Andrew C. Miller

Cardiac rehabilitation using the Family-Centered Empowerment Model versus home-based cardiac rehabilitation in patients with myocardial infarction: a randomised controlled trial.

Objective To determine if a hybrid cardiac rehabilitation (CR) programme using the Family-Centered Empowerment Model (FCEM) as compared with standard CR will improve patient quality of life, perceived stress and state anxiety of patients with myocardial infarction (MI). Methods We conducted a randomised controlled trial in which patients received either standard home CR or CR using the FCEM strategy. Patient empowerment was measured with FCEM questionnaires preintervention and postintervention for a total of 9 assessments. Quality of life, perceived stress, and state and trait anxiety were assessed using the 36-Item Short Form Health Survey (SF-36), the 14-item Perceived Stress, and the 20-item State and 20-item Trait Anxiety questionnaires, respectively. Results 70 patients were randomised. Baseline characteristics were similar. Ejection fraction was significantly higher in the intervention group at measurements 2 (p=0.01) and 3 (p=0.001). Exercise tolerance measured as walking distance was significantly improved in the intervention group throughout the study. The quality of life results in the FCEM group showed significant improvement both within the group over time (p<0.0001) and when compared with control (p<0.0001). Similarly, the perceived stress and state anxiety results showed significant improvement both within the FCEM group over time (p<0.0001) and when compared with control (p<0.0001). No significant difference was found either within or between groups for trait anxiety. Conclusions The family-centred empowerment model may be an effective hybrid cardiac rehabilitation method for improving the physical and mental health of patients post-MI; however, further study is needed to validate these findings. Clinical Trials.gov identifier NCT02402582. Trial registration number NCT02402582.

Opinions on the Legitimacy of Brain Death Among Sunni and Shi’a Scholars

Abstract The concept of brain death poses a great challenge to clinicians who may be required to bridge the interface of culture, religion, law, and medicine. This review discusses and applies Islamic jurisprudence to the question of whether brain death is accepted as true death under Islamic law. Among the five sources of Islamic law, the Qur’an and Sunnah do not directly address brain death. Scholarly consensus (Ijmā’) does not exist, and Qiya does not apply. When applying Ijtihad, the identified collection of non-binding fatwā offer conflicting results. Debate continues as to the validity of brain-death criteria within Islamic circles.

High-Frequency Ventilation Modalities as Salvage Therapy for Smoke Inhalation–Associated Acute Lung Injury: A Systematic Review

Background: Smoke inhalation–associated acute lung injury (SI-ALI) is a major cause of morbidity and mortality in victims of fire tragedies. To date, there are no evidence-based guidelines on ventilation strategies in acute respiratory distress syndrome (ARDS) after smoke inhalation. We reviewed the existing literature for clinical studies of salvage mechanical ventilation (MV) strategies in patients with SI-ALI, focusing on mortality and pneumonia as outcomes. Methods: A systematic search was designed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Risk of bias assessment was performed using the Newcastle-Ottawa Quality Assessment Scale (NOS; 0 to 9 stars), with a score ≥7 being the threshold for inclusion in the meta-analysis. A systematic search strategy was used to search 10 databases. Clinical studies were included in which patients: (1) experienced smoke inhalation, (2) treated with MV, and (3) described a concurrent or historical control group. Results: A total of 226 potentially relevant studies were identified, of which 7 studies on high-frequency percussive ventilation (HFPV) met inclusion criteria. No studies met inclusion for meta-analysis (NOS ≥ 7). In studies comparing HFPV to conventional mechanical ventilation (CMV), mortality and pneumonia incidence improved in 3 studies and remained unchanged in 3 others. No change in ventilator days or ICU length of stay was observed; however, oxygenation and work of breathing improved with HFPV. Conclusions: Mechanical ventilation in patients with SI-ALI has not been well studied. High-frequency percussive ventilation may decrease in-hospital mortality and pneumonia incidence when compared to CMV. The absence of “good” quality evidence precluded meta-analysis. Based upon low-quality evidence, there was a very weak recommendation that HFPV use may be associated with lower mortality and pneumonia rates in patients with SI-ALI. Given SI-ALI’s unique underlying pathophysiology, and its potential implications on therapy, randomized controlled studies are required to ensure that patients receive the safest and most effective care. Trial Registration: The study was registered with PROSPERO International prospective register of systematic reviews (#47015).

