These data indicate that intensive SBP reduction following ICH predispose patients to secondary organ injury that may impact long-term outcomes. Our data suggest that a more modest lowering of the SBP within 48 h, as recommended in the most recent guidelines, may minimize the risk of further adverse events.

Sampling bias and the robustness of ecological metrics for plant-damage-type association networks.

Plants and their insect herbivores have been a dominant component of the terrestrial ecological landscape for the past 410 million years and feature intricate evolutionary patterns and co-dependencies. A complex systems perspective allows for both detailed resolution of these evolutionary relationships as well as comparison and synthesis across systems. Using proxy data of insect herbivore damage (denoted by the damage type or DT) preserved on fossil leaves, functional bipartite network representations provide insights into how plant-insect associations depend on geological time, paleogeographical space, and environmental variables such as temperature and precipitation. However, the metrics measured from such networks are prone to sampling bias. Such sensitivity is of special concern for plant-DT association networks in paleontological settings where sampling effort is often severely limited. Here, we explore the sensitivity of functional bipartite network metrics to sampling intensity and identify sampling thresholds above which metrics appear robust to sampling effort. Across a broad range of sampling efforts, we find network metrics to be less affected by sampling bias and/or sample size than richness metrics, which are routinely used in studies of fossil plant-DT interactions. These results provide reassurance that cross-comparisons of plant-DT networks offer insights into network structure and function and support their widespread use in paleoecology. Moreover, these findings suggest novel opportunities for using plant-DT networks in neontological terrestrial ecology to understand functional aspects of insect herbivory across geological time, environmental perturbations, and geographic space.

Real-World Reversal of Factor Xa Inhibition in the Setting of Major Life-Threatening Bleeding or Urgent Surgery.

Background: Management of major life-threatening bleeding with factor Xa (FXa) inhibition poses complex challenges involving novel direct reversal agents competing with non-specific preexisting strategies. The recent availability of andexanet alfa (AA) led to a health-system guideline incorporating its use alongside the most commonly used historic agent, four-factor prothrombin complex concentrate (4F-PCC). Objectives: The objective was to characterize the use and efficacy of AA and 4F-PCC for reversal of FXa inhibition after implementation of the health-system guideline. Methods: This multi-hospital, retrospective cohort study included patients aged >18 years administered either AA or 4F-PCC between October 2018 to June 2020 with the indication for urgent reversal of FXa inhibitor-induced coagulopathy. The primary outcome assessed hemostatic efficacy between treatment groups. Secondary outcomes evaluated adjunct blood product administration, incidence of repeat pharmacologic reversal, incidence of thromboembolism, intensive care unit and hospital length of stays, and in-hospital mortality. Results: Eighty-five patients were included; 33 patients received AA and 52 patients received 4F-PCC. Effective hemostasis was achieved at similar rates in both treatment groups (84.8% vs 76.9%; P = .373). Thrombotic events occurring during the observed hospitalization were more frequent among the AA treated group (18% vs 3.8%, P = .027). No differences were observed for other secondary outcomes. Conclusion: Guideline use resulted in similar rates of effective hemostasis with a higher incidence of VTE in patients receiving AA. Further exploration with a larger, prospective study to evaluate these findings is warranted.

The pharmacist's role in implementation of the ABCDEF bundle into clinical practice.

PURPOSE: To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. SUMMARY: Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. CONCLUSIONS: Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.

Plant and insect herbivore community variation across the Paleocene-Eocene boundary in the Hanna Basin, southeastern Wyoming.

Ecosystem function and stability are highly affected by internal and external stressors. Utilizing paleobotanical data gives insight into the evolutionary processes an ecosystem undergoes across long periods of time, allowing for a more complete understanding of how plant and insect herbivore communities are affected by ecosystem imbalance. To study how plant and insect herbivore communities change during times of disturbance, we quantified community turnover across the Paleocene--Eocene boundary in the Hanna Basin, southeastern Wyoming. This particular location is unlike other nearby Laramide basins because it has an abundance of late Paleocene and Eocene coal and carbonaceous shales and paucity of well-developed paleosols, suggesting perpetually high water availability. We sampled approximately 800 semi-intact dicot leaves from five stratigraphic levels, one of which occurs late in the Paleocene-Eocene thermal maximum (PETM). Field collections were supplemented with specimens at the Denver Museum of Nature & Science. Fossil leaves were classified into morphospecies and herbivore damage was documented for each leaf. We tested for changes in plant and insect herbivore damage diversity using rarefaction and community composition using non-metric multidimensional scaling ordinations. We also documented changes in depositional environment at each stratigraphic level to better contextualize the environment of the basin. Plant diversity was highest during the mid-late Paleocene and decreased into the Eocene, whereas damage diversity was highest at the sites with low plant diversity. Plant communities significantly changed during the late PETM and do not return to pre-PETM composition. Insect herbivore communities also changed during the PETM, but, unlike plant communities, rebound to their pre-PETM structure. These results suggest that insect herbivore communities responded more strongly to plant community composition than to the diversity of species present.

Factors influencing US medical students' decision to pursue surgery.

BACKGROUND: Interest and applications to surgery have steadily decreased over recent years in the United States. The goal of this review is to collect the current literature regarding US medical students' experience in surgery and factors influencing their intention to pursue surgery as a career. We hypothesize that multiple factors influence US medical students' career choice in surgery. METHODS: Six electronic databases (PubMed, SCOPUS, Web of Science, Education Resources Information Center, Embase, and PsycINFO) were searched. The inclusion criteria were studies published after the new century related to factors influencing surgical career choice among US medical students. Factors influencing US medical student surgical career decision-making were recorded. A quality index score was given to each article selected to minimize risk of bias. RESULTS: We identified 38 relevant articles of more than 1000 nonduplicated titles. The factors influencing medical student decision for a surgical career were categorized into five domains: mentorship and role model (n = 12), experience (clerkship n = 9, stereotype n = 4), timing of exposure (n = 9), personal (lifestyle n = 8, gender n = 6, finance n = 3), and others (n = 2). CONCLUSIONS: This comprehensive systemic review identifies mentorship, experience in surgery, stereotypes, timing of exposure, and personal factors to be major determinants in medical students' decisions to pursue surgery. These represent areas that can be improved to attract applicants to general surgery residencies. Surgical faculty and residents can have a positive influence on medical students' decisions to pursue surgery as a career. Early introduction to the field of surgery, as well as recruitment strategies during the preclinical and clinical years of medical school can increase students' interest in a surgical career.