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External Validation of Updated Prediction Models for Neurological Outcomes at 90 Days in Patients With Out-of-Hospital Cardiac Arrest. J Am Heart Assoc 2024; 13:e033824. [PMID: 38700024 DOI: 10.1161/jaha.123.033824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/04/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Few prediction models for individuals with early-stage out-of-hospital cardiac arrest (OHCA) have undergone external validation. This study aimed to externally validate updated prediction models for OHCA outcomes using a large nationwide dataset. METHODS AND RESULTS We performed a secondary analysis of the JAAM-OHCA (Comprehensive Registry of In-Hospital Intensive Care for Out-of-Hospital Cardiac Arrest Survival and the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest) registry. Previously developed prediction models for patients with cardiac arrest who achieved the return of spontaneous circulation were updated. External validation was conducted using data from 56 institutions from the JAAM-OHCA registry. The primary outcome was a dichotomized 90-day cerebral performance category score. Two models were updated using the derivation set (n=3337). Model 1 included patient demographics, prehospital information, and the initial rhythm upon hospital admission; Model 2 included information obtained in the hospital immediately after the return of spontaneous circulation. In the validation set (n=4250), Models 1 and 2 exhibited a C-statistic of 0.945 (95% CI, 0.935-0.955) and 0.958 (95% CI, 0.951-0.960), respectively. Both models were well-calibrated to the observed outcomes. The decision curve analysis showed that Model 2 demonstrated higher net benefits at all risk thresholds than Model 1. A web-based calculator was developed to estimate the probability of poor outcomes (https://pcas-prediction.shinyapps.io/90d_lasso/). CONCLUSIONS The updated models offer valuable information to medical professionals in the prediction of long-term neurological outcomes for patients with OHCA, potentially playing a vital role in clinical decision-making processes.
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Primary neonatal and pediatric ECMO transport: First experience in Spain. Perfusion 2024; 39:797-806. [PMID: 36881730 DOI: 10.1177/02676591231161268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION The organization of primary Extracorporeal membrane oxygenation (ECMO) transport is highly variable. METHODS To present the experience of the first mobile pediatric ECMO program in Spain, we designed a prospective descriptive study of all primary neonatal and pediatric (0-16 years) ECMO transports carried out over 10 years. The main variables recorded include demographic information, patient background, clinical data, ECMO indications, adverse events, and main outcomes. RESULTS 39 primary ECMO transports were carried out with a 66.7% survival to hospital discharge. The median age was 1.24 months[IQR: 0.09-96]. Cannulation was mostly peripheral venoarterial (33/39). The mean response time from the call from the sending center to the departure of the ECMO team was 4 h[2.2-8]. The median inotropic score at the time of cannulation was 70[17.2-206.5], with a median oxygenation index of 40.5[29-65]. In 10% of the cases, ECMO-CPR was performed. Adverse events occurred in 56.4%, mostly related to the means of transport (40% overall). On arrival at the ECMO center, 44% of the patients underwent interventions. The median PICU stay was 20.5 days[11-32]. 5 patients developed neurological sequels. Statistically significant differences between survivors and deceased patients were not found. CONCLUSIONS A good survival rate, with a low prevalence of serious adverse events, suggests a clear benefit of primary ECMO transport when conventional therapeutic measures are exhausted and the patient is too unstable to undergo conventional transport. A nationwide primary ECMO-transport program must therefore be offered to all patients regardless of their location.
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Effectiveness of Blended Versus Traditional Refresher Training for Cardiopulmonary Resuscitation: Prospective Observational Study. JMIR MEDICAL EDUCATION 2024; 10:e52230. [PMID: 38683663 DOI: 10.2196/52230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/08/2023] [Accepted: 03/31/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Generally, cardiopulmonary resuscitation (CPR) skills decline substantially over time. By combining web-based self-regulated learning with hands-on practice, blended training can be a time- and resource-efficient approach enabling individuals to acquire or refresh CPR skills at their convenience. However, few studies have evaluated the effectiveness of blended CPR refresher training compared with that of the traditional method. OBJECTIVE This study investigated and compared the effectiveness of traditional and blended CPR training through 6-month and 12-month refresher sessions with CPR ability indicators. METHODS This study recruited participants aged ≥18 years from the Automated External Defibrillator Donation Project. The participants were divided into 4 groups based on the format of the CPR training and refresher training received: (1) initial traditional training (a 30-minute instructor-led, hands-on session) and 6-month traditional refresher training (Traditional6 group), (2) initial traditional training and 6-month blended refresher training (an 18-minute e-learning module; Mixed6 group), (3) initial traditional training and 12-month blended refresher training (Mixed12 group), and (4) initial blended training and 6-month blended refresher training (Blended6 group). CPR knowledge and performance were evaluated immediately after initial training. For each group, following initial training but before refresher training, a learning effectiveness assessment was conducted at 12 and 24 months. CPR knowledge was assessed using a written test with 15 multiple-choice questions, and CPR performance was assessed through an examiner-rated skill test and objectively through manikin feedback. A generalized estimating equation model was used to analyze changes in CPR ability indicators. RESULTS This study recruited 1163 participants (mean age 41.82, SD 11.6 years; n=725, 62.3% female), with 332 (28.5%), 270 (23.2%), 258 (22.2%), and 303 (26.1%) participants in the Mixed6, Traditional6, Mixed12, and Blended6 groups, respectively. No significant between-group difference was observed in knowledge acquisition after initial training (P=.23). All groups met the criteria for high-quality CPR skills (ie, average compression depth: 5-6 cm; average compression rate: 100-120 beats/min; chest recoil rate: >80%); however, a higher proportion (98/303, 32.3%) of participants receiving blended training initially demonstrated high-quality CPR skills. At 12 and 24 months, CPR skills had declined in all the groups, but the decline was significantly higher in the Mixed12 group, whereas the differences were not significant between the other groups. This finding indicates that frequent retraining can maintain high-quality CPR skills and that blended refresher training is as effective as traditional refresher training. CONCLUSIONS Our findings indicate that 6-month refresher training sessions for CPR are more effective for maintaining high-quality CPR skills, and that as refreshers, self-learning e-modules are as effective as instructor-led sessions. Although the blended learning approach is cost and resource effective, factors such as participant demographics, training environment, and level of engagement must be considered to maximize the potential of this approach. TRIAL REGISTRATION IGOGO NCT05659108; https://www.cgmh-igogo.tw.
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Scandinavian perspectives on life support at the border of viability. Front Pediatr 2024; 12:1394077. [PMID: 38720944 PMCID: PMC11076765 DOI: 10.3389/fped.2024.1394077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/26/2024] [Indexed: 05/12/2024] Open
Abstract
Advances in neonatal medicine have allowed us to rescue extremely preterm infants. However, both long-term vulnerability and the burden of treatment in the neonatal period increase with decreasing gestational age. This raises questions about the justification of life support when a baby is born at the border of viability, and has led to a so-called "grey zone", where many professionals are unsure whether provision of life support is in the child's best interest. Despite cultural, political and economic similarities, the Scandinavian countries differ in their approach to periviable infants, as seen in their respective national guidelines and practices. In Sweden, guidelines and practice are more rescue-focused at the lower end of the border of viability, Danish guidelines emphasizes the need to involve parental views in the decision-making process, whereas Norway appears to be somewhere in between. In this paper, I will give an overview of national consensus documents and practices in Norway, Sweden and Denmark, and reflect on the ethical justification for the different approaches.