Effects of Stress on Critical Care Nurses: A National Cross-Sectional Study

Background: Health care is a demanding field, with a high level of responsibility and exposure to emotional and physical danger. High levels of stress may result in depression, anxiety, burnout syndrome, and in extreme cases, post-traumatic stress disorder. The aim of this study was to determine which personal, professional, and organizational variables are associated with greater perceived stress among critical care nurses for purposes of developing integrative solutions to decrease stress in the future. Methods: We conducted a correlation research survey using a cross-sectional design and an in-person survey method. The questionnaire consisted of 2 parts: (1) socioeconomic, professional, and institutional variables and (2) work stressors. Surveys were conducted between January 1, 2011, and December 1, 2015. Multistage cluster random sampling was utilized for data collection. Inclusion criteria were (1) age ≥18 years, (2) registered nurse, (3) works in the intensive care unit (ICU), and (4) willing and able to complete the survey. Results: We surveyed 21 767 ICU nurses in Iran and found that male sex, lower levels of peer collaboration, working with a supervisor in the unit, nurse–patient ratios, and working in a surgical ICU were positively associated with greater stress levels. Increasing age and married status were negatively associated with stress. Intensive care unit type (semi-closed vs open), ICU bed number, shift time, working on holidays, education level, and demographic factors including body mass index, and number of children were not significantly associated with stress levels. Conclusion: As the largest study of its kind, these findings support those found in various European, North, and South American studies. Efforts to decrease workplace stress of ICU nurses by focusing on facilitating peer collaboration, improving resource availability, and staffing ratios are likely to show the greatest impact on stress levels.

Impact of the Affordable Care Act Medicaid expansion on emergency department high utilizers with ambulatory care sensitive conditions: A cross-sectional study

Objectives: The effect of the Affordable Care Act on emergency department (ED) high utilizers has not yet been thoroughly studied. We sought to determine the impact of changes in insurance eligibility following the 2014 Medicaid expansion on ED utilization for ambulatory care sensitive conditions (ACSC) by high ED utilizers in an urban safety net hospital. Methods: High utilizers were defined as patients with ≥ 4 visits in the 6 months before their most recent visit in the study period (July–December before and after Marylands Medicaid expansion in January 2014). A differences‐in‐differences approach using logistic regression was used to investigate if differences between high and low utilizer cohorts changed from before and after the expansion. Results: During the study period, 726 (4.1%) out of 17,795 unique patients in 2013 and 380 (2.4%) of 16,458 during the same period in 2014 were high utilizers (p‐value < 0.001). ACSC‐associated visit predicted being a high utilizer in 2013 (OR 1.66 (95% CI [1.37, 2.01])) and 2014 (OR 1.65 (95% CI [1.27, 2.15])) but this was not different between years (OR ratio 0.99, 95% CI [0.72, 1.38], p‐value 0.97). Conclusion: Although the proportion of high utilizers decreased significantly after Marylands Medicaid expansion, ACSC‐associated ED visits by high ED utilizers were unaffected.

Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium

Purpose: We investigated the impact of delirium on illness severity, psychological state, and memory in acute respiratory distress syndrome patients with very long ICU stay. Materials and methods: Prospective cohort study in the medical‐surgical ICUs of 2 teaching hospitals. Very long ICU stay (>75 days) and prolonged delirium (≥40 days) thresholds were determined by ROC analysis. Subjects were ≥18 years, full‐code, and provided informed consent. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation IV, Simplified Acute Physiology Score‐3, and Sequential Organ Failure Assessment scores. Psychological impact was assessed using the Hospital Anxiety and Depression Scale, Impact of Event Scale‐Revised, and the 14‐question Post‐Traumatic Stress Syndrome (PTSS‐14). Memory was assessed using the ICU Memory Tool survey. Results: 181 subjects were included. Illness severity did not correlate with delirium duration. On logistic regression, only PTSS‐14 < 49 correlated with delirium (p = 0.001; 95% CI 1.011, 1.041). 49% remembered their ICU stay clearly. 47% had delusional memories, 50% reported intrusive memories, and 44% reported unexplained feelings of panic or apprehension. Conclusion: Delirium was associated with memory impairment and PTSS‐14 scores suggestive of PTSD, but not illness severity. Highlights:Prospective longitudinal cohort study of ARDS patients with very long ICU stay.Delirium duration did not correlate with illness severity, depression or anxiety.44% reported unexplained feelings of panic or apprehension.On logistic regression, only PTSS‐14 < 49 significantly correlated with delirium duration (p = 0.001; 95% CI 1.011, 1.041).Significant memory impairment was observed. 49% remembered their ICU stay clearly, 47% had delusional memories, and 50% reported intrusive memories.

Experimental Assessment and Future Applications of the Shikani Tracheostomy Speaking Valve

PURPOSE Tracheostomy speaking valve use may increase airflow resistance and work of breathing. It remains unclear which valve offers the best performance characteristics. We compared the performance characteristics of the Shikani speaking valve (SSV; unidirectional-flow ball valve) with those of the Passy-Muir valve (PMV; bias-closed flapper valve). METHOD Airflow resistance was measured for both the SSV and the PMV at 8 flow amplitudes and in 3 orientations (-15°, 0°, +20°) in the bias-open and bias-closed configurations. RESULTS Significantly lower airflow resistance was observed for the SSV (bias open) compared with the PMV at -15° (p < .001), 0° (p < .001), and +20° (p = .006) from the horizon. No significant difference was observed between the PMV and the SSV (bias-closed) configuration at any of the tested angles. A nonsignificant trend toward decreased airflow resistance was observed between the SSV bias-open and bias-closed configurations at each of the angles tested. CONCLUSIONS The SSV demonstrated lower airflow resistance compared with the PMV across 8 flow amplitudes in the bias-open configuration at -15°, 0°, and +20° from the horizon. Further investigation is needed to determine the clinical impact of these findings on patient comfort, work of breathing, phonation, and airway protection during swallowing.