OBJECTIVE:Critical care guidelines recommend a single target value for mean arterial blood pressure in critically ill patients. However, growing evidence regarding cerebral autoregulation challenges ...this concept and supports individualizing mean arterial blood pressure targets to prevent brain and kidney hypo- or hyperperfusion. Regional cerebral oxygen saturation derived from near-infrared spectroscopy is an acceptable surrogate for cerebral blood flow and has been validated to measure cerebral autoregulation. This study suggests a novel mechanism to construct autoregulation curves based on near-infrared spectroscopy–measured cerebral oximetry.
DESIGN:Case-series study.
SETTING:Neurocritical care unit in a tertiary medical center.
PATIENTS:Patients with acute neurologic injury and Glasgow coma scale score less than or equal to 8.
MEASUREMENTS AND MAIN RESULTS:Autoregulation curves were plotted using the fractional-polynomial model in Stata after multimodal continuous monitoring of regional cerebral oxygen saturation and mean arterial blood pressure. Individualized autoregulation curves of seven patients exhibited varying upper and lower limits of autoregulation and provided useful clinical information on the autoregulation trend (curves moving to the right or left during the acute coma period). The median lower and upper limits of autoregulation were 86.5 mm Hg (interquartile range, 74–93.5) and 93.5 mm Hg (interquartile range, 83–99), respectively.
CONCLUSIONS:This case-series study showed feasibility of delineating real trends of the cerebral autoregulation plateau and direct visualization of the cerebral autoregulation curve after at least 24 hours of recording without manipulation of mean arterial blood pressure by external stimuli. The integration of multimodal monitoring at the bedside with cerebral oximetry provides a noninvasive method to delineate daily individual cerebral autoregulation curves.
Abstract
Introduction
Placing a magnet over a Permanent Pacemaker (PPM) or Implanted Cardioverter-Defibrillator (ICD) may cause the device to pace asynchronously or inhibit tachyarrhythmia detection, ...respectively, potentially preventing delivery of electrical shocks. Manufacturers for masks used with positive airway pressure devices have started using magnets in place of more traditional headgear clips to connect the headgear to mask. Mask manufactures do not list presence of a PPM/ICD as a contraindication to use of a mask with magnet but do recommend keeping the mask some distance away from PPM/ICD. A published case series describes two patients with magnet response events captured during PPM/ICD interrogation that correlated with nightly use of CPAP. The authors were able to replicate the response by placing the mask with magnet directly over the patient’s pulse generate site. Although we advise all patients with implanted device to avoid use of masks with magnets, select patients refuse to stop using mask with magnets regardless of our policy. We, therefore, started offering these patients referral for PPM/ICD interrogation to evaluate for an interaction between mask with magnet and PPM/ICD as next best alternative.
Methods
We retrospectively reviewed all patients (n=10) referred for routine PPM/ICD interrogation to test whether the mask with magnet interacted with PPM/ICD when mask on face as during normal use (i.e., simulated normal use) or magnetic area of mask placed directly over the PPM/ICD (i.e., direct contact).
Results
Although no interaction was detected in any patient (n=10) with simulated normal use (0 %), one interaction was documented with direct contact (10 %).
Conclusion
Although simulated normal use of masks with magnets did not demonstrate any interactions, it is concerning that one patient (10 % of patients) demonstrated an interaction with direct contact of magnetic area of mask over the PPM/ICD. It is not uncommon for patients to remove a mask during the night while sleeping. This preliminary data along with the published case series calls for further research and increased awareness of this potential interaction for both sleep and cardiac health care providers.
Support (If Any)
None
The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program developed and manages a framework for identification, replication, and diffusion of promising practices throughout the ...nation's largest integrated health care system. DoE identifies promising practices through a "Shark Tank" competition with winning bidders receiving external implementation facilitation. DoE further supports diffusion of successful practices across the VHA.
This article presents results of a mixed methods implementation evaluation of DoE, focusing on program reach, program participation and decisions to adopt innovative practices, implementation processes, and practice sustainment. Data sources include practice adoption metrics, focus groups with bidders (two focus groups), observations of DoE events (seven events), surveys of stakeholders (five separate surveys), and semistructured interviews of facility directors, practice developers, implementation teams, and facilitators (133 participants).
In the first four Shark Tank cohorts (2016-2018), 1,676 practices were submitted; 47 were designated Gold Status Practices (practices with facilitated implementation). Motivation for participation varied. Generally, staff led projects targeting problems they felt passionate about, facility directors focused on big-picture quality metrics and getting middle manager support, and frontline staff displayed variable motivation to implement new projects. Approximately half of facilitated implementation efforts were successful; barriers included insufficient infrastructure, staff, and resources. At the facility level, 73.3% of facilities originating or receiving facilitated implementation support have maintained the practice. VHA-wide, 834 decisions to adopt these practices were made.
