Letters

ers erroneously generalize our patient outcomes to an allcomer septic shock population. Azimi and Vincent1 reported that despite achieving hemodynamic stability, patients with septic shock and a persistently high heart rate (mean [SD], 102 [6]/min) and greater ongoing norepinephrine requirements after 24 hours subsequently died, yet lactate levels (mean [SD], 2.6 [0.6] mmol/L) were only marginally elevated. However, in the survivors, heart rate had fallen to a mean [SD] of 87 [4]/ min after stabilization and lactate levels were comparable. These findings are similar to ours. The SAPS II score is a poor discriminator of outcome in septic shock; for example, mortality differed nearly 2-fold yet the median SAPS score differed by just 8 points in 2 corticosteroid studies.2,3 Thus, we contend that persistent tachycardia and high norepinephrine requirements are better prognosticators. We also recognized the point regarding timing and main cause of death; however, it is difficult to draw firm conclusions from this specific and relatively small subset of patients. We cautioned that “although mortality was not a primary end point, the unexpectedly large intergroup difference does not exclude the possibility of a chance finding or a contribution from unknown confounding factors.” Drs Bouglé and Mira criticize the amount of fluid administered and the use of central venous pressure monitoring. However, the fluid input over 96 hours in our patients was comparable with that in another trial.4 The central venous pressure measurements in our patients averaged 12 to 13 mm Hg during the first 96 hours, corresponding to the SSC recommendations for the first 6 hours of resuscitation.5 Whether this is an appropriate target beyond the first 6 hours is an important question, but one not addressed by the guidelines. In addition, all of our patients had pulmonary artery catheter monitoring. Dr Lin questions aspects of antibiotic appropriateness and source control. As per institutional policy, infections requiring source control, such as peritonitis and necrotizing fasciitis, were treated when indicated by urgent surgery. Following SSC guidelines, empirical broad-spectrum antibiotics were given within the first 6 hours.3 Round-the-clock advice was forthcoming from infectious disease specialists. Empirical broad-spectrum antibiotics included piptazobactam or carbapenems for gram-negative coverage plus, as indicated, vancomycin, linezolid, or daptomycin for gram-positive coverage, and fungal coverage based on risk factors. De-escalation was applied once culture results became available. For patients with carbapenem-resistant organisms, empirical antibiotic therapy included colistin plus meropenem and possibly tigecycline.6 Andrea Morelli, MD Christian Ertmer, MD Mervyn Singer, MD, FRCP Author Affiliations: Department of Anesthesiology and Intensive Care, University of Rome, “La Sapienza,” Rome, Italy (Morelli); Department of Anesthesiology, Intensive Care, and Pain Medicine, University of Muenster, Muenster, Germany (Ertmer); Bloomsbury Institute of Intensive Care Medicine, University College London, London, England (Singer).

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Corresponding Author: Andrea Morelli, MD, University of Rome, Viale del Policlinico 155, Rome 00161, Italy (andrea.morelli@uniroma1). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Morelli reported receiving honoraria for speaking at Baxter symposia. Dr Singer reported serving as a consultant and receiving honoraria for speaking and chairing symposia for Baxter. No other disclosures were reported. 1. Azimi G, Vincent JL. Ultimate survival from septic shock. Resuscitation. 1986;14(4):245-253. 2. Annane D, Sébille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288(7):862-871. 3. Sprung CL, Annane D, Keh D, et al; CORTICUS Study Group. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111-124. 4. Boyd JH, Forbes J, Nakada T-A, Walley KR, Russell JA. Fluid resuscitation in septic shock. Crit Care Med. 2011;39(2):259-265. 5. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign. Crit Care Med. 2013;41(2):580-637. 6. Tumbarello M, Viale P, Viscoli C, et al. Predictors of mortality in bloodstream infections caused by Klebsiella pneumoniae carbapenemase-producing K pneumoniae. Clin Infect Dis. 2012;55(7):943-950.

Treating Patients With Learning Disabilities To the Editor Ms Rossignol and Dr Paasche-Orlow1 described legislation related to educational services for individuals with disabilities and recommended accommodations for use by physicians. In addition to a number of inaccuracies (eg, the comprehensive federal Special Education law was passed in 1975, not 1990; the Individual Education Program [IEP] provides more than just accommodations2), we have concerns about the recommendations provided. First, we are concerned about using the question “Have you ever had an IEP?” as a screening method. Simply knowing that a patient has (or had) an IEP provides little information about that person’s strengths and needs. Even knowing that a patient had an IEP due to a learning disability would not be very illuminating due to the heterogeneity among those who share the diagnosis. Furthermore, this question assumes that all individuals with disabilities are identified as such and receive services through an IEP; some receive no services and some receive accommodations through another mechanism (eg, a 504 plan3). In fact, individuals with disabilities who were not identified or did not receive services through an IEP might need the most support in understanding medical information. Additionally, there continues to be stigma associated with the presence of disabilities and receipt of special education services. Asking patients whether they had an IEP, particularly at intake, might have the unfortunate effect of discouraging conversation about learning needs. Second, the accommodations Rossignol and PaascheOrlow described in their Table are, in many cases, good practices for engaging all patients, regardless of whether they have a specific learning disability. For example, even patients without dyscalculia might have trouble calculating medication dosing, and even patients without nonverbal learning disabilities would benefit from a clear and simple care plan. A preferable approach (regardless of whether a patient has a disability) is to apply the principles of Universal Design for Learning,4 which is an approach to customizing instruction for