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ChatGPT's Performance in Cardiac Arrest and Bradycardia Simulations Using the American Heart Association's Advanced Cardiovascular Life Support Guidelines: Exploratory Study. J Med Internet Res 2024; 26:e55037. [PMID: 38648098 DOI: 10.2196/55037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND ChatGPT is the most advanced large language model to date, with prior iterations having passed medical licensing examinations, providing clinical decision support, and improved diagnostics. Although limited, past studies of ChatGPT's performance found that artificial intelligence could pass the American Heart Association's advanced cardiovascular life support (ACLS) examinations with modifications. ChatGPT's accuracy has not been studied in more complex clinical scenarios. As heart disease and cardiac arrest remain leading causes of morbidity and mortality in the United States, finding technologies that help increase adherence to ACLS algorithms, which improves survival outcomes, is critical. OBJECTIVE This study aims to examine the accuracy of ChatGPT in following ACLS guidelines for bradycardia and cardiac arrest. METHODS We evaluated the accuracy of ChatGPT's responses to 2 simulations based on the 2020 American Heart Association ACLS guidelines with 3 primary outcomes of interest: the mean individual step accuracy, the accuracy score per simulation attempt, and the accuracy score for each algorithm. For each simulation step, ChatGPT was scored for correctness (1 point) or incorrectness (0 points). Each simulation was conducted 20 times. RESULTS ChatGPT's median accuracy for each step was 85% (IQR 40%-100%) for cardiac arrest and 30% (IQR 13%-81%) for bradycardia. ChatGPT's median accuracy over 20 simulation attempts for cardiac arrest was 69% (IQR 67%-74%) and for bradycardia was 42% (IQR 33%-50%). We found that ChatGPT's outputs varied despite consistent input, the same actions were persistently missed, repetitive overemphasis hindered guidance, and erroneous medication information was presented. CONCLUSIONS This study highlights the need for consistent and reliable guidance to prevent potential medical errors and optimize the application of ChatGPT to enhance its reliability and effectiveness in clinical practice.
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Effects of a Serious Smartphone Game on Nursing Students' Theoretical Knowledge and Practical Skills in Adult Basic Life Support: Randomized Wait List-Controlled Trial. JMIR Serious Games 2024; 12:e56037. [PMID: 38578690 PMCID: PMC11031703 DOI: 10.2196/56037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/19/2024] [Accepted: 03/10/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Retention of adult basic life support (BLS) knowledge and skills after professional training declines over time. To combat this, the European Resuscitation Council and the American Heart Association recommend shorter, more frequent BLS sessions. Emphasizing technology-enhanced learning, such as mobile learning, aims to increase out-of-hospital cardiac arrest (OHCA) survival and is becoming more integral in nursing education. OBJECTIVE The aim of this study was to investigate whether playing a serious smartphone game called MOBICPR at home can improve and retain nursing students' theoretical knowledge of and practical skills in adult BLS. METHODS This study used a randomized wait list-controlled design. Nursing students were randomly assigned in a 1:1 ratio to either a MOBICPR intervention group (MOBICPR-IG) or a wait-list control group (WL-CG), where the latter received the MOBICPR game 2 weeks after the MOBICPR-IG. The aim of the MOBICPR game is to engage participants in using smartphone gestures (eg, tapping) and actions (eg, talking) to perform evidence-based adult BLS on a virtual patient with OHCA. The participants' theoretical knowledge of adult BLS was assessed using a questionnaire, while their practical skills were evaluated on cardiopulmonary resuscitation quality parameters using a manikin and a checklist. RESULTS In total, 43 nursing students participated in the study, 22 (51%) in MOBICPR-IG and 21 (49%) in WL-CG. There were differences between the MOBICPR-IG and the WL-CG in theoretical knowledge (P=.04) but not in practical skills (P=.45) after MOBICPR game playing at home. No difference was noted in the retention of participants' theoretical knowledge and practical skills of adult BLS after a 2-week break from playing the MOBICPR game (P=.13). Key observations included challenges in response checks with a face-down manikin and a general neglect of safety protocols when using an automated external defibrillator. CONCLUSIONS Playing the MOBICPR game at home has the greatest impact on improving the theoretical knowledge of adult BLS in nursing students but not their practical skills. Our findings underscore the importance of integrating diverse scenarios into adult BLS training. TRIAL REGISTRATION ClinicalTrials.gov (NCT05784675); https://clinicaltrials.gov/study/NCT05784675.
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Withdrawal of Left Ventricular Assist Device in Dementia: A Case Report. J Palliat Med 2024. [PMID: 38451550 DOI: 10.1089/jpm.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Left ventricular assistance devices (LVADs) are one type of life support with the unique quality of allowing recipients to live outside the hospital. This case report explores the decision by a patient and their family to withdraw LVAD therapy in the setting of dementia and consultant team recommendations at odds with one another due to the patient's simultaneous alertness and lack of decisional capacity. It then discusses the guiding principles that led to the withdrawal of LVAD therapy and lessons drawn from the experience by the care team.
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Nitric Oxide on Extracorporeal Membrane Oxygenation in Neonates and Children (NECTAR Trial): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e43760. [PMID: 36920455 PMCID: PMC10131908 DOI: 10.2196/43760] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/11/2023] [Accepted: 01/28/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) provides support for the pulmonary or cardiovascular function of children in whom the predicted mortality risk remains very high. The inevitable host inflammatory response and activation of the coagulation cascade due to the extracorporeal circuit contribute to additional morbidity and mortality in these patients. Mixing nitric oxide (NO) into the sweep gas of ECMO circuits may reduce the inflammatory and coagulation cascade activation during ECMO support. OBJECTIVE The purpose of this study is to test the feasibility and safety of mixing NO into the sweep gas of ECMO systems and assess its effect on inflammation and coagulation system activation through a pilot randomized controlled trial. METHODS The Nitric Oxide on Extracorporeal Membrane Oxygenation in Neonates and Children (NECTAR) trial is an open-label, parallel-group, pilot randomized controlled trial to be conducted at a single center. Fifty patients who require ECMO support will be randomly assigned to receive either NO mixed into the sweep gas of the ECMO system at 20 ppm for the duration of ECMO or standard care (no NO) in a 1:1 ratio, with stratification by support type (veno-venous vs veno-arterial ECMO). RESULTS Outcome measures will focus on feasibility (recruitment rate and consent rate, and successful inflammatory marker measurements), the safety of the intervention (oxygenation and carbon dioxide control within defined parameters and methemoglobin levels), and proxy markers of efficacy (assessment of cytokines, chemokines, and coagulation factors to assess the impact of NO on host inflammation and coagulation cascade activation, clotting of ECMO components, including computer tomography scanning of oxygenators for clot assessments), bleeding complications, as well as total blood product use. Survival without ECMO and the length of stay in the pediatric intensive care unit (PICU) are clinically relevant efficacy outcomes. Long-term outcomes include neurodevelopmental assessments (Ages and Stages Questionnaire, Strength and Difficulties Questionnaire, and others) and quality of life (Pediatric Quality of Life Inventory and others) measured at 6 and 12 months post ECMO cannulation. Analyses will be conducted on an intention-to-treat basis. CONCLUSIONS The NECTAR study investigates the safety and feasibility of NO as a drug intervention during extracorporeal life support and explores its efficacy. The study will investigate whether morbidity and mortality in patients treated with ECMO can be improved with NO. The intervention targets adverse outcomes in patients who are supported by ECMO and who have high expected mortality and morbidity. The study will be one of the largest randomized controlled trials performed among pediatric patients supported by ECMO. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12619001518156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376869. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/43760.
