Forecasting water demand across a rapidly urbanizing region.

Urban growth and climate change together complicate planning efforts meant to adapt to increasingly scarce water supplies. Several studies have independently examined the impacts of urban planning and climate change on water demand, but little attention has been given to their combined impact. Here we forecast urban water demand using a Geographically Weighted Regression model informed by socio-economic, environmental and landscape pattern metrics. The purpose of our study is to evaluate how future scenarios of population densities and climate warming will jointly affect water demand across two rapidly growing U.S. states (North Carolina and South Carolina). Our forecasts indicate that regional water demand by 2065 will increase by 37%-383% relative to the baseline in 2010, across all scenarios of change. Our results show future water demand will increase under rising temperatures, but could be ameliorated by policies that promote higher density development and urban infill. These water-efficient land use policies show a 5% regional reduction in water demand and up to 25% reduction locally for counties with the highest expected population growth by 2065. For rural counties experiencing depopulation, the land use policies we considered are insufficient to significantly reduce water demand. For expanding communities seeking to increase their adaptive capacity to changing socio-environmental conditions, our framework can assist in developing sustainable solutions.

Investigation of an Opioid Prescribing Protocol After Third Molar Extraction Procedures.

PURPOSE: The United States is experiencing an epidemic of opioid overdoses and deaths. The relation between prescription opioids and opioid abuse is well documented. Oral and maxillofacial surgeons and other dentists are proportionately among the most prevalent prescribers of opioids. Practitioners are looking for evidence-based ways to decrease excess opioid prescriptions and adequately manage postoperative pain. The authors recently analyzed the impact of a mandated nonopioid prescribing protocol at their institution. Although broad guidelines have been useful for treating postoperative pain, there are no procedure-specific guidelines for managing pain after third molar extraction. The purpose of this study was to determine whether an opioid prescribing protocol was sufficient to decrease opioid prescribing after third molar extractions. MATERIALS AND METHODS: This retrospective study compared the use of opioids prescribed for patients undergoing third molar extraction before introducing and after implementing a postoperative opioid prescribing protocol. The inclusion criterion was third molar extraction performed at the Division of Oral and Maxillofacial Surgery at the University of Minnesota (Minneapolis, MN) during the fourth quarters of 2015 and 2017 with complete records. RESULTS: The number of opioid prescriptions decreased and the number of nonopioid analgesics prescribed increased for all procedure codes after implementation of the protocol. Higher Current Dental Terminology (CDT) codes were associated with increased opioid prescriptions, indicating increased surgical difficulty was a rationale for opioid prescriptions. The mean number of opioid tablets per prescription was 15.9 in 2015 and decreased to 11.5 in 2017. No statistical difference was observed for average tablets for various CDT codes. CONCLUSION: Data from this study suggest an acute postoperative pain opioid prescribing protocol leads to fewer opioid prescriptions after third molar extraction procedures, less variance in opioid prescribing among practitioners, a decreased number of opioid tablets prescribed per patient, and safe and effective management of acute postoperative pain.

Pioglitazone, a PPARγ agonist, reduces cisplatin-evoked neuropathic pain by protecting against oxidative stress.

