BACKGROUND:Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health ...status which may last for months and years after hospital discharge.
OBJECTIVES:To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families.
PARTICIPANTS:Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge.
DESIGN:Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems.
MEASUREMENTS AND MAIN RESULTS:Three major themes emerged from the conference regarding(1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member.
CONCLUSIONS:Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.
As bedrock weathers to regolith - defined here as weathered rock, saprolite, and soil - porosity grows, guides fluid flow, and liberates nutrients from minerals. Though vital to terrestrial life, the ...processes that transform bedrock into soil are poorly understood, especially in deep regolith, where direct observations are difficult. A 65-m-deep borehole in the Calhoun Critical Zone Observatory, South Carolina, provides unusual access to a complete weathering profile in an Appalachian granitoid. Co-located geophysical and geochemical datasets in the borehole show a remarkably consistent picture of linked chemical and physical weathering processes, acting over a 38-m-thick regolith divided into three layers: soil; porous, highly weathered saprolite; and weathered, fractured bedrock. The data document that major minerals (plagioclase and biotite) commence to weather at 38 m depth, 20 m below the base of saprolite, in deep, weathered rock where physical, chemical and optical properties abruptly change. The transition from saprolite to weathered bedrock is more gradational, over a depth range of 11-18 m. Chemical weathering increases steadily upward in the weathered bedrock, with intervals of more intense weathering along fractures, documenting the combined influence of time, reactive fluid transport, and the opening of fractures as rock is exhumed and transformed near Earth's surface.
Traditional and nontraditional cardiovascular disease risk factors are highly prevalent in children with chronic kidney disease (CKD). We examined the longitudinal association of adiposity with ...cardiac damage among children with CKD and explored whether this association was modified by sex.
Prospective cohort study.
Children with mild-to-moderate CKD enrolled in the Chronic Kidney Disease in Children (CKiD) Study at 49 pediatric nephrology centers across North America.
Age- and sex-specific body mass index (BMI) z score.
Age- and sex-specific left ventricular mass index (LVMI) z score and left ventricular hypertrophy (LVH).
Longitudinal analyses using mixed-effects models to estimate sex-specific associations of BMI z scores with LVMI z score and with LVH, accounting for repeated measurements over time.
Among 725 children with 2,829 person-years of follow-up, median age was 11.0 years and median estimated glomerular filtration rate was 52.6mL/min/1.73m2. Nearly one-third of both boys and girls were overweight or obese, median LVMI z score was 0.18 (IQR: −0.67, 1.08), and 11% had LVH. Greater BMI z scores were independently associated with greater LVMI z scores and greater odds of LVH. For each 1-unit higher BMI z score, LVMI z score was 0.24 (95% CI, 0.17-0.31) higher in boys and 0.38 (95% CI, 0.29-0.47) higher in girls (Pinteraction = 0.01). For each 1-unit higher BMI z score, the odds of LVH was 1.5-fold (95% CI, 1.1-2.1) higher in boys and 3.1-fold (95% CI, 1.8-4.4) higher in girls (Pinteraction = 0.005).
Not all children had repeated measurements. LVH is a surrogate and not a hard cardiac outcome. The observational design limits causal inference.
In children, adiposity is independently associated with the markers of cardiac damage, LVMI z score and LVH. This association is stronger among girls than boys. Pediatric overweight and obesity may therefore have a substantial impact on cardiovascular risk among children with CKD.
To identify differences in socioeconomic factors (SES) and subclinical cardiovascular disease (CVD) markers by race among Chronic Kidney Disease in Children (CKiD) participants and determine whether ...differences in CVD markers persist after adjusting for SES.
Analysis of 3,103 visits with repeated measures from 628 children (497 White participants; 131 African American participants) enrolled in the CKiD study.
Children with mild-moderate CKD with at least 1 cardiovascular (CV) parameter (ambulatory blood pressure, left ventricular mass index LVMI, or lipid profile) measured.
African American race.
Ambulatory hypertension, LVMI, triglycerides, high-density lipoprotein cholesterol.
Due to increased CV risks of glomerular disease, the analysis was stratified by CKD cause. Inverse probability weighting was used to adjust for SES (health insurance, household income, maternal education, food insecurity, abnormal birth history). Linear and logistic regression were used to evaluate association of race with CV markers.
African American children were disproportionately affected by adverse SES. African Americans with nonglomerular CKD had more instances of ambulatory hypertension and higher LVMI but more favorable lipid profiles. After adjustment for SES, age, and sex, the magnitude of differences in these CV markers was attenuated but remained statistically significant. Only LVMI differed by race in the glomerular CKD group, despite adjustment for SES.