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Survival Outcome in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation Support: Early Experience from a University Hospital in Thailand. Surg J (N Y) 2023; 9:e44-e51. [PMID: 36793996 PMCID: PMC9925292 DOI: 10.1055/s-0043-1761444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/30/2022] [Indexed: 02/16/2023] Open
Abstract
Objective Extracorporeal membrane oxygenation (ECMO) is a relatively new technology used for life support in patients with cardiopulmonary failure from various causes. The objective of this study is to review the first 5-year experience in adopting this technology in a teaching hospital in southern Thailand. Methods The data of ECMO-supported patients in Songklanagarind Hospital, from the years 2014 to 2018, were retrospectively reviewed. Data sources were from electronic medical records and the database of the perfusion service. Parameters in focus included prior conditions and indications of ECMO, type of ECMO and cannulation method, complications during and after the treatment, and discharge statuses. Results A total of 83 patients received ECMO life support during the 5-year period and the number of cases per year increased. The proportion of venovenous: venoarterial ECMO in our institute was 49:34 cases and there were three cases who used ECMO as a part of cardiopulmonary resuscitation. Moreover, there were 57 cases who used ECMO for cardiac failure and 26 cases were for respiratory causes, while premature withdrawal was decided in 26 cases (31.3%). Overall survival from ECMO was 35/83 cases (42.2%) and survival to discharge was 32/83 (38.6%). During therapy, ECMO could restore serum pH to the normal range in all cases. Furthermore, those who used ECMO for respiratory failure had significantly higher survival probability (57.7%) when compared to the cardiac counterpart (29.8%, p -value = 0.03). Patients with younger ages also had significantly better survival outcomes. The most common complications were cardiac (75 cases, 85.5%), followed by renal (45 cases, 54.2%), and hematologic systems (38 cases, 45.8%). In those who survived to discharge, average ECMO duration was 9.7 days. Conclusion Extracorporeal life support is a technology that bridges the patients with cardiopulmonary failure to their recovery or definitive surgery. Despite the high complication rate, survival can be expected, especially in respiratory failure cases and relatively young patients.
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Indications for hand and glove disinfection in Advanced Cardiovascular Life Support: A manikin simulation study. Front Med (Lausanne) 2023; 9:1025449. [PMID: 36687411 PMCID: PMC9853186 DOI: 10.3389/fmed.2022.1025449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/05/2022] [Indexed: 01/09/2023] Open
Abstract
Background and aim There are no investigations on hand hygiene during cardiopulmonary resuscitation (CPR), even though these patients are at high risk for healthcare-associated infections. We aimed to evaluate the number of indicated hand hygiene per CPR case in general and the fraction that could be accomplished without delay for other life-saving techniques through standardized observations. Materials and methods In 2022, we conducted Advanced Cardiovascular Life Support (ACLS) courses over 4 days, practicing 33 ACLS case vignettes with standard measurements of chest compression fractions and hand hygiene indications. A total of nine healthcare workers (six nurses and three physicians) participated. Results A total of 33 training scenarios resulted in 613 indications for hand disinfection. Of these, 150 (24%) occurred before patient contact and 310 (51%) before aseptic activities. In 282 out of 310 (91%) indications, which have the highest impact on patient safety, the medication administrator was responsible; in 28 out of 310 (9%) indications, the airway manager was responsible. Depending on the scenario and assuming 15 s to be sufficient for alcoholic disinfection, 56-100% (mean 84.1%, SD ± 13.1%) of all indications could have been accomplished without delaying patient resuscitation. Percentages were lower for 30-s of exposure time. Conclusion To the best of our knowledge, this is the first study investigating the feasibility of hand hygiene in a manikin CPR study. Even if the feasibility is overestimated due to the study setup, the fundamental conclusion is that a relevant part of the WHO indications for hand disinfection can be implemented without compromising quality in acute care, thus increasing the overall quality of patient care.
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Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study. Neurosurgery 2022; 91:e45-e50. [PMID: 35471648 PMCID: PMC9514740 DOI: 10.1227/neu.0000000000002020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/05/2022] [Indexed: 12/21/2022] Open
Abstract
Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.
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New European Resuscitation Council guidelines for pediatric life support and their implications for pediatric anesthesia: An educational article. Paediatr Anaesth 2022; 32:497-503. [PMID: 34964208 DOI: 10.1111/pan.14389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/27/2022]
Abstract
In this educational article, we summarize the changes in the new European Resuscitation Council guidelines for Pediatric Life Support, emphasizing the most important aspects for the anesthesiologist. Among these are: the use of two-thumb-encircling technique for thorax compressions in infants, 10 ml/kg as the standard volume fluid bolus and ventilation after intubation at an age-dependent rate. Using a fictitious case, we present a point-by-point summary of the changes and briefly mention some of the evidence behind them, referring the reader to the full guidelines for further evidence. We also give a summary of the incidence, causes, challenges, treatment, and prognosis of pediatric cardiac arrest in the operating room.
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Digital Teaching in Medical Education: Scientific Literature Landscape Review. JMIR MEDICAL EDUCATION 2022; 8:e32747. [PMID: 35138260 PMCID: PMC8867298 DOI: 10.2196/32747] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/19/2021] [Accepted: 12/20/2021] [Indexed: 05/30/2023]
Abstract
BACKGROUND Digital teaching in medical education has grown in popularity in the recent years. However, to the best of our knowledge, no bibliometric report to date has been published that analyzes this important literature set to reveal prevailing topics and trends and their impacts reflected in citation counts. OBJECTIVE We used a bibliometric approach to unveil and evaluate the scientific literature on digital teaching research in medical education, demonstrating recurring research topics, productive authors, research organizations, countries, and journals. We further aimed to discuss some of the topics and findings reported by specific highly cited works. METHODS The Web of Science electronic database was searched to identify relevant papers on digital teaching research in medical education. Basic bibliographic data were obtained by the "Analyze" and "Create Citation Report" functions of the database. Complete bibliographic data were exported to VOSviewer for further analyses. Visualization maps were generated to display the recurring author keywords and terms mentioned in the titles and abstracts of the publications. RESULTS The analysis was based on data from 3978 papers that were identified. The literature received worldwide contributions with the most productive countries being the United States and United Kingdom. Reviews were significantly more cited, but the citations between open access vs non-open access papers did not significantly differ. Some themes were cited more often, reflected by terms such as virtual reality, innovation, trial, effectiveness, and anatomy. Different aspects in medical education were experimented for digital teaching, such as gross anatomy education, histology, complementary medicine, medicinal chemistry, and basic life support. Some studies have shown that digital teaching could increase learning satisfaction, knowledge gain, and even cost-effectiveness. More studies were conducted on trainees than on undergraduate students. CONCLUSIONS Digital teaching in medical education is expected to flourish in the future, especially during this era of COVID-19 pandemic.