Painful peripheral neuropathy is a dose-limiting side effect of cisplatin treatment. Using a murine model of cisplatin-induced hyperalgesia, we determined whether a PPARγ synthetic agonist, pioglitazone, attenuated the development of neuropathic pain and identified underlying mechanisms. Cisplatin produced mechanical and cold hyperalgesia and decreased electrical thresholds of Aδ and C fibers, which were attenuated by coadministration of pioglitazone (10 mg/kg, intraperitoneally [i.p.]) with cisplatin. Antihyperalgesic effects of pioglitazone were blocked by the PPARγ antagonist T0070907 (10 mg/kg, i.p.). We hypothesized that the ability of pioglitazone to reduce the accumulation of reactive oxygen species (ROS) in dorsal root ganglion (DRG) neurons contributed to its antihyperalgesic activity. Effects of cisplatin and pioglitazone on somatosensory neurons were studied on dissociated mouse DRG neurons after 24 hours in vitro. Incubation of DRG neurons with cisplatin (13 µM) for 24 hours increased the occurrence of depolarization-evoked calcium transients, and these were normalized by coincubation with pioglitazone (10 µM). Oxidative stress in DRG neurons was considered a significant contributor to cisplatin-evoked hyperalgesia because a ROS scavenger attenuated hyperalgesia and normalized the evoked calcium responses when cotreated with cisplatin. Pioglitazone increased the expression and activity of ROS-reducing enzymes in DRG and normalized cisplatin-evoked changes in oxidative stress and labeling of mitochondria with the dye MitoTracker Deep Red, indicating that the antihyperalgesic effects of pioglitazone were attributed to its antioxidant properties in DRG neurons. These data demonstrate clear benefits of broadening the use of the antidiabetic drug pioglitazone, or other PPARγ agonists, to minimize the development of cisplatin-induced painful neuropathy.

Addressing the Opioid Epidemic: Impact of Opioid Prescribing Protocol at the University of Minnesota School of Dentistry.

Prescription opioid medications continue to be abused on an epidemic level and have been shown to be a "gateway" drug to heroin abuse. Individuals experimenting with opioids commonly fall in the 10- to 19-year age range in which dentists are the highest prescribers. To reduce the number of excess opioids, the Department of Oral and Maxillofacial Surgery, University of Minnesota, developed and implemented an evidence-based opioid prescribing policy. Data were collected via electronic health record for the previous year and compared with the year following the protocol implementation. The results showed a drastic decrease (>46%) in the number of prescriptions given over a 1-year period. All departments reported a decrease in opioid prescriptions and the average number of tablets per prescription. The concern of undertreating pain was not found to be significant, as there was no increase in after-hours calls, recall appointments, or documentable emergency room visits. The results support the efficacy of an opioid prescribing policy's ability to lower the frequency and number of opioids given to patients, while still adequately treating patients' pain. Continued evaluation and modifications of the protocol and close monitoring of prescriber habits will enhance patients' pain control while also limiting the number of opioids available for abuse.

Critical Care Basic Ultrasound Learning Goals for American Anesthesiology Critical Care Trainees: Recommendations from an Expert Group.

OBJECTIVE: In this review, we define learning goals and recommend competencies concerning focused basic critical care ultrasound (CCUS) for critical care specialists in training. DESIGN: The narrative review is, and the recommendations contained herein are, sponsored by the Society of Critical Care Anesthesiologists. Our recommendations are based on a structured literature review by an expert panel of anesthesiology intensivists and cardiologists with formal training in ultrasound. Published descriptions of learning and training routines from anesthesia-critical care and other specialties were identified and considered. Sections were written by groups with special expertise, with dissent included in the text. RESULTS: Learning goals and objectives were identified for achieving competence in the use of CCUS at a specialist level (critical care fellowship training) for diagnosis and monitoring of vital organ dysfunction in the critical care environment. The ultrasound examination was divided into vascular, abdominal, thoracic, and cardiac components. For each component, learning goals and specific skills were presented. Suggestions for teaching and training methods were described. DISCUSSION: Immediate bedside availability of ultrasound resources can dramatically improve the ability of critical care physicians to care for critically ill patients. Anesthesia--critical care medicine training should have definitive expectations and performance standards for basic CCUS interpretation by anesthesiology--critical care specialists. The learning goals in this review reflect current trends in the multispecialty critical care environment where ultrasound-based diagnostic strategies are already frequently applied. These competencies should be formally taught as part of an established anesthesiology-critical care medicine graduate medical education programs.

Minimally invasive thoracic left ventricular assist device implantation; case series demonstrating an integrated multidisciplinary strategy.