Study design limits causal inference.
African American children with CKD are disproportionately affected by socioeconomic disadvantages compared with White children. The degree to which CV markers differ by race is influenced by disease etiology. African Americans with nonglomerular CKD have increased LVMI, more ambulatory hypertension, and favorable lipid profile, but attenuation in magnitude after adjustment for SES was observed. African Americans with glomerular CKD had increased LVMI, which persisted after SES adjustment. As many social determinants of health were not captured, future research should examine effects of systemic racism on CV health in this population.
We applied a spectroscopic analysis to Airborne Visible/InfraRed Imaging Spectrometer (AVIRIS) data collected from low and medium altitudes during and after the Deepwater Horizon oil spill to ...delineate the distribution of oil-damaged canopies in the marshes of Barataria Bay, Louisiana. Spectral feature analysis compared the AVIRIS data to reference spectra of oiled marsh by using absorption features centered near 1.7 and 2.3μm, which arise from CH bonds in oil. AVIRIS-derived maps of oiled shorelines from the individual dates of July 31, September 14, and October 4, 2010, were 89.3%, 89.8%, and 90.6% accurate, respectively. A composite map at 3.5m grid spacing, accumulated from the three dates, was 93.4% accurate in detecting oiled shorelines. The composite map had 100% accuracy for detecting damaged plant canopy in oiled areas that extended more than 1.2m into the marsh. Spatial resampling of the AVIRIS data to 30m reduced the accuracy to 73.6% overall. However, detection accuracy remained high for oiled canopies that extended more than 4m into the marsh (23 of 28 field reference points with oil were detected). Spectral resampling of the 3.5m AVIRIS data to Landsat Enhanced Thematic Mapper (ETM) spectral response greatly reduced the detection of oil spectral signatures. With spatial resampling of simulated Landsat ETM data to 30m, oil signatures were not detected. Overall, ~40km of coastline, marsh comprised mainly of Spartina alterniflora and Juncus roemerianus, were found to be oiled in narrow zones at the shorelines. Zones of oiled canopies reached on average 11m into the marsh, with a maximum reach of 21m. The field and airborne data showed that, in many areas, weathered oil persisted in the marsh from the first field survey, July 10, to the latest airborne survey, October 4, 2010. The results demonstrate the applicability of high spatial resolution imaging spectrometer data to identifying contaminants in the environment for use in evaluating ecosystem disturbance and response.
► AVIRIS data analyzed to delineate marsh oiled during the Deepwater Horizon incident ► Spectral feature analysis used to detect oiled marsh was 93.4% accurate. ► Oil damage to the marsh at some sites resulted in erosion of exposed sediments. ► Oiled zones were detected along 40km of shoreline in Barataria Bay, Louisiana. ► The Bay Jimmy area contained a high concentration of oiled marsh in narrow zones.
Toward consensus on self-management support Mills, Susan L.; Brady, Teresa J.; Jayanthan, Janaki ...
Health promotion international,
12/2017, Letnik:
32, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Self-management support (SMS) initiatives have been hampered by insufficient attention to underserved and disadvantaged populations, a lack of integration between health, personal and social domains, ...over emphasis on individual responsibility and insufficient attention to ethical issues. This paper describes a SMS framework that provides guidance in developing comprehensive and coordinated approaches to SMS that may address these gaps and provides direction for decision makers in developing and implementing SMS initiatives in key areas at local levels. The framework was developed by researchers, policy-makers, practitioners and consumers from 5 English-speaking countries and reviewed by 203 individuals in 16 countries using an e-survey process. While developments in SMS will inevitably reflect local and regional contexts and needs, the strategic framework provides an emerging consensus on how we need to move SMS conceptualization, planning and development forward. The framework provides definitions of self-management (SM) and SMS, a collective vision, eight guiding principles and seven strategic directions. The framework combines important and relevant SM issues into a strategic document that provides potential value to the SMS field by helping decision-makers plan SMS initiatives that reflect local and regional needs and by catalyzing and expanding our thinking about the SMS field in relation to system thinking; shared responsibility; health equity and ethical issues. The framework was developed with the understanding that our knowledge and experience of SMS is continually evolving and that it should be modified and adapted as more evidence is available, and approaches in SMS advance.