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People die in six ways and each is politics: Infrastructure and the possible. CONTEMPORARY POLITICAL THEORY 2022; 21:175-197. [PMCID: PMC8414030 DOI: 10.1057/s41296-021-00518-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 06/07/2023]
Abstract
Critical infrastructure services determine where people can survive and what they can do with their survival. This fact conditions political possibilities at a fundamental level but remains underexplored in the literature. Those who wish to extend the boundaries of political action, or to win protections and the possibility of a new political community for themselves and others, should focus a substantial part of their energies and attention on developing alternative infrastructure systems for supporting human life. Without such systems, political action – no matter how revolutionary or ingenious – will ultimately find itself constrained by its position within the zones of survivability established by existing forms of infrastructure and by the hierarchies and configurations of power linked with those forms of infrastructure. As a result, those who wish to change current political and economic conditions should think of the capacity to take care of everyone as a condition for such change rather than its result.
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Biologically-Based and Physiochemical Life Support and In Situ Resource Utilization for Exploration of the Solar System-Reviewing the Current State and Defining Future Development Needs. Life (Basel) 2021; 11:844. [PMID: 34440588 PMCID: PMC8398003 DOI: 10.3390/life11080844] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/02/2021] [Accepted: 08/07/2021] [Indexed: 12/02/2022] Open
Abstract
The future of long-duration spaceflight missions will place our vehicles and crew outside of the comfort of low-Earth orbit. Luxuries of quick resupply and frequent crew changes will not be available. Future missions will have to be adapted to low resource environments and be suited to use resources at their destinations to complete the latter parts of the mission. This includes the production of food, oxygen, and return fuel for human flight. In this chapter, we performed a review of the current literature, and offer a vision for the implementation of cyanobacteria-based bio-regenerative life support systems and in situ resource utilization during long duration expeditions, using the Moon and Mars for examples. Much work has been done to understand the nutritional benefits of cyanobacteria and their ability to survive in extreme environments like what is expected on other celestial objects. Fuel production is still in its infancy, but cyanobacterial production of methane is a promising front. In this chapter, we put forth a vision of a three-stage reactor system for regolith processing, nutritional and atmospheric production, and biofuel production as well as diving into what that system will look like during flight and a discussion on containment considerations.
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Life Support Preferences in the Context of COVID-19: Results from a National US Survey. Med Decis Making 2021; 41:963-969. [PMID: 34053355 DOI: 10.1177/0272989x211016313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Transitioning to Web-Based Learning in Basic Life Support Training During the COVID-19 Pandemic to Battle the Fear of Out-of-Hospital Cardiac Arrest: Presentation of Novel Methods. J Med Internet Res 2021; 23:e27108. [PMID: 33886488 PMCID: PMC8153032 DOI: 10.2196/27108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/28/2021] [Accepted: 03/22/2021] [Indexed: 01/19/2023] Open
Abstract
Ongoing training in the area of basic life support aims to encourage and sustain the willingness to act in out-of-hospital cardiac arrest situations among first aiders. The contribution of witnesses and first aiders has diminished rapidly, as suspicion associated with the COVID-19 pandemic has risen. In this paper, we present teaching methods from the medical education field to create a new teaching-learning process for sustaining the prehospital involvement of first aiders and encourage new first aiders. The most important benefit-improving outcomes-can be achieved by introducing a variety of teaching-learning methods and formative assessments that provide participants with immediate feedback to help them move forward in the basic life support course. The new reality of web-based learning that has been introduced by the pandemic requires an innovative approach to traditional training that involves techniques and methods that have been proven to be useful in other fields.
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We Want More Than Life-Sustaining Treatment during End-of-Life Care: Focus-Group Interviews. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094415. [PMID: 33919357 PMCID: PMC8122594 DOI: 10.3390/ijerph18094415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 12/30/2022]
Abstract
We qualitatively investigated end-of-life care needs. Data were collected via focus-group interviews with three groups: young adults, middle-aged adults, and older adults. The key question was, "What kind of care would you like to receive at the end of life?" Interview data were transcribed and analyzed using content analysis. End-of-life care needs were classified into six categories: life-sustaining treatment needs, physical care needs, emotional care needs, environmental needs, needs for respect, and needs for preparation for death. Because the Korean culture is family-oriented and talking about death is taboo, Korean patients at the end of their life do not make decisions about life-sustaining treatment or actively prepare for death. Therefore, to provide proper end-of-life care, conversations and shared decision-making among patients and their families are crucial. Further, we must respect patients' dignity and help them achieve a good death by understanding patients' basic care preferences. Future research should continue examining end-of-life care needs that reflect the social and cultural context of Korea to inform instrument development.
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Differences in Basic Life Support Knowledge Between Junior Medical Students and Lay People: Web-Based Questionnaire Study. J Med Internet Res 2021; 23:e25125. [PMID: 33620322 PMCID: PMC7943337 DOI: 10.2196/25125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/06/2021] [Accepted: 01/31/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early cardiopulmonary resuscitation and prompt defibrillation markedly increase the survival rate in the event of out-of-hospital cardiac arrest (OHCA). As future health care professionals, medical students should be trained to efficiently manage an unexpectedly encountered OHCA. OBJECTIVE Our aim was to assess basic life support (BLS) knowledge in junior medical students at the University of Geneva Faculty of Medicine (UGFM) and to compare it with that of the general population. METHODS Junior UGFM students and lay people who had registered for BLS classes given by a Red Cross-affiliated center were sent invitation links to complete a web-based questionnaire. The primary outcome was the between-group difference in a 10-question score regarding cardiopulmonary resuscitation knowledge. Secondary outcomes were the differences in the rate of correct answers for each individual question, the level of self-assessed confidence in the ability to perform resuscitation, and a 6-question score, "essential BLS knowledge," which only contains key elements of the chain of survival. Continuous variables were first analyzed using the Student t test, then by multivariable linear regression. Fisher exact test was used for between-groups comparison of binary variables. RESULTS The mean score was higher in medical students than in lay people for both the 10-question score (mean 5.8, SD 1.7 vs mean 4.2, SD 1.7; P<.001) and 6-question score (mean 3.0, SD 1.1 vs mean 2.0, SD 1.0; P<.001). Participants who were younger or already trained scored consistently better. Although the phone number of the emergency medical dispatch center was well known in both groups (medical students, 75/80, 94% vs lay people, 51/62, 82%; P=.06), most participants were unable to identify the criteria used to recognize OHCA, and almost none were able to correctly reorganize the BLS sequence. Medical students felt more confident than lay people in their ability to perform resuscitation (mean 4.7, SD 2.2 vs mean 3.1, SD 2.1; P<.001). Female gender and older age were associated with lower confidence, while participants who had already attended a BLS course prior to taking the questionnaire felt more confident. CONCLUSIONS Although junior medical students were more knowledgeable than lay people regarding BLS procedures, the proportion of correct answers was low in both groups, and changes in BLS education policy should be considered.
