Perceptions of shared decision making in gastroenterology and inflammatory bowel disease: A qualitative analysis.

OBJECTIVE: Shared decision-making (SDM) is the partnership and discussion between clinicians and patients to make an appropriate decision based on scientific evidence and patient preferences. Many benefits are associated with SDM; however, little is known about its awareness or use by inflammatory bowel disease (IBD) clinicians in gastroenterology departments across Israel. This study aims to identify barriers and facilitators in implementing SDM as standard practice to achieve optimal disease management and personalized care for patients with IBD. METHODS: Sixteen semi-structured interviews were conducted with IBD clinicians across Israel to identify the barriers and facilitators for SDM use. An interview guide was developed, based on the systematic approach of the Theoretical Domain Framework (TDF). Interview transcripts were coded into theoretical domains to identify factors that may impact SDM. RESULTS: Sixteen gastroenterologists from nine different hospitals were interviewed. Common TDF domains that presented as barriers were: knowledge, skills, social/professional role and identity, environmental context and resources, and reinforcement. Most participants had never heard the precise term "shared decision making" and lacked formal training on SDM. CONCLUSION: This study identified key barriers and facilitators to SDM in IBD clinics across Israel. Main barriers of SDM include limited or nonexistent training; clinicians were unaware of SDM guidelines or techniques. The main facilitators of SDM were clinicians' social and professional role and identity and their beliefs about the influence of IBD and/or CD. PRACTICE IMPLICATIONS: These influencing factors and TDF domains identified provide a basis for developing future interventions to improve the implementation of SDM within IBD management.

Plasma 25-Hydroxyvitamin D Levels at Initiation of Care and Duration of Mechanical Ventilation in Critically Ill Surgical Patients.

OBJECTIVE: Limited data exist regarding the relationship between plasma 25-hydroxyvitamin D levels and duration of respiratory support. Our goal was to explore whether vitamin D status at the time of intensive care unit (ICU) admission is associated with duration of mechanical ventilation in critically ill surgical patients. MATERIALS AND METHODS: We analyzed data from a prospective cohort study involving 210 critically ill surgical patients. To explore the relationship between admission plasma 25-hydroxyvitamin D levels and duration of mechanical ventilation, we performed a Poisson regression while controlling for clinically relevant covariates. Only patients who required ≥48 hours of mechanical ventilation and survived ≥24 hours after discontinuation of respiratory support were included in the analytic cohort. RESULTS: Ninety-four patients met inclusion criteria. Mean (standard deviation) plasma 25-hydroxyvitamin D level was 16 (7) ng/mL and median (interquartile range) duration of mechanical ventilation was 4 (2-7) days. Poisson regression analysis, adjusted for age, sex, race, body mass index, primary surgical service, Acute Physiology and Chronic Health Evaluation II score, and season of ICU admission, demonstrated an inverse association of plasma 25-hydroxyvitamin D levels with duration of mechanical ventilation (incident rate ratio per 10 ng/mL, 0.66; 95% confidence interval, 0.54-0.82). CONCLUSIONS: In our cohort of critically ill surgical patients, plasma 25-hydroxyvitamin D levels measured on ICU admission were inversely associated with the duration of respiratory support. Randomized controlled trials are needed to assess whether vitamin D supplementation can influence duration of mechanical ventilation in surgical ICU patients.

The Association of Vitamin D Status and Pre-operative Physical Activity in Patients with Hip or Knee Osteoarthritis.

BACKGROUND: Vitamin D is important for musculoskeletal health and may have significant implications for maintaining physical activity in elderly patients. Our goal was to investigate whether serum 25-hydroxyvitamin D (25OHD) levels are associated with pre-operative physical activity in patients who are offered elective knee or hip joint replacement surgery. METHODS: We performed a single-center, retrospective analysis of patients who had elective knee or hip replacement surgery from 2002 to 2012. To investigate the association of serum 25OHD levels with pre-operative physical activity, as assessed by the University of California, Los Angeles (UCLA) activity scale, we performed a multivariable logistic regression analysis while controlling for age, sex, race, body mass index, American Society of Anesthesiologists physical status score, and season. RESULTS: We identified 182 patients who met inclusion criteria. Mean (± standard deviation) 25OHD level and UCLA activity scale score were 29±13 ng/mL and 4±2, respectively. Patients with 25OHD levels <20 ng/mL were almost three times more likely to have UCLA activity scale scores ≤3 [adjusted odds ratio 2.78; 95% confidence interval 1.72-9.17]. Further adjusting for "type of 25OHD assay" or "type of joint surgery" did not materially change this result. CONCLUSION: In our cohort of knee or hip joint replacement surgery patients, 25OHD levels were associated with pre-operative physical activity scores. Prospective, randomized, clinical trials are needed to verify whether optimizing pre-operative vitamin D status may improve physical activity and influence clinical decision-making in knee or hip joint replacement surgery candidates.

Prospective study of vitamin D status at initiation of care in critically ill surgical patients and risk of 90-day mortality.