OBJECTIVES: The present report describes the authors' initial experience with implantation of the Heartware left ventricular assist devices (HeartWare Inc., Framingham, MA). via a minimally invasive surgical approach without cardiopulmonary bypass. A detailed overview of the anesthesiologist's role during the procedure, characteristics of the patient population, and short-term clinical outcomes are provided, and the clinical considerations that influence the decision to implant this device via an off-pump minimally invasive approach are outlined. DESIGN: Retrospective medical record review. SETTING: University hospital. PARTICIPANTS: Thirteen patients with advanced heart failure deemed candidates for off-pump minimally invasive left ventricular Heartware implantation as a bridge to heart transplantation. INTERVENTIONS: The Heartware left ventricular assist device was implanted in all 13 patients via a minimally invasive approach. MEASUREMENTS AND MAIN RESULTS: One patient required unplanned cardiopulmonary bypass to control bleeding around the left ventricular outflow cannula. The average operating room time was 249.8 minutes±46.2 minutes. Six of 13 patients required no intraoperative red blood cell transfusions. Seven patients were extubated within 12 hours after surgery. Two patients required reintubation within 48 hours. No patients required reoperation for bleeding. Average intensive care unit and hospital lengths of stay were 7.2±3.9 days and 13.4±3.6 days, respectively. There were no in-hospital deaths. CONCLUSIONS: Minimally invasive off-pump left ventricular Heartware implantation is an emerging alternative to placement by midline sternotomy. The authors speculate, based on their limited experience, that an off-pump thoracic strategy may be a desirable option for some patients and that clinical outcomes may be non-inferior to placement by midline sternotomy with cardiopulmonary bypass.

Hemodynamic transesophageal echocardiography after left ventricular assist device implantation.

OBJECTIVE: The authors hypothesized that the clinical profile of patients undergoing hTEE after continuous flow left ventricular assist device (CF-LVAD) implant would be in patients with greater acuity, more blood product utilization, and longer length of ICU stay, and that hTEE would change clinical management. DESIGN: Retrospective review. SETTING: University hospital. PARTICIPANTS: One hundred consecutive patients receiving a CF-LVAD. INTERVENTIONS: Retrospective review using a standardized electronic form of a miniaturized disposable transesophageal echocardiography probe that documented not only physical findings but also changes in hemodynamic management (hTEE) in CF-LVAD patients. MEASUREMENTS AND MAIN RESULTS: Of the 100 patients, 41 received an hTEE probe. The INTERMACS score, Leitz-Miller Score, and Kormos score indicated the hTEE group had a statistically significant greater risk of morbidity and mortality. Interoperatively, the hTEE group received more blood products and was more likely to have an open chest. Postoperatively, the hTEE group received more blood products, had a longer total length of stay, and had increased mortality. ICU length of stay, days on inotropes and days on mechanical ventilation were not statistically significant between the 2 groups. Information obtained from hTEE changed ICU management in 72% of studies. CONCLUSION: Retrospective review of CF-LVAD patients revealed that postoperative hTEE is used in sicker CF-LVAD patients and frequently leads to changes in ICU clinical management.

Implementing goal-directed protocols reduces length of stay after cardiac surgery.

OBJECTIVE: To test the effect of a high reliability organization (HRO) intervention on patient lengths of stay in the CVICU and hospital. The authors proposed that (1) higher safety related evidence based protocol (SREBP) team compliance scores and (2) lower SREBP milestone scores are associated with shorter lengths of CVICU and hospital stay. DESIGN: A prospective, longitudinal observational evaluation was used to assess the effects of SREBP-focused rounding processes and a milestone-tracking tool. SETTING: United States, university academic medical center's 27-bed CVICU. PARTICIPANTS: Six hundred sixty-five adult cardiac surgery patients and the CVICU care team (100 registered nurses and 16 clinical providers) participated. MEASUREMENTS AND MAIN RESULTS: Team compliance was the proportion of SREBP-related team behaviors exhibited during daily rounds. Patients' milestone scores were the cumulative difference between actual and expected times for 4 SREBP milestones over 48 hours. Milestones achieved earlier than expected indicated reduced complication risk, and milestones achieved later than expected indicated increased risk. As team compliance increased, CVICU length of stay decreased 0.66 (95% CI: -0.04 to 1.28; p = 0.08) days; hospital stay decreased 0.89 times (95% CI: 0.77-1.03; p = 0.008). As the mean milestone scores increased from -7 to 12, length of ICU stay increased 2.63 (95% CI: 1.66-3.59; p<0.001) days; hospital length of stay increased 1.44 times (95% CI: 1.23-1.7; p = 0.05). CONCLUSIONS: A milestone-driven pathway supported by team rounding was associated with decreased lengths of CVICU and hospital stay. However, tracking patient trajectories by milestones suggests a more complex relationship than anticipated and presents new opportunities for SREBP implementation and research.