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The effect of knowledge levels of individuals receiving basic first aid training in Turkey on the applications of first aid. Niger J Clin Pract 2020; 23:1449-1455. [PMID: 33047705 DOI: 10.4103/njcp.njcp_686_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives To evaluate the knowledge level of individuals who attended a first aid training update program, and to determine the factors affecting their approaches in such cases. Methods This is a descriptive cross-sectional study. The sample of the research consists of 747 individuals (laypersons) who applied to the first aid training update organized in an institution in Istanbul providing health education between 01.02.2018 and 01.08.2018, and who agreed to participate in the research. These first aid trainings are provided by healthcare professionals who have first aid certificate of authority within the scope of first aid regulation. Data were collected using the "Participant Information Form" and the "Basic First Aid Knowledge Level Evaluation Form". Results The participants administered first aid within the three years of time following their basic first aid training course (24.6%). They administered first aid primarily in emergency cases of fainting (29.6%) and the majority of them (95.7%) did not perform cardiopulmonary resuscitation during their basic first aid effort. Of the participants, 73.9% answered incorrectly the question: "The letter 'A' in the abbreviation ABC of basic life support administration stands for airway". In our study, it was also found that there was a significant relationship between the total knowledge score and the number of trainings update and first aid intervention in the last three years (P < 0.05, P < 0.001, respectively). Conclusions It was determined that individuals had a high level of knowledge about basic first aid and one-quarter of the participants had administered first aid in the last three years. In order for individuals not to lose their knowledge and skills gained through first aid training; updating training and providing first aid training programs to individuals in society can be a guide for bystanders who provide faster and sufficient first aid in cases of emergency.
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Living on Borrowed Breath: Respiratory Distress, Social Breathing, and the Vital Movement of Ventilators. Med Anthropol Q 2020; 35:102-119. [PMID: 32812269 PMCID: PMC7461308 DOI: 10.1111/maq.12603] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022]
Abstract
Based on ethnographic research in a public hospital trauma intensive care unit in Mumbai, India, this article formulates the concept of "social breathing" to analyze how breath is central to values of life at the edges of death. Case studies of emergency resuscitation, intubation, and ventilation each illustrate breathing's sociality, as people and machines move air both materially and immaterially. Amid the hospital's rationing of life support technologies, forms of life that seem to be self-regulated are better understood as relational movements of breath. Social breathing stands to reshape our understanding of the biopolitics of intensive care by drawing attention to uncertain techniques of the body. These techniques move at the hinge between person and environment, self and other, public and private health care systems, and medicine and machine. Life's valuation at this hinge takes shape through breath moving against its limits. Ultimately, the article argues that it is crucial to understand how ventilators mediate the edges of life and death by tracing the circulations of life support as the movements of life itself. As patients, families, and hospital workers struggle to make and manage breath, we might better grapple with the social relations that emerge as life support shapes life.
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International technical transfer of training systems and skills in emergency medicine and trauma management: experiences of the National Center for Global Health and Medicine, Japan. Glob Health Med 2020; 2:24-28. [PMID: 33330770 DOI: 10.35772/ghm.2019.01016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/17/2020] [Accepted: 01/28/2020] [Indexed: 11/08/2022]
Abstract
For over 20 years, the National Center for Global Health and Medicine (NCGM), Japan has been involved in international assistance for emergency medicine and trauma management in many countries, including Bolivia, Vietnam, Laos, Cambodia, and Mongolia. Among the NCGM activities conducted, the most important is technical assistance for the appropriate transfer of training systems and skills in life support management. In most of the target countries, the development and execution of customized simulation training suitable for each setting has successfully motivated trainees, who are healthcare workers responsible for improving emergency medical services in their home country. Moreover, the development of appropriate training systems for trainers selected from among capable participants has played a key role in the subsequent sustained conducting of training courses independent of NCGM involvement.
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Pressure and flow properties of cannulae for extracorporeal membrane oxygenation II: drainage (venous) cannulae. Perfusion 2020; 34:65-73. [PMID: 30966909 DOI: 10.1177/0267659119830514] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of extracorporeal life support devices such as extracorporeal membrane oxygenation in adults requires cannulation of the patient's vessels with comparatively large diameter cannulae to allow circulation of large volumes of blood (>5 L/min). The cannula diameter and length are the major determinants for extracorporeal membrane oxygenation flow. Manufacturing companies present pressure-flow charts for the cannulae; however, these tests are performed with water. Aims of this study were 1. to investigate the specified pressure-flow charts obtained when using human blood as the circulating medium and 2. to support extracorporeal membrane oxygenation providers with pressure-flow data for correct choice of the cannula to reach an optimal flow with optimal hydrodynamic performance. Eighteen extracorporeal membrane oxygenation drainage cannulae, donated by the manufacturers (n = 6), were studied in a centrifugal pump driven mock loop. Pressure-flow properties and cannula features were described. The results showed that when blood with a hematocrit of 27% was used, the drainage pressure was consistently higher for a given flow (range 10%-350%) than when water was used (data from each respective manufacturer's product information). It is concluded that the information provided by manufacturers in line with regulatory guidelines does not correspond to clinical performance and therefore may not provide the best guidance for clinicians.
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Abstract
PURPOSE Family meetings in the medical intensive care unit can improve outcomes. Little is known about when meetings occur in practice. We aimed to determine the time from admission to family meetings in the medical intensive care unit and assess the relationship of meetings with mortality. METHODS We performed a prospective cohort study of critically ill adult patients admitted to the medical intensive care unit at an urban academic medical center. Using manual chart review, the primary outcome was any attempt at holding a family meeting within 72 hours of admission. Competing risk models estimated the time from admission to family meeting and to patient death or discharge. RESULTS Of the 131 patients who met inclusion criteria in the 12-month study period, the median time from admission to family meeting was 4 days. Fewer than half of patients had a documented family meeting within 72 hours of admission (n = 60/131, 46%), with substantial interphysician variability in meeting rates ranging from 28% to 63%. Patients with family meetings within 72 hours were 30 times more likely to die within 72 hours (32% vs 1%, P < .001). Of the 55 patients who died in the intensive care unit, 27 (49%) had their first family meeting within 1 day of death. CONCLUSIONS Family meetings occur considerably later than 72 hours and are often held in close proximity to a patient's death. This suggests for some physicians, family meetings may primarily be used to negotiate withdrawal of life support rather than to support the patient and family.