OBJECTIVES: 1) To characterize vitamin D status at initiation of critical care in surgical ICU patients and 2) to determine whether this vitamin D status is associated with the risk of prolonged hospital length of stay, 90-day readmission, and 90-day mortality. DESIGN: Prospective cohort study. SETTING: A teaching hospital in Boston, MA. PATIENTS: Hundred surgical ICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mean (± SD) serum total 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels were 17 ± 8 ng/mL and 32 ± 19 pg/mL, respectively. Mean calculated bioavailable 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D were 2.5 ± 2.0 ng/mL and 6.6 ± 5.3 pg/mL, respectively. Receiver-operating characteristic curve analysis demonstrated that all of four vitamin D measures predicted the three clinical outcomes; total 25-hydroxyvitamin D was not inferior to the other measures. Median (interquartile range) hospital length of stay was 11 days (8-19 d). Poisson regression analysis, adjusted for biologically plausible covariates, demonstrated an association of total 25-hydroxyvitamin D with hospital length of stay (incident rate ratio per 1 ng/mL, 0.98; 95% CI, 0.97-0.98). The 90-day readmission and mortality rates were 24% and 22%, respectively. Even after adjustment for biologically plausible covariates, there remained significant associations of total 25-hydroxyvitamin D with readmission (odds ratio per 1 ng/mL, 0.84; 95% CI, 0.74-0.95) and mortality (odds ratio per 1 ng/mL, 0.84; 95% CI, 0.73-0.97). CONCLUSIONS: Serum 25-hydroxyvitamin D levels within 24 hours of ICU admission may identify patients at high risk for prolonged hospitalization, readmission, and mortality. Randomized trials are needed to assess whether vitamin D supplementation can improve these clinically relevant outcomes in surgical ICU patients.

Association between preoperative 25-hydroxyvitamin D level and hospital-acquired infections following Roux-en-Y gastric bypass surgery.

IMPORTANCE: Postoperative hospital-acquired infections (HAIs) may result from disruption of natural barrier sites. Recent studies have linked vitamin D status and barrier site integrity. OBJECTIVE: To investigate the association between preoperative vitamin D status and the risk for HAIs. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was performed using propensity score methods to construct a matched-pairs cohort to reduce baseline differences between patients with 25-hydroxyvitamin D (25[OH]D) levels less than 30 ng/mL vs 30 ng/mL or greater. Multivariable logistic regression analysis was then performed to examine the association between 25(OH)D levels and HAIs while adjusting for additional perioperative factors. Locally weighted scatterplot smoothing was used to depict the relationship between increasing 25(OH)D levels and the risk for HAIs. This study was conducted in a single, teaching hospital in Boston, Massachusetts, and involved 770 gastric bypass surgery patients between January 1, 2007, and December 31, 2011. EXPOSURES: Preoperative 25(OH)D levels. MAIN OUTCOMES AND MEASURES: Association between preoperative 25(OH)D levels and the risk for postoperative HAIs. RESULTS: The risk for HAIs was 3-fold greater (adjusted odds ratio, 3.05; 95% CI, 1.34-6.94) in patients with 25(OH)D levels less than 30 ng/mL vs 30 ng/mL or greater. Further adjustment for additional perioperative factors did not materially change this association. Locally weighted scatterplot smoothing analysis depicted a near inverse linear relationship between vitamin D status and the risk for HAIs for 25(OH)D levels around 30 ng/mL. CONCLUSIONS AND RELEVANCE: In our patient cohort, a significant inverse association was observed between preoperative 25(OH)D levels and the risk for HAIs. These results suggest that preoperative 25(OH)D levels may be a modifiable risk factor for postoperative nosocomial infections. Prospective studies must determine whether there is a potential benefit to preoperative optimization of vitamin D status.

Systemic administration of an antagonist of the ATP-sensitive receptor P2X7 improves recovery after spinal cord injury.

Traumatic spinal cord injury is characterized by an immediate, irreversible loss of tissue at the lesion site, as well as a secondary expansion of tissue damage over time. Although secondary injury should, in principle, be preventable, no effective treatment options currently exist for patients with acute spinal cord injury (SCI). Excessive release of ATP by the traumatized tissue, followed by activation of high-affinity P2X7 receptors, has previously been implicated in secondary injury, but no clinically relevant strategy by which to antagonize P2X7 receptors has yet, to the best of our knowledge, been reported. Here we have tested the neuroprotective effects of a systemically administered P2X7R antagonist, Brilliant blue G (BBG), in a weight-drop model of thoracic SCI in rats. Administration of BBG 15 min after injury reduced spinal cord anatomic damage and improved motor recovery without evident toxicity. Moreover, BBG treatment directly reduced local activation of astrocytes and microglia, as well as neutrophil infiltration. These observations suggest that BBG not only protected spinal cord neurons from purinergic excitotoxicity, but also reduced local inflammatory responses. Importantly, BBG is a derivative of a commonly used blue food color (FD&C blue No. 1), which crosses the blood-brain barrier. Systemic administration of BBG may thus comprise a readily feasible approach by which to treat traumatic SCI in humans.