Etomidate use and postoperative outcomes among cardiac surgery patients.

BACKGROUND: Although a single dose of etomidate can cause relative adrenal insufficiency, the impact of etomidate exposure on postoperative outcomes is unknown. The objective of this study was to examine the association between a single induction dose of etomidate and clinically important postoperative outcomes after cardiac surgery. METHODS: The authors retrospectively examined the association between etomidate exposure during induction of anesthesia and postoperative outcomes in patients undergoing cardiac surgery from January 2007 to December 2009 by using multivariate logistic regression analyses and Cox proportional hazards regression analyses. Postoperative outcomes of interest were severe hypotension, mechanical ventilation hours, hospital length of stay, and in-hospital mortality. RESULTS: Sixty-two percent of 3,127 patients received etomidate. Etomidate recipients had a higher incidence of preoperative congestive heart failure (23.0 vs. 18.3%; P = 0.002) and a lower incidence of preoperative cardiogenic shock (1.3 vs. 4.0%; P < 0.001). The adjusted odds ratio for severe hypotension and in-hospital mortality associated with receiving etomidate was 0.80 (95% CI, 0.58-1.09) and 0.75 (95% CI, 0.45-1.24), respectively, and the adjusted hazard ratio for time to mechanical ventilation removal and time to hospital discharge was 1.10 (95% CI, 1.00-1.21) and 1.07 (95% CI, 0.97-1.18), respectively. Propensity score analysis did not change the association between etomidate use and postoperative outcomes. CONCLUSIONS: In this study, there was no evidence to suggest that etomidate exposure was associated with severe hypotension, longer mechanical ventilation hours, longer length of hospital stay, or in-hospital mortality. Etomidate should remain an option for induction of anesthesia in cardiac surgery patients.

Early bispectral index and sedation requirements during therapeutic hypothermia predict neurologic recovery following cardiac arrest.

OBJECTIVES: To test the hypothesis that low bispectral index scores and low sedative requirements during therapeutic hypothermia predict poor neurologic outcome. DESIGN: Observational study of a prospectively collected cohort. SETTING: Cardiovascular ICU. PATIENTS: One hundred sixty consecutive cardiac arrest patients treated with therapeutic hypothermia. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Eighty-four of the 141 subjects (60%) who survived hypothermia induction were discharged from the ICU with poor neurologic outcome, defined as a cerebral performance category score of 3, 4, or 5. These subjects had lower bispectral index (p < 0.001) and sedative requirements (p < 0.001) during hypothermia compared with the 57 subjects discharged with good outcome. Early prediction of neurologic recovery was best 7 hours after ICU admission, and median bispectral index scores at that time were 31 points lower in subjects discharged with poor outcome (11 [interquartile range, 4-29] vs 42 [37-49], p < 0.001). Median sedation requirements decreased by 17% (interquartile range, -50 to 0%) 7 hours after ICU admission in subjects with poor outcome but increased by 50% (interquartile range, 0-142%) in subjects with good outcome (p < 0.001). Each 10-point decrease in bispectral index was independently associated with a 59% increase in the odds of poor outcome (95% CI, 32-76%; p < 0.001). The model including bispectral index and sedative requirement correctly reclassified 15% of subjects from good to poor outcome and 1% of subjects from poor to good outcome. The model incorrectly reclassified 1% of subjects from poor to good outcome but did not incorrectly reclassify any from good to poor outcome. CONCLUSIONS: Bispectral index scores and sedative requirements early in the course of therapeutic hypothermia improve the identification of patients who will not recover from brain anoxia. The ability to accurately predict nonrecovery after cardiac arrest could facilitate discussions with families, reduce patient suffering, and limit use of ICU resources in futile cases.