PurposeAlthough recombinant human interleukin-15 (rhIL-15) has generated much excitement as an immunotherapeutic agent for cancer, activity in human clinical trials has been modest to date, in part ...due to the risks of toxicity with significant dose escalation. Since pulmonary metastases are a major site of distant failure in human and dog cancers, we sought to investigate inhaled rhIL-15 in dogs with naturally occurring lung metastases from osteosarcoma (OSA) or melanoma. We hypothesized a favorable benefit/risk profile given the concentrated delivery to the lungs with decreased systemic exposure.Experimental designWe performed a phase I trial of inhaled rhIL-15 in dogs with gross pulmonary metastases using a traditional 3+3 cohort design. A starting dose of 10 µg twice daily × 14 days was used based on human, non-human primate, and murine studies. Safety, dose-limiting toxicities (DLT), and maximum tolerated dose (MTD) were the primary objectives, while response rates, progression-free and overall survival (OS), and pharmacokinetic and immune correlative analyses were secondary.ResultsFrom October 2018 to December 2020, we enrolled 21 dogs with 18 dogs reaching the 28-day response assessment to be evaluable. At dose level 5 (70 μg), we observed two DLTs, thereby establishing 50 µg twice daily × 14 days as the MTD and recommended phase 2 dose. Among 18 evaluable dogs, we observed one complete response >1 year, one partial response with resolution of multiple target lesions, and five stable disease for an overall clinical benefit rate of 39%. Plasma rhIL-15 quantitation revealed detectable and sustained rhIL-15 concentrations between 1-hour and 6 hour postnebulization. Decreased pretreatment lymphocyte counts were significantly associated with clinical benefit. Cytotoxicity assays of banked peripheral blood mononuclear cells revealed significant increases in peak cytotoxicity against canine melanoma and OSA targets that correlated with OS.ConclusionsIn this first-in-dog clinical trial of inhaled rhIL-15 in dogs with advanced metastatic disease, we observed promising clinical activity when administered as a monotherapy for only 14 days. These data have significant clinical and biological implications for both dogs and humans with refractory lung metastases and support exploration of combinatorial therapies using inhaled rhIL-15.
The aim of this study was to evaluate the comparative effectiveness of an online, interdisciplinary, interactive course designed to increase the ability to accurately interpret the fiberoptic ...endoscopic exam of the swallow (FEES) procedure to traditional, face-to-face (F2F) lectures for both graduate medical education (GME) and graduate speech language pathology (GSLP) programs.
This was a prospective, quantitative, nonrandomized study. Participants were medical residents in physical medicine and rehabilitation from two affiliated programs and graduate students in speech language pathology from two instructional cohorts at a single institution. Group 1, traditional group (n=51), participated in F2F lectures using an audience response system, whereas Group 2, online group (n=57), participated in an online, interactive course. The main outcome measure was pre- and post-course FEES knowledge test scores.
For Group 1, the mean pre-course score was 26.94 (SD=3.24) and the post-course score was 34.96 (SD=2.51). Differences between pre- and post-course scores for Group 1 were significant (
=-16.38,
≤0.0001). For Group 2, the mean pre-course score was 27.05 (SD=2.74) and the post-course score was 34.05 (SD=2.84). Differences between pre- and post-course scores for Group 2 were significant (
=-13.5,
≤0.0001). The mean knowledge change score for Group 1 and Group 2 was 8.01 (SD=3.50) and 7.04 (SD=3.91), respectively (nonsignificant,
=1.372,
=0.173), suggesting groups made similar gains.
Incorporating technology into GME and GSLP programs yielded comparable gains to traditional lectures. Findings support the use of online education as a viable alternative to the traditional F2F classroom format for the instruction of the cognitive component of the FEES procedure.
Despite the importance of blood pressure (BP) control in chronic kidney disease (CKD), few longitudinal studies on its trends exist for pediatric patients with CKD. Here we longitudinally analyzed ...casual data in 578 children with CKD and annual BP measurements standardized for age, gender, and height. At baseline, 124 children were normotensive, 211 had elevated BP, and 243 had controlled hypertension. Linear mixed-effects models accounting for informative dropout determined factors associated with BP changes over time and relative sub-hazards (RSH) identified factors associated with the achievement of controlled BP in children with baseline elevated BP. Younger age, black children, higher body mass index, and higher proteinuria at baseline were associated with higher standardized BP levels. Overall average BP decreased during follow-up, but nephrotic-range proteinuria and increased proteinuria and body mass index were risk factors for increasing BP over time. Only 46% of hypertensive patients achieved controlled BP during follow-up; least likely were those with nephrotic-range proteinuria (RSH 0.19), black children (RSH 0.42), and children with baseline glomerular filtration rate under 40ml/min per 1.73m2 (RSH 0.58). Thus, of many coexisting factors, nephrotic-range proteinuria was most strongly associated with poor BP control and worsening BP over time. Future research should focus on strategies to reduce proteinuria, as this may improve BP control and slow the progression of CKD.
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