DoE has resulted in the identification of many candidate practices, promoted adoption of promising practices by facility directors, and supported practice implementation and diffusion across the VHA.
Increasing awareness of the harms that artificial intelligence (AI) systems can cause has inspired a movement towards creating more human-centered AI (HCAI). One way in which AI systems can be made ...more human-centered is by focusing on the effects they have on people's needs. However, existing theories of technology impact in HCAI drawn from human-computer interaction (HCI) and related fields such as psychology are not able to account for the ways in which both needs and the impact of technology on these are dynamically shaped by the social context. To address this limitation, in this paper we outline a Social Self-Determination Model (SSDM) of AI system impact. SSDM proposes that people's needs for self-determination can be individual or collective in a particular context depending on features of the person and their environment. Accordingly, because AI systems treat people differently depending on the groups they belong to, they can make needs for individual or collective self-determination psychologically relevant and either fulfill or hamper these. SSDM can be used to help designers and developers create more human-centered AI systems by quantifying the effects of these systems and the social environment in which they are embedded on people's fundamental psychological needs and wellbeing.
There are challenges associated with measuring sustainment of evidence-informed practices (EIPs). First, the terms sustainability and sustainment are often falsely conflated: sustainability assesses ...the likelihood of an EIP being in use in the future while sustainment assesses the extent to which an EIP is (or is not) in use. Second, grant funding often ends before sustainment can be assessed. The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program is one of few large-scale models of diffusion; it seeks to identify and disseminate practices across the VHA system. The DoE sponsors "Shark Tank" competitions, in which leaders bid on the opportunity to implement a practice with approximately 6 months of implementation support. As part of an ongoing evaluation of the DoE, we sought to develop and pilot a pragmatic survey tool to assess sustainment of DoE practices.
In June 2020, surveys were sent to 64 facilities that were part of the DoE evaluation. We began analysis by comparing alignment of quantitative and qualitative responses; some facility representatives reported in the open-text box of the survey that their practice was on a temporary hold due to COVID-19 but answered the primary outcome question differently. As a result, the team reclassified the primary outcome of these facilities to Sustained: Temporary COVID-Hold. Following this reclassification, the number and percent of facilities in each category was calculated. We used directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), to analyze open-text box responses.
A representative from forty-one facilities (64%) completed the survey. Among responding facilities, 29/41 sustained their practice, 1/41 partially sustained their practice, 8/41 had not sustained their practice, and 3/41 had never implemented their practice. Sustainment rates increased between Cohorts 1-4.
The initial development and piloting of our pragmatic survey allowed us to assess sustainment of DoE practices. Planned updates to the survey will enable flexibility in assessing sustainment and its determinants at any phase after adoption. This assessment approach can flex with the longitudinal and dynamic nature of sustainment, including capturing nuances in outcomes when practices are on a temporary hold. If additional piloting illustrates the survey is useful, we plan to assess the reliability and validity of this measure for broader use in the field.
Vascular dysfunction, an independent risk factor for cardiovascular disease, often persists in patients with hypertension, despite improvements in blood pressure control induced by antihypertensive ...medications. As some of these medications may directly affect vascular function, this study sought to comprehensively examine the impact of reducing blood pressure, by a non-pharmacological approach (5 days of sodium restriction), on vascular function in 22 hypertensive individuals (14 males/8 females, 50±10 y). Following a 2-week withdrawal of antihypertensive medications, two 5-day dietary phases, liberal sodium (LS, 200 mmol/d) followed by restricted sodium (RS, 10mmol/day), were completed. Resting blood pressure was assessed and vascular function, at both the conduit and microvascular levels, was evaluated by brachial artery flow mediated dilation (FMD), reactive hyperemia, progressive handgrip exercise (HG), and passive leg movement (PLM). Despite a sodium restriction-induced fall in blood pressure (LS: 141±14/85±9; RS 124±12/79±9 mmHg, p<0.01 for both systolic and diastolic blood pressure), FMD (LS: 4.6±1.8%; RS: 5.1±2.1%, p=0.27), and reactive hyperemia (LS: 548±201; RS: 615±206 ml, p=0.08) were not altered. Similarly, brachial artery vasodilation during HG exercise was not different between conditions (LS: Δ 0.36±0.19 mm; RS: Δ 0.42±0.18 mm, p=0.16). Lastly, PLM-induced changes in peak blood flow (LS: 5.3±2.5; RS: 5.8±3.6ml/min/mmHg, p=0.30) and the total vasodilatory response (LS: 2.00.9–2.5 vs. RS: 1.71.1–2.6ml/min/mmHg; p = 0.5) were also not different between conditions. Thus, vascular dysfunction, at both the conduit and microvascular levels, persists in patients with hypertension even when blood pressure is acutely reduced by a non-pharmacological approach.