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Does Calculated Prognostic Estimation Lead to Different Outcomes Compared With Experience-Based Prognostication in the ICU? A Systematic Review. Crit Care Explor 2019; 1:e0004. [PMID: 32166250 DOI: 10.1097/cce.0000000000000004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Little is known about the impact of providing calculator/guideline based versus clinical experiential-based prognostic estimates to patients/caregivers in the ICU. We sought to determine whether studies have compared types of prognostic estimation in the ICU and associations with outcomes. Data Sources Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases searched were PubMed, Embase, Web of Science, and Cochrane Library. The search was run on January 4, 2016, and April 12, 2017. References for included articles were searched. Study Selection Studies meeting the following criteria were included in the analysis: communication of prognostic estimates, a comparator group, and in the adult ICU setting. Data Extraction Titles/abstracts were reviewed by two researchers. We identified 10,704 articles of which 10 met inclusion criteria. Seven of the studies included estimates obtained from calculators/guidelines and three were based on subjective estimation wherein clinicians were asked to estimate prognosis based on experience. Only the seven using calculated/guideline based estimation were used for pooled analysis. Of these, one was a randomized trial, and six were nonrandomized before/after studies. All of the studies communicated the calculated/guideline-based estimates to the clinician. Two studies involved the communication of calculated prognostic estimates to the ICU physicians for all ICU patients. Four included identification of high-risk patients based on guidelines or review of historical local data which triggered a palliative care/ethics consultation, and one study included communication to physicians about guideline based likely outcomes for neurologic recovery for patients with out-of-hospital cardiac arrest survivors. The comparator arm in all studies was usual care without protocolized prognostication. Data Synthesis Included studies were assessed for risk of bias. The most common outcomes measured were hospital mortality; do-not-resuscitate status; and medical ICU length of stay. In pooled analyses, there was an association between calculated/guideline based prognostic estimation and decreased medical ICU length of stay as well as increased do-not-resuscitate status, but no difference in hospital mortality. Conclusions Protocolized assessment of calculator/guideline based prognosis in ICU patients is associated with decreased medical ICU length of stay and increased do-not-resuscitate status but does not have a significant effect on mortality. Future studies should explore how communicating these estimates to physicians changes behaviors including communication to patients/families and whether calculator/guideline based prognostication is associated with improved patient and family rated outcomes.
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Testing New Concepts for Crop Cultivation in Space: Effects of Rooting Volume and Nitrogen Availability. Life (Basel) 2018; 8:E45. [PMID: 30301223 PMCID: PMC6316757 DOI: 10.3390/life8040045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 09/24/2018] [Accepted: 10/03/2018] [Indexed: 01/18/2023] Open
Abstract
Long term human missions to the Moon and Mars, rely on life support systems for food production and regeneration of resources. In the EU H2020 TIME SCALE-project, an advanced life support system concept was developed to facilitate plant research and technology demonstration under different gravity conditions. Ground experiments assessed irrigation systems and effects of rooting- and nutrient solution volume. The maximal allowed volume for existing International Space Station research facilities (3.4 L) was able to support cultivation of two lettuce heads for at least 24 days. A smaller rooting volume (0.6 L) increased root biomass after 24 days, but induced a 5% reduction in total biomass at day 35. Regulating effects of nitrate supply on plant water fluxes in light and dark were also investigated. At low concentrations of nitrate in the nutrient solution, both transpiration and stomatal conductance increased rapidly with increasing nitrate concentration. During day-time this increase levelled off at high concentrations, while during nigh-time there was a distinct decline at supra optimal concentrations. Plants supplied with nitrate concentrations as low as 1.25 mM did not show visible signs of nutrient stress or growth reduction. These findings hold promise for both reducing the environmental impact of terrestrial horticulture and avoiding nutrient stress in small scale closed cultivation systems for space.
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A Decision Aid to Support Shared Decision Making About Mechanical Ventilation in Severe Chronic Obstructive Pulmonary Disease Patients (InformedTogether): Feasibility Study. J Particip Med 2018; 10:e7. [PMID: 32461812 PMCID: PMC7251980 DOI: 10.2196/jopm.9877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Severe Chronic Obstructive Pulmonary Disease patients are often unprepared to make decisions about accepting intubation for respiratory failure. We developed a Web-based decision aid, InformedTogether, to facilitate severe Chronic Obstructive Pulmonary Disease patients’ preparation for decision making about whether to accept invasive mechanical ventilation for respiratory failure. Objective We describe feasibility testing of the InformedTogether decision aid. Methods Mixed methods, pre- and postintervention feasibility study in outpatient pulmonary and geriatric clinics. Clinicians used InformedTogether with severe Chronic Obstructive Pulmonary Disease patients. Patient-participants completed pre- and postassessments about InformedTogether use. The outcomes measured were the following: feasibility/acceptability, communication (Combined Outcome Measure for Risk Communication [COMRADE], Medical Communication Competency Scale [MCCS], Observing Patient Involvement [OPTION] scales), and effectiveness of InformedTogether on changing patients' knowledge, Decisional Conflict Scale, and motivation. Results We enrolled 11 clinicians and 38 Chronic Obstructive Pulmonary Disease patients at six sites. Feasibility/acceptability: Clinicians and patients gave positive responses to acceptability questions (mean 74.1/89 max [SD 7.24] and mean 59.63/61 [SD 4.49], respectively). Communication: 96% of clinicians stated InformedTogether improved communication (modified MCCS mean 44.54/49 [SD 2.97]; mean OPTION score 32.03/48 [SD 9.27]; mean COMRADE Satisfaction 4.31/5.0 [SD 0.58]; and COMRADE Confidence 4.18/5.0 [SD 0.56]). Preference: Eighty percent of patients discussed preferences with their surrogates by 1-month. Effectiveness: Knowledge scores increased significantly after using InformedTogether (mean difference 3.61 [SD 3. 44], P=.001) and Decisional Conflict decreased (mean difference Decisional Conflict Scale pre/post -13.76 [SD 20.39], P=.006). Motivation increased after viewing the decision aid. Conclusions InformedTogether supports high-quality communication and shared decision making among Chronic Obstructive Pulmonary Disease patients, clinicians, and surrogates. The increased knowledge and opportunity to deliberate and discuss treatment choices after using InformedTogether should lead to improved decision making at the time of critical illness.
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Editorial: Extra-Corporeal Membrane Oxygenation in Pediatric Cardiac Patients. Front Pediatr 2018; 6:204. [PMID: 30105222 PMCID: PMC6077222 DOI: 10.3389/fped.2018.00204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/28/2018] [Indexed: 11/13/2022] Open
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Factors Associated with the Need for, and the Impact of, Extracorporeal Membrane Oxygenation in Children with Congenital Heart Disease during Admissions for Cardiac Surgery. CHILDREN-BASEL 2017; 4:children4110101. [PMID: 29165381 PMCID: PMC5704135 DOI: 10.3390/children4110101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/02/2017] [Accepted: 11/15/2017] [Indexed: 12/21/2022]
Abstract
Introduction: This study aimed to determine factors associated with the need for extracorporeal membrane oxygenation (ECMO) in children with congenital heart disease (CHD) during admission for cardiac surgery (CS). A secondary aim was to determine how ECMO impacted length, cost, and mortality of the admission. Methods: Data from the Kids’ Inpatient Database (KIDS) were utilized. Admissions with CHD under 18 years of age with cardiac surgery were included. Need for ECMO in these admissions was then identified. Univariate analysis was conducted to compare characteristics between admissions with and without ECMO. Regression analyses were conducted to determine what factors were independently associated with ECMO and whether ECMO independently impacted admission characteristics. Results: A total of 46,176 admissions with CHD and CS were included in the final analysis. Of these, 798 (1.7%) required ECMO. Median age of ECMO admissions was 0.5 years. The following were associated with ECMO: decreased age, heart failure, acute kidney injury, arrhythmia, double outlet right ventricle, atrioventricular septal defect, transposition, Ebstein anomaly, hypoplastic left heart syndrome, common arterial trunk, tetralogy of Fallot, coronary anomaly, valvuloplasty, repair of total anomalous pulmonary venous connection, arterial switch, RV to PA conduit placement, and heart transplant (p < 0.01). ECMO independently increased length of stay by 17.8 days, cost of stay by approximately $415,917, and inpatient mortality 22-fold. Conclusion: Only a small proportion of CHD patients undergoing CS require ECMO, although these patients require increased resource utilization and have high mortality. Specific cardiac lesions, cardiac surgeries, and comorbidities are associated with increased need for ECMO.
