Background Management of delirium in intensive care units is challenging because effective therapies are lacking. Music is a promising nonpharmacological intervention. Objectives To determine the feasibility and acceptability of personalized music (PM), slow-tempo music (STM), and attention control (AC) in patients receiving mechanical ventilation in an intensive care unit, and to estimate the effect of music on delirium. Methods A randomized controlled trial was performed in an academic medical-surgical intensive care unit. After particular inclusion and exclusion criteria were applied, patients were randomized to groups listening to PM, relaxing STM, or an audiobook (AC group). Sessions lasted 1 hour and were given twice daily for up to 7 days. Patients wore noise-canceling headphones and used mp3 players to listen to their music/audiobook. Delirium and delirium severity were assessed twice daily by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the CAM-ICU-7, respectively. Results Of the 1589 patients screened, 117 (7.4%) were eligible. Of those, 52 (44.4%) were randomized, with a recruitment rate of 5 patients per month. Adherence was higher in the groups listening to music (80% in the PM and STM groups vs 30% in the AC group; P = .01), and 80% of patients surveyed rated the music as enjoyable. The median number (interquartile range) of delirium/coma-free days by day 7 was 2 (1-6) for PM, 3 (1-6) for STM, and 2 (0-3) for AC (P = .32). Median delirium severity was 5.5 (1-7) for PM, 3.5 (0-7) for STM, and 4 (1-6.5) for AC (P = .78). Conclusions Music delivery is acceptable to patients and is feasible in intensive care units. Further research testing use of this promising intervention to reduce delirium is warranted.

INTRODUCTION: Clostridioides difficile infection (CDI) is common in patients with cirrhosis and is associated with poor outcomes. CDI risk factors in this population have been well characterized; however, risk factors of recurrent CDI (R-CDI) after treatment have not been explored. We sought to estimate the incidence of R-CDI and its associated risk factors in patients with cirrhosis. METHODS: We performed a cohort study of patients with cirrhosis hospitalized with CDI between 2012 and 2016. We collected patient characteristics, including detailed information on the CDI, features of the underlying liver disease, and outcomes including R-CDI, hospital readmission, and mortality. R-CDI was defined as CDI occurring 2–8 weeks after the initial episode. Cox proportional hazards model was used to identify variables independently associated with the outcomes. RESULTS: A total of 257 hospitalized patients with cirrhosis and CDI were included. CDI was community associated in 22.6%. The incidence of R-CDI was 11.9%. R-CDI was not significantly associated with medications at hospital admission or discharge. Independent risk factors of R-CDI included increased Charlson Comorbidity Index (hazard ratio [HR] 1.30; 95% confidence interval [CI]: 1.09–1.55) and use of lactulose (HR 2.58; 95% CI: 1.09–6.09). The 30-day readmission rate was 37%, and readmission was associated with increased Charlson Comorbidity Index (HR 1.12; 95% CI: 1.03–1.23) and Model for End-Stage Liver Disease score (HR 1.04; 95% CI: 1.01–1.07). The 90-day mortality was 22.8%. DISCUSSION: In patients with cirrhosis, R-CDI is associated with comorbidity burden and lactulose use. Attention to these factors might aid clinicians in efforts to prevent R-CDI and improve outcomes in this population.

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Gastric bypass related hyperammonemia (GaBHA) is a rare and potentially fatal complication following bariatric surgery. Proposed mechanisms include unmasking a genetic disorder involving the urea cycle, severe nutritional deficiencies, or stress induced from acute illness. We present a case of GaBHA that progressed to cerebral edema requiring three weeks of mechanical ventilation. A 57-year-old malnourished, Caucasian female with a distant history of Roux-En-Y gastric bypass was transferred for a diffuse ulcerated rash. She was evaluated one week prior and given cephalexin for presumed cellulitis of her lower extremities. On our initial evaluation the patient was hypothermic (33.7 C) and tachycardic (110 bpm). Physical exam revealed normal mentation, injected eyes with exudate and a desquamated rash on arms, legs, and feet (Figure 1). Shortly after admission the patient became progressively encephalopathic, hypoxemic, and hypotensive. She was intubated and placed on vasopressors as well as broad-spectrum antibiotics. Work-up of her encephalopathy included a brain MRI that showed diffuse cerebral edema and an ammonia of 136 MCMOL/L (11-32 MCMOL/L) that peaked at 251 after initiating tube feeds. A clear source of infection was not found, but she received treatment for cellulitis and aspiration pneumonia. Imaging of liver noted hepatic steatosis with normal liver and coagulation function. GaBHA was suspected and she was started on a low protein diet (less than 10 g/day), L-carnitine replacement, and multivitamins including zinc, niacin, and vitamin C. Continuous renal replacement therapy was started for ammonia clearance and weaned off after stabilization of ammonia. We observed slow improvement in her encephalopathy and myopathy allowing extubated twenty-two days later. Ultimately the exact mechanism causing GaBHA wasn't apparent. Likely multifactorial from both vitamin and mineral deficiencies (Zinc 14 ug/dL, Copper 41 ug/dL and Vitamin-C 16 umol/L) and septicemia. Our treatment was aimed at restricting protein and supplementing vitamins and co-factors like L-carnitine. Limiting protein and muscle breakdown by providing other macronutrients decreases the amount of amino acids getting hydrolyzed into ammonia. In addition, stimulating an anabolic state helps prevent fat oxidation. Carnitine is an essential co-factor in transportation of fatty acids into the mitochondria for βoxidation. Limiting fat oxidation, by higher levels of insulin for example, and supplementing co-factors will prevent another mechanism for hyperammonemia via metabolites of urea cycle. Case reports have also theorized medications, like antibiotics, altering the gut microbiome inducing GaBHA. We recommend increased vigilance for GaBHA in patients with a history of bariatric surgery.