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individual needs that has been endorsed by more than 40 major professional organizations.5 Implementation of these principles is accomplished through presentation of information to all patients in multiple modes (eg, visual, auditory, printed text), checking frequently for understanding, and encouraging all patients to use any method of communication appropriate for them. This is designed to reach the widest range of patients (regardless of ability and cultural and linguistic background) to maximize collaboration. Donna Lehr, PhD Jennifer Greif Green, PhD Nancy Harayama, EdD Author Affiliations: School of Education, Boston University, Boston, Massachusetts. Corresponding Author: Donna Lehr, PhD, Boston University, 2 Silber Way, Boston, MA 02215 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Rossignol LN, Paasche-Orlow MK. Empowering patients who have specific learning disabilities. JAMA. 2013;310(14):1445-1446. 2. Education for All Handicapped Children Act, Pub L No. 94-14220 (1975). 3. Rehabilitation Act §504, 29 USC §701 et seq (1973). 4. Rose D, Meyer A. A Practical Reader in Universal Design for Learning. Cambridge, MA: Harvard Education Press; 2006. 5. National Center on Universal Design for Learning. About the National UDL Task Force. http://www.udlcenter.org/advocacy/taskforce. Accessed October 28, 2013.

In Reply The Individuals with Disabilities Education Act1 was enacted in 1990 and was preceded by the Education for All Handicapped Children Act of 1975.2 In fact, provisions for protecting students with disabilities existed in multiple prior legislative efforts, such as the Vocational Rehabilitation Act Amendments of 19543 and the Rehabilitation Act of 1973,4 which established the 504 plans in use today and was mentioned by Dr Lehr and colleagues. The 504 plan is used for students with disabilities who do not require specialized instruction. Lehr and colleagues point out that asking patients if they had an IEP will not find people missed by the education system. We agree and have acknowledged the lack of research into the sensitivity and specificity of such questions. They express concern about the risk of stigma associated with asking such a question. We agree and recognize the importance of reducing shame and stigma throughout the care continuum. Nonetheless, IEP documents represent a trove of information. In many cases (>12.3% of public school students), a patient’s history and results of testing and accommodations that could help effective communication are completely unknown to their physician.5

Lehr and colleagues point out that the IEP provides more than just accommodations. We agree. The IEP includes a variety of information such as the type and frequency of services to be provided to the child by the school system, transportation requirements, emergency evacuation plans, testing accommodations, and health requirements. Our Viewpoint was not a general review of IEPs; we focused on the most relevant details to draw attention to the possibility that IEPs and other sources of information can provide a path to improved communication and patient education for people with learning disabilities when they become patients. Lehr and colleagues criticize our suggestion of asking patients how they best learn. They point to the Universal Design for Learning framework as an alternative approach to customizing instruction for individual needs. However, their criticism is misplaced. In the Universal Design for Learning, learners are offered ways of customizing the display of information and different ways to receive auditory or visual information. In fact, customizing instructions based on individual needs is precisely what we promote by encouraging health care practitioners to ask patients with learning disabilities the strategies that they and their educators have determined to be effective. We agree that comprehension should be evaluated for all critical self-care tasks and have advanced the teach-back technique to improve communication and patient education.6 Such an approach can help a broad array of patients, not just those with learning disabilities. However, we also believe that it is valuable to understand and respond to the specific learning needs of patients who have learning disabilities. Lisa N. Rossignol, MA Michael K. Paasche-Orlow, MD, MPH, MA Author Affiliations: Sociology of Medicine, University of New Mexico, Albuquerque (Rossignol); Department of Medicine, Boston University School of Medicine, Boston, Massachusetts (Paasche-Orlow). Corresponding Author: Lisa N. Rossignol, MA, University of New Mexico, PO Box 11095, Albuquerque, NM 87192 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Individuals with Disabilities Education Act, 20 USC §1400 et seq (1990). 2. Education for All Handicapped Children Act, Pub L No. 94-14220 (1975). 3. Vocational Rehabilitation Act Amendments, Pub L No. 83-565 (1954). 4. Rehabilitation Act §504, 29 USC §701 et seq (1973). 5. National Center for Education Statistics website. Characteristics of public, private, and Bureau of Indian Education elementary and secondary schools in the United States. http://nces.ed.gov/pubs2009/2009321/tables/sass0708 _2009321_s12n_02.asp. Accessed November 10, 2013. 6. Volandes AE, Paasche-Orlow MK. Health literacy, health inequality and a just healthcare system. Am J Bioeth. 2007;7(11):5-10.

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Treating patients with learning disabilities.

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