Sepsis causes immune dysregulation and endotheliitis, with an increase in mid-regional pro-adrenomedullin (MR-proADM). The aim of the study is to determine an MR-proADM value that, in addition to clinical diagnosis, can identify patients with localized infection or those with sepsis/septic shock, with specific organ damage or with the need for intensive care unit (ICU) transfer and prognosis. The secondary aim is to correlate the MR-proADM value with the length of stay (LOS). In total, 301 subjects with sepsis (124/301 with septic shock) and 126 with localized infection were retrospectively included. In sepsis, MR-proADM >= 3.39 ng/mL identified acute kidney injury (AKI); >= 2.99 ng/mL acute respiratory distress syndrome (ARDS); >= 2.28 ng/mL acute heart failure (AHF); >= 2.55 ng/mL Glascow Coma Scale (GCS) < 15; >= 3.38 multi-organ involvement; >= 3.33 need for ICU transfer; >= 2.0 Sequential Organ Failure Assessment (SOFA) score >= 2; and >= 3.15 ng/mL non-survivors. The multivariate analysis showed that MR-proADM >= 2 ng/mL correlates with AKI, anemia and SOFA score >= 2, and MR-proADM >= 3 ng/mL correlates with AKI, GCS < 15 and SOFA score >= 2. A correlation between mortality and AKI, GCS < 15, ICU transfer and cathecolamine administration was found. In localized infection, MR-proADM at admission >= 1.44 ng/mL identified patients with AKI; >= 1.0 ng/mL with AHF; and >= 1.44 ng/mL with anemia and SOFA score >= 2. In the multivariate analysis, MR-proADM >= 1.44 ng/mL correlated with AKI, anemia, SOFA score >= 2 and AHF. MR-proADM is a marker of oxidative stress due to an infection, reflecting severity proportionally to organ damage.

Sepsis causes immune dysregulation and endotheliitis, with an increase in mid-regional pro-adrenomedullin (MR-proADM). The aim of the study is to determine an MR-proADM value that, in addition to clinical diagnosis, can identify patients with localized infection or those with sepsis/septic shock, with specific organ damage or with the need for intensive care unit (ICU) transfer and prognosis. The secondary aim is to correlate the MR-proADM value with the length of stay (LOS). In total, 301 subjects with sepsis (124/301 with septic shock) and 126 with localized infection were retrospectively included. In sepsis, MR-proADM ¿ 3.39 ng/mL identified acute kidney injury (AKI); ¿2.99 ng/mL acute respiratory distress syndrome (ARDS); ¿2.28 ng/mL acute heart failure (AHF); ¿2.55 ng/mL Glascow Coma Scale (GCS) < 15; ¿3.38 multi-organ involvement; ¿3.33 need for ICU transfer; ¿2.0 Sequential Organ Failure Assessment (SOFA) score ¿ 2; and ¿3.15 ng/mL non-survivors. The multivariate analysis showed that MR-proADM ¿ 2 ng/mL correlates with AKI, anemia and SOFA score ¿ 2, and MR-proADM ¿ 3 ng/mL correlates with AKI, GCS < 15 and SOFA score ¿ 2. A correlation between mortality and AKI, GCS < 15, ICU transfer and cathecolamine administration was found. In localized infection, MR-proADM at admission ¿ 1.44 ng/mL identified patients with AKI; ¿1.0 ng/mL with AHF; and ¿1.44 ng/mL with anemia and SOFA score ¿ 2. In the multivariate analysis, MR-proADM ¿ 1.44 ng/mL correlated with AKI, anemia, SOFA score ¿ 2 and AHF. MR-proADM is a marker of oxidative stress due to an infection, reflecting severity proportionally to organ damage.

Background One of the most important challenges in medical education is the preparation of multiple-choice questions able to discriminate between students with different academic level. Average questions may be very easy for students with good performance, reducing their discriminant power in this group of students. The aim of this study was to analyze if the discriminative power of multiple-choice questions is different according to the students' academic performance. Methods We retrospectively analyzed the difficulty and discrimination indices of 257 multiple-choice questions used for the end of course examination of pathophysiology and analyzed whether the discrimination indices were lower in students with good academic performance (group 1) than in students with moderate/poor academic performance (group 2). We also evaluated whether case-based questions maintained their discriminant power better than factual questions in both groups of students or not. Comparison of the difficulty and discrimination indices between both groups was based on the Wilcoxon test. Results Difficulty index was significantly higher in group 1 (median: 0.78 versus 0.56; P < 0.001) and discrimination index was significantly higher in group 2 (median: 0.21 versus 0.28; P < 0.001). Factual questions had higher discriminative indices in group 2 than in group 1 (median: 0.28 versus 0.20; P < 0.001), but discriminative indices of case-based questions did not differ significantly between groups (median: 0.30 versus 0.24; P = 0.296). Conclusions Multiple-choice question exams have lower discriminative power in the group of students with high scores. The use of clinical vignettes may allow to maintain the discriminative power of multiple-choice questions.