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The Paradox of End-of-Life Hospital Treatment Intensity among Black Patients: A Retrospective Cohort Study. J Palliat Med 2017; 21:69-77. [PMID: 29106315 DOI: 10.1089/jpm.2016.0557] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Black patients are more likely than white patients to die in the hospital with intensive care and life-sustaining treatments and less likely to use hospice. Regional concentration of high end-of-life (EOL) treatment intensity practice patterns may disproportionately affect black patients. We calculated and compared race-specific hospital-level EOL treatment intensity in Pennsylvania. METHODS We conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions, 2001-2007, among black and white admissions ≥21 years old at high probability of dying (HPD) (≥15% predicted probability of dying at admission). We calculated hospitals' race-specific observed, expected, and Bayes' shrunken observed-to-expected ratios of intensive care unit (ICU) admission, ICU length of stay (LOS), intubation/mechanical ventilation, hemodialysis, tracheostomy, and gastrostomy among HPD admissions; and an empirically weighted EOL treatment intensity index summing these ratios. RESULTS There were 35,609 black HPD admissions (27,576 unique patients) and 311,896 white HPD admissions (252,662 unique patients) to 182 hospitals. Among 95 hospitals with ≥30 black HPD admissions, 80% of black admissions were concentrated in 29 hospitals, where black-specific observed and expected EOL measures were usually higher than white-specific measures (p < 0.001 for all but 5/24 measures). Hospitals' black-specific and white-specific observed-to-expected ratios of ICU and life-sustaining treatment (LST) (rho 0.52-0.90) and EOL index (rho = 0.92) were highly correlated. However, black-specific observed-to-expected ratios and overall EOL intensity index were consistently lower than white-specific ratios (p < 0.001 for all except hemodialysis). CONCLUSIONS In Pennsylvania, black-serving hospitals have higher standardized EOL treatment intensity than nonblack-serving hospitals, contributing to black patients' relatively higher use of intensive treatment. However, conditional on being admitted to the same high-intensity hospital and after risk adjustment, blacks are less intensively treated than whites.
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A bench evaluation of fraction of oxygen in air delivery and tidal volume accuracy in home care ventilators available for hospital use. J Thorac Dis 2016; 8:3639-3647. [PMID: 28149559 DOI: 10.21037/jtd.2016.12.64] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Turbine-powered ventilators are not only designed for long-term ventilation at home but also for hospital use. It is important to verify their capabilities in delivering fraction of oxygen in air (FIO2) and tidal volume (VT). METHODS We assessed the FIO2 accuracy and the VT delivery in four home care ventilators (HCV) on the bench. The four HCV were Astral 150, Elisée 150, Monnal T50 and Trilogy 200 HCV, which were connected to a lung model (ASL 5000). For assessing FIO2 accuracy, lung model was set to mimic an obstructive lung and HCV were set in volume controlled mode (VC). They supplied with air, 3 or 15 L/min oxygen and FIO2 was measured by using a ventilator tester (Citrex H4TM). For the VT accuracy, the lung model was set in a way to mimic three adult configurations (normal, obstructive, or restrictive respiratory disorder) and one pediatric configuration. Each HCV was set in VC. Two VT (300 and 500 mL) in adult lung configuration and one 50 mL VT in pediatric lung configuration, at two positive end expiratory pressures 5 and 10 cmH2O, were tested. VT accuracy was measured as volume error (the relative difference between set and measured VT). Statistical analysis was performed by suing one-factor ANOVA with a Bonferroni correction for multiple tests. RESULTS For Astral 150, Elisée 150, Monnal T50 and Trilogy 200, FIO2 averaged 99.2%, 93.7%, 86.3%, and 62.1%, respectively, at 15 L/min oxygen supplementation rate (P<0.001). Volume error was 0.5%±0%, -38%±0%, -9%±0%, -29%±0% and -36%±0% for pediatric lung condition (P<0.001). In adult lung configurations, Monnal T50 systematically over delivered VT and Trilogy 150 was sensitive to lung configuration when VT was set to 300 mL at either positive end-expiratory pressure (PEEP). CONCLUSIONS HCV are different in terms of FIO2 efficiency and VT delivery.
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Abstract
Space synthetic biology is a branch of biotechnology dedicated to engineering biological systems for space exploration, industry and science. There is significant public and private interest in designing robust and reliable organisms that can assist on long-duration astronaut missions. Recent work has also demonstrated that such synthetic biology is a feasible payload minimization and life support approach as well. This article identifies the challenges and opportunities that lie ahead in the field of space synthetic biology, while highlighting relevant progress. It also outlines anticipated broader benefits from this field, because space engineering advances will drive technological innovation on Earth.
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Part 3: Ethical Issues: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2016; 132:S383-96. [PMID: 26472991 DOI: 10.1161/cir.0000000000000254] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
OBJECTIVE Advanced Cardiovascular Life Support (ACLS) in life-threatening situations is perceived as a basic skill for dental professionals. However, medical emergency training in dental schools is often not standardized. The dental students' knowledge transfer to an ACLS setting thus remains questionable. The aim of the study was to evaluate dental pre-doctorate students' practical competence in ACLS in a standardized manner to enable the curriculum to be adapted to meet their particular needs. MATERIALS AND METHODS Thirty dental students (age 25.47 ± 1.81; 16 male/14 female) in their last year of dental studies were randomly assigned to 15 teams. Students' ability to successfully manage ACLS was assessed by a scenario-based approach (training module: Laerdal® ALS Skillmaster). Competence was assessed by means of (a) an observation chart, (b) video analysis and (c) training module analysis (Laerdal HeartSim®4000; Version 1.4). The evaluation was conducted by a trained anesthesiologist with regard to the 2010 guidelines of the European Resuscitation Council (ERC). RESULTS Only five teams (33.3%) checked for all three vital functions (response, breathing and circulation). All teams initiated cardiopulmonary resuscitation (CPR). Only 54.12% of the compressions performed during CPR were sufficient. Four teams stopped the CPR after initiation. In total, 93% of the teams used the equipment for bag-valve-mask ventilation and 53.3% used the AED (Automated external defibrillator). CONCLUSIONS ACLS training on a regular basis is necessary and, consistent with a close link between dentistry and medicine, should be a standardized part of the medical emergency curriculum for dental students with a specific focus on the deficiencies revealed in this study.