Intraoperative mechanical ventilation is a major component of general anesthesia. The extent to which various intraoperative tidal volumes and positive end-expiratory pressures (PEEP) effect on ...postoperative hypoxia and lung injury remains unclear. We hypothesized that adults having orthopedic surgery, ventilation using different tidal volumes and PEEP levels affect the oxygenation within first hour in the postoperative care unit.
We conducted a two-by-two factorial crossover cluster trial at the Cleveland Clinic Main Campus. We enrolled patients having orthopedic surgery with general anesthesia who were assigned to factorial clusters with tidal volumes of 6 or 10 ml/kg of predicted body weight and to PEEP of 5 or 8 cm H2O in 1-week clusters. The primary outcome was the effect of tidal volume or PEEP on time-weighted average peripheral oxygen saturation measured by pulse oximetry divided by the fraction of inspired oxygen (Spo2/Fio2 ratio) during the initial postoperative hour.
We enrolled 2,860 patients who had general anesthesia for orthopedic surgery from September 2018 through October 2020. The interaction between tidal volume and PEEP was not significant (P = 0.565). The mean ± SD time-weighted average of Spo2/Fio2 ratio was 353 ± 47 and not different in patients assigned to high and low tidal volume (estimated effect, 3.5%; 97.5% CI, -0.4% to 7.3%; P = 0.042), for those assigned to high and low PEEP (estimated effect, -0.2%; 97.5% CI, -4.0% to 3.6%; P = 0.906). We did not find significant difference in ward Spo2/Fio2 ratio, pulmonary complications, and duration of hospitalization among patients assigned to various tidal volumes and PEEP levels.
Among adults having major orthopedic surgery, postoperative oxygenation is similar, with tidal volumes between 6 and 10 ml/kg and PEEP between 5 and 8 cm H2O. Our results suggest that any combination of tidal volumes between 6 and 10 ml/kg and PEEP between 5 versus 8 ml cm H2O can be used safely for orthopedic surgery.
Older adults make up half of those with cancer and are prone to mood disorders, such as depression and severe anxiety, resulting in negative repercussions on their health-related quality-of-life ...(HRQOL). Educational interventions have been shown to reduce adverse psychological outcomes. We examined the effect of educational interventions on the severity of psychological outcomes in older adults with cancer (OAC) in the community.
This PRISMA-adherent systematic review involved a search of PubMed, MedLine, Embase and PsycINFO for randomised controlled trials (RCTs) that evaluated educational interventions impacting the severity of depression, anxiety and HRQOL in OAC. Random effects meta-analyses and meta-regressions were used for the primary analysis.
Fifteen RCTs were included. Meta-analyses showed a statistically insignificant decrease in the severity of depression (SMD = -0.30, 95%CI: -0.69; 0.09), anxiety (SMD = -0.30, 95%CI: -0.73; 0.13) and improvement in overall HRQOL scores (SMD = 0.44, 95%CI: -0.16; 1.04). However, subgroup analyses revealed that these interventions were particularly effective in reducing the severity of depression and anxiety in specific groups, such as OAC aged 60-65, those with early-stage cancer, those with lung cancer and those treated with chemotherapy. A systematic review found that having attained a higher education and income level increased the efficacy of interventions in decreasing the severity of adverse psychological outcomes.
Although overall meta-analyses were statistically insignificant, subgroup meta-analyses highlighted a few specific subgroups that the educational interventions were effective for. Future interventions can be implemented to target these vulnerable groups.
Abstract
A number of governmental and nongovernmental organizations have made significant efforts to encourage the development of artificial intelligence in line with a series of aspirational ...concepts such as transparency, interpretability, explainability, and accountability. The difficulty at present, however, is that these concepts exist at a fairly abstract level, whereas in order for them to have the tangible effects desired they need to become more concrete and specific. This article undertakes precisely this process of concretisation, mapping how the different concepts interrelate and what in particular they each require in order to move from being high-level aspirations to detailed and enforceable requirements. We argue that the key concept in this process is accountability, since unless an entity can be held accountable for compliance with the other concepts, and indeed more generally, those concepts cannot do the work required of them. There is a variety of taxonomies of accountability in the literature. However, at the core of each account appears to be a sense of “answerability”; a need to explain or to give an account. It is this ability to call an entity to account which provides the impetus for each of the other concepts and helps us to understand what they must each require.
Highlights • Non-invasive waterborne hormone collection was used to measure CORT release in newts. • Courting and non-courting, male and female newts were compared. • An acute increase in CORT was ...associated with courtship behavior in both sexes. • Males exhibited higher CORT in and out of courtship than did females. • Highlights that CORT can be associated with mating behavior in both sexes.
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