ACNP intensivist: a new ICU care delivery model and its supporting educational programs.

The purposes of this article are to describe a physician (MD)/acute care nurse practitioner (ACNP) intensivist model for delivery of critical care services in a tertiary academic medical center and to describe an innovative nurse practitioner educational program developed to support the model. In an effort to address the current shortage of intensivists, Vanderbilt Medical Center has developed and refined a multidisciplinary intensivist MD/ACNP teams to provide expanded critical care services. The ACNPs, in collaboration with intensivist MDs, function as intensivist teams and are responsible for developing and executing the daily medical plan, bedside procedures, and emergency response. These teams provide 24-h a day coverage of tertiary level ICUs, and provide several unique benefits over traditional resident ICU staffing models. As the concept of the MD/ACNP intensivist team has developed, Vanderbilt University School of Nursing ACNP Program has expanded its curriculum to provide graduates with the knowledge, skills, and experiences to safely manage unstable critically ill patients. Multidisciplinary critical care teams of MD intensivists who work in collaboration with ACNP intensivists address the current shortfall of intensivists and represent a cost-effective means for expanding ICU coverage and increasing ICU bed availability while maintaining Leap Frog ICU staffing compliance.

Comparison of expert and novice performance of a simulated transesophageal echocardiography examination.

INTRODUCTION: Training in transesophageal echocardiography (TEE) requires a significant commitment of time and resources on behalf of the trainees and the instructors. Training opportunities may be limited in the busy clinical environment. Medical simulation has emerged as a complementary means by which to develop clinical skills. Transesophageal echocardiography simulators have been commercially available for several years, yet their ability to distinguish experts from novices has not been demonstrated. We used a standardized assessment tool to distinguish experts from novices using a commercially available TEE simulator. METHODS: Anesthesiologists certified in advanced perioperative TEE and anesthesiology resident physicians were recruited into the expert and novice cohorts, respectively. The cohorts were recruited from 2 academic medical centers. The novice cohort received a structured introduction to the basic TEE examination. Both cohorts then proceeded to perform a basic TEE examination involving normal cardiac anatomy, which was evaluated by blinded raters using a standardized assessment tool. RESULTS: The expert cohort consistently demonstrated the ability to obtain standard TEE imaging views in less time and more accurately than the novice cohort during the course of a simulated TEE examination. CONCLUSIONS: A simulated transesophageal examination of normal cardiac anatomy in concert with a standardized assessment tool permits ample discrimination between expert and novice echocardiographers as defined for this investigation. Future research will examine in detail the role echocardiography simulators should play during echocardiography training including assessment of training level.

Episodic monoplane transesophageal echocardiography impacts postoperative management of the cardiac surgery patient.

OBJECTIVE: A new slender, flexible, and miniaturized disposable monoplane transesophageal TEE probe has been approved for episodic hemodynamic transesophageal echocardiographic monitoring. The authors hypothesized that episodic monoplane TEE with a limited examination would help guide the postoperative management of high-risk cardiac surgery patients. DESIGN: The authors analyzed the initial consecutive observational experience with the miniaturized transesophageal echocardiography monitoring system (ClariTEE, ImaCor, Uniondale, New York). SETTING: Single institution in a university setting. PARTICIPANTS: Unstable cardiac surgery patients. INTERVENTIONS: The authors assessed fluid responsiveness, echocardiographic data, and concordance among hemodynamic data. MEASUREMENTS AND MAIN RESULTS: From June 2010 to February 2011, 21 unstable cardiac surgery patients with postoperative instability were identified. Two patients (10%) required reoperation for bleeding and tamponade physiology. Right ventricular dysfunction was diagnosed by episodic TEE monitoring in 7 patients (33%), while hypovolemia was documented in 12 patients (57%). Volume responsiveness was documented in 11 patients. In this observational study, discordance between hemodynamic monitoring and episodic TEE was qualitatively observed in 14 patients (66%). CONCLUSION: The authors demonstrated the ability of episodic monoplane TEE to identify discordance between hemodynamic monitoring to better define clinical scenarios in unstable cardiac surgery patients. For these challenging patients, limited episodic TEE assessment has become a cornerstone of ICU care in this institution.