Background: To analyze the long-term outcomes for advanced cancer patients admitted to an intermediate care unit (ImCU), an analysis of a do not resuscitate orders (DNR) subgroup was made. Methods: A retrospective observational study was conducted from 2006 to January 2019 in a single academic medical center of cancer patients with stage IV disease who suffered acute severe complications. The Simplified Acute Physiology Score 3 (SAPS 3) was used as a prognostic and severity score. In-hospital mortality, 30-day mortality and survival after hospital discharge were calculated. Results: Two hundred and forty patients with stage IV cancer who attended at an ImCU were included. In total, 47.5% of the cohort had DNR orders. The two most frequent reasons for admission were sepsis (32.1%) and acute respiratory failure (excluding sepsis) (38.7%). Mortality in the ImCU was 10.8%. The mean predicted in-hospital mortality according to SAPS 3 was 51.9%. The observed in-hospital mortality was 37.5% (standard mortality ratio of 0.72). Patients discharged from hospital had a median survival of 81 (30.75-391.25) days (patients with DNR orders 46 days (19.5-92.25), patients without DNR orders 162 days (39.5-632)). The observed mortality was higher in patients with DNR orders: 52.6% vs. 23.8%, p 0 < 0.001. By multivariate logistic regression, a worse ECOG performance status (3-4 vs. 0-2), a higher SAPS 3 Score and DNR orders were associated with a higher in-hospital mortality. By multivariate analysis, non-invasive mechanical ventilation, higher bilirubin levels and DNR orders were significantly associated with 30-day mortality. Conclusion: For patients with advanced cancer disease, even those with DNR orders, who suffer from acute complications or require continuous monitoring, an ImCU-centered multidisciplinary management shows encouraging results in terms of observed-to-expected mortality ratios.

Intermediate care units (ImCUs) have been shown as appropriate units for the management of selected septic patients. Developing specific protocols for residents in training may be useful for their medical performance. The objective of this study was to analyze whether a simulation-based learning bundle is useful for residents while acquiring competencies in the management of sepsis during their internship in an ImCU. A prospective study, set in a tertiary-care academic medical center was performed enrolling residents who performed their internship in an ImCU from 2014 to 2017. The pillars of the simulation-based learning bundle were sepsis scenario in the simulation center, instructional material, and sepsis lecture, and management of septic patients admitted in the ImCU. Each resident was evaluated in the beginning and at the end of their internship displaying a sepsis-case scenario in the simulation center. The authors developed a sepsis-checklist that residents must fulfill during their performance which included 5 areas: hemodynamics (0¿10), oxygenation (0¿5), antibiotic therapy (0¿9), organic injury (0¿5), and miscellaneous (0¿4). ...

Background: Active learning strategies such as formative assessment through clinical cases may help to get a deeper learning. We have studied the effect of this kind of online formative assessment in pathophysiology teaching. Methods: Seven brief clinical cases were used to give formative assessment in the first semester of a pathophysiology course. To evaluate its effect on learning, we analyzed the proportion of students that passed the end of semester exam with a score above 60 over 100. We also analyzed the effect of the intervention according to the students' previous academic performance. Results: Ninety-six students participated in the study and sat the exam. Sixty-five of them passed it. Students that passed the exam had a higher previous academic performance and had done a higher number of exercises of formative assessment, both in univariate and multivariate analysis. The participants were divided in three groups, according to their previous academic performance. In the intermediate group, the number of cases done by the students who passed the exam was significantly higher than in those who did not pass it (median: 4 versus 0; P = 0.009). Conclusion: Formative assessment through web-based clinical cases was followed by an improvement of the academic results in pathophysiology, mainly in students with intermediate performance.

Background: Writing multiple choice questions may be a valuable tool for medical education. We asked medical students to generate multiple choice questions and studied its effect on their exams. We hypothesized that students generating questions would improve their learning. Methods: We randomized students in their second and third years at the School of Medicine to write four multiple choice questions on two different sections of General Pathology (Immunopathology and Electrolyte and acid-base status; second year) and Pathophysiology (Blood and Respiratory system; third year). We analyzed whether students writing questions on a section had better results in the exam test in that section than the rest of the students. Results: Seventy-five (38.2%) students wrote questions for General Pathology and 109 (47.6%) for Pathophysiology. Students that wrote questions obtained significantly better results in the exam than those who did not. In General Pathology, students who wrote questions about Immunopathology obtained better results in that section than those who wrote questions about the other section (5.13 versus 3.86 over 10; P¿=¿0.03). In Pathophysiology, the differences between both groups were not significant, but students who wrote good questions about Respiratory system obtained better results in that section than those who wrote good questions about Blood (6.07 versus 4.28 over 10; P¿=¿0.015). Male students wrote good questions in Pathophysiology more frequently than female students (28.1% versus 10.4%; P¿=¿0.02). Conclusions: The writing of multiple choice questions by medical students may improve their learning. A gender effect may also influence this intervention. Future investigations should refine its potential role in teaching.

Purpose: The Intermediate Care Unit Severity Score (IMCUSS) is an easy to calculate predictor of in-hospital death, and the only such tool developed for patients in the intermediate care setting. We sought to examine its external validity. Materials and methods: Using data from patients admitted to the intermediate care unit (IMCU) of an urban academic medical center from July to December of 2012, model discrimination and calibration for predicting in-hospital death were assessed using the area under the receiver operating characteristic (AUROC) and the Hosmer-Lemeshow goodness-of-fit chi-squared (HL GOF X-2) test, respectively. The standardized mortality ratio (SMR) with 95% confidence intervals (95% CI) was also calculated. Results: The cohort included data from 628 unique admissions to the IMCU. Overall hospital mortality was 8.3%. The median IMCUSS was 10 (Interquartile Range: 0-16), with 229 (36%) patients having a score of zero. The AUROC for the IMCUSS was 0.72 (95% CI: 0.64-0.78), the HL GOF X-2=30.7 (P < 0.001), and the SMR was 1.22 (95% CI: 0.91-1.60). Conclusions: The IMCUSS exhibited acceptable discrimination, poor calibration, and underestimated mortality. Other centers should assess the performance of the IMCUSS before adopting its use. (C) 2018 Elsevier Inc. All rights reserved.