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Abstract
OBJECTIVES To validate the recently described Mercy method for weight estimation in an independent cohort of children living in the United States. METHODS Anthropometric data including weight, height, humeral length, and mid upper arm circumference were collected from 976 otherwise healthy children (2 months to 14 years old). The data were used to examine the predictive performances of the Mercy method and four other weight estimation strategies (the Advanced Pediatric Life Support [APLS] method, the Broselow tape, and the Luscombe and Owens and the Nelson methods). RESULTS THE MERCY METHOD DEMONSTRATED ACCURACY COMPARABLE TO THAT OBSERVED IN THE ORIGINAL STUDY (MEAN ERROR: -0.3 kg; mean percentage error: -0.3%; root mean square error: 2.62 kg; 95% limits of agreement: 0.83-1.19). This method estimated weight within 20% of actual for 95% of children compared with 58.7% for APLS, 78% for Broselow, 54.4% for Luscombe and Owens, and 70.4% for Nelson. Furthermore, the Mercy method was the only weight estimation strategy which enabled prediction of weight in all of the children enrolled. CONCLUSIONS The Mercy method proved to be highly accurate and more robust than existing weight estimation strategies across a wider range of age and body mass index values, thereby making it superior to other existing approaches.
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Recommendations to limit life support: a national survey of critical care physicians. Am J Respir Crit Care Med 2012; 186:633-9. [PMID: 22837382 PMCID: PMC3480524 DOI: 10.1164/rccm.201202-0354oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 07/14/2012] [Indexed: 11/16/2022] Open
Abstract
RATIONALE There is debate about whether physicians should routinely provide patient surrogates with recommendations about limiting life support. OBJECTIVES To explore physicians' self-reported practices and attitudes. METHODS A cross-sectional, stratified survey of 1,000 randomly selected US critical care physicians was mailed. We included a vignette to experimentally examine how surrogate desire for a recommendation and physician agreement with the surrogate modified whether physicians would provide a recommendation. MEASUREMENTS AND MAIN RESULTS Proportion of respondents reporting they routinely provide surrogates with a recommendation and how responses varied based on vignette characteristics. A total of 608 (66%) of 922 eligible physicians participated. Approximately one (22%) in five reported always providing surrogates with a recommendation, whereas 1 (11%) in 10 reported rarely or never doing so. Almost all respondents reported comfort making recommendations (92%) and viewed them as appropriate (93%). Most also viewed recommendations as a critical care physician's duty (87%) and did not view them as unduly influential (80%). Approximately two-fifths (41%) believed recommendations were only appropriate if sought by surrogates. In response to the vignettes, nearly all respondents (91%) provided a recommendation when the surrogate requested a recommendation and the physician agreed with the surrogate's likely decision. Physicians were less likely to provide an unwanted recommendation, both when physicians agreed (29%) and disagreed with the surrogate's likely decision (44%). CONCLUSIONS There is substantial variation among physicians' self-reported use of recommendations to surrogates of critically ill adults. Surrogates' desires for recommendations and physicians' agreement with surrogates' likely decisions may have important influence on whether recommendations are provided.
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Prehospital trauma care reduces mortality. Ten-year results from a time-cohort and trauma audit study in Iraq. Scand J Trauma Resusc Emerg Med 2012; 20:13. [PMID: 22304808 PMCID: PMC3298775 DOI: 10.1186/1757-7241-20-13] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 02/03/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Blunt implementation of Western trauma system models is not feasible in low-resource communities with long prehospital transit times. The aims of the study were to evaluate to which extent a low-cost prehospital trauma system reduces trauma deaths where prehospital transit times are long, and to identify specific life support interventions that contributed to survival. METHODS In the study period from 1997 to 2006, 2,788 patients injured by land mines, war, and traffic accidents were managed by a chain-of-survival trauma system where non-graduate paramedics were the key care providers. The study was conducted with a time-period cohort design. RESULTS 37% of the study patients had serious injuries with Injury Severity Score ≥ 9. The mean prehospital transport time was 2.5 hours (95% CI 1.9 - 3.2). During the ten-year study period trauma mortality was reduced from 17% (95% CI 15 -19) to 4% (95% CI 3.5 - 5), survival especially improving in major trauma victims. In most patients with airway problems, in chest injured, and in patients with external hemorrhage, simple life support measures were sufficient to improve physiological severity indicators. CONCLUSION In case of long prehospital transit times simple life support measures by paramedics and lay first responders reduce trauma mortality in major injuries. Delegating life-saving skills to paramedics and lay people is a key factor for efficient prehospital trauma systems in low-resource communities.
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Abstract
BACKGROUND Although experts advocate that physicians should express empathy to support family members faced with difficult end-of-life decisions for incapacitated patients, it is unknown whether and how this occurs in practice. OBJECTIVES To determine whether clinicians express empathy during deliberations with families about limiting life support, to develop a framework to understand these expressions of empathy, and to determine whether there is an association between more empathic statements by clinicians and family satisfaction with communication. DESIGN Multi-center, prospective study of audiotaped physician-family conferences in intensive care units of four hospitals in 2000-2002. MEASUREMENTS We audiotaped 51 clinician-family conferences that addressed end-of-life decisions. We coded the transcripts to identify empathic statements and used constant comparative methods to categorize the types of empathic statements. We used generalized estimating equations to determine the association between empathic statements and family satisfaction with communication. MAIN RESULTS There was at least one empathic statement in 66% (34/51) of conferences with a mean of 1.6 +/- 1.6 empathic statements per conference (range 0-8). We identified three main types of empathic statements: statements about the difficulty of having a critically ill loved one (31% of conferences), statements about the difficulty of surrogate decision-making (43% of conferences), and statements about the difficulty of confronting death (27% of conferences). Only 30% of empathic statements were in response to an explicit expression of emotion by family members. There was a significant association between more empathic statements and higher family satisfaction with communication (p = 0.04). CONCLUSIONS Physicians vary considerably in the extent to which they express empathy to surrogates during deliberations about life support, with no empathic statements in one-third of conferences. There is an association between more empathic statements and higher family satisfaction with communication.
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Abstract
It is widely accepted in clinical ethics that removing a patient from a ventilator at the patient's request is ethically permissible. This constitutes voluntary passive euthanasia. However, voluntary active euthanasia, such as giving a patient a lethal overdose with the intention of ending that patient's life, is ethically proscribed, as is assisted suicide, such as providing a patient with lethal pills or a lethal infusion. Proponents of voluntary active euthanasia and assisted suicide have argued that the distinction between killing and letting die is flawed and that there is no real difference between actively ending someone's life and "merely" allowing them to die. This paper shows that, although this view is correct, there is even less of a distinction than is commonly acknowledged in the literature. It does so by suggesting a new perspective that more accurately reflects the moral features of end-of-life situations: if a patient is mentally competent and wants to die, his body itself constitutes unwarranted life support unfairly prolonging his or her mental life.
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'No resuscitation' orders: perspectives, policies, problems and procedures. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 1985; 31:1675-1678. [PMID: 21274178 PMCID: PMC2327843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Chedoke-McMaster Hospitals in Hamilton have evolved a 'No CPR' Policy for over seven years. This article describes some of the important ethical, administrative and practical clinical factors in successful application of a 'No CPR' order to the management of terminally ill patients. The role of the attending physician is critical in negotiating 'No CPR' decisions with patients and families. Physicians' attitudes toward death and their perceptions of their professional responsibilities for patients determine if and how an order will be written. Several clinical strategies are suggested to help negotiate a 'no CPR' decision.
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