Delirium in the cardiovascular ICU: exploring modifiable risk factors.

OBJECTIVE: Delirium, an acute organ dysfunction, is common among critically ill patients leading to significant morbidity and mortality; its epidemiology in a mixed cardiology and cardiac surgery ICU is not well established. We sought to determine the prevalence and risk factors for delirium among cardiac surgery ICU patients. DESIGN: Prospective observational study. SETTING: Twenty-seven-bed medical-surgical cardiac surgery ICU. PATIENTS: Two hundred consecutive patients with an expected cardiac surgery ICU length of stay >24 hrs. INTERVENTIONS: None. MEASUREMENTS: Baseline demographic data and daily assessments for delirium using the validated and reliable Confusion Assessment Method for the ICU were recorded, and quantitative tracking of delirium risk factors were conducted. Separate analyses studied the role of admission risk factors for occurrence of delirium during the cardiac surgery ICU stay and identified daily occurring risk factors for the development of delirium on a subsequent cardiac surgery ICU day. MAIN RESULTS: Prevalence of delirium was 26%, similar among cardiology and cardiac surgical patients. Nearly all (92%) exhibited the hypoactive subtype of delirium. Benzodiazepine use at admission was independently predictive of a three-fold increased risk of delirium (odds ratio 3.1 [1, 9.4], p = 0.04) during the cardiac surgery ICU stay. Of the daily occurring risk factors, patients who received benzodiazepines (2.6 [1.2, 5.7], p = 0.02) or had restraints or devices that precluded mobilization (2.9 [1.3, 6.5], p < 0.01) were more likely to have delirium the following day. Hemodynamic status was not associated with delirium. CONCLUSIONS: Delirium occurred in one in four patients in the cardiac surgery ICU and was predominately hypoactive in subtype. Chemical restraints via use of benzodiazepines or the use of physical restraints/restraining devices predisposed patients to a greater risk of delirium, pointing to areas of quality improvement that would be new to the vast majority of cardiac surgery ICUs.

Implementation of a standardized pathway for the treatment of cardiac arrest patients using therapeutic hypothermia: "CODE ICE".

Out-of-hospital cardiac arrest is common and is associated with high mortality. The majority of in-hospital deaths from resuscitated victims of cardiac arrest are due to neurologic injury. Therapeutic hypothermia (TH) is now recommended for the management of comatose survivors of cardiac arrest. The rapid triage and standardized treatment of cardiac arrest patients can be challenging, and implementation of a TH program requires a multidisciplinary team approach. In 2010, we revised our institution's TH protocol, creating a "CODE ICE" pathway to improve the timely and coordinated care of cardiac arrest patients. As part of CODE ICE, we implemented comprehensive care pathways including measures such as a burst paging system and computerized physician support tools. "STEMI on ICE" integrates TH with our regional ST-elevation myocardial infarction network. Retrospective data were collected on 150 consecutive comatose cardiac arrest victims treated with TH (n = 82 pre-CODE ICE and n = 68 post-CODE ICE) from 2007 to 2011. After implementation of CODE ICE, the mean time to initiation of TH decreased from 306 ± 165 minutes to 196 ± 144 minutes (P < 0.001), and the time to target temperature decreased from 532 ± 214 minutes to 392 ± 215 minutes (P < 0.001). There was no significant change in survival or neurologic outcome at hospital discharge. Through the implementation of CODE ICE, we were able to reduce the time to initiation of TH and time to reach target temperature. Additional studies are needed to determine the effect of CODE ICE and similar pathways on clinical outcomes after cardiac arrest.