Clinical Burden of Chronic Obstructive Pulmonary Disease in Patients with Suboptimal Peak Inspiratory Flow.

Introduction: Many patients with chronic obstructive pulmonary disease (COPD) may derive inadequate benefit from dry powder inhalers (DPIs) because of suboptimal peak inspiratory flow (sPIF). Objectives: To assess the clinical burden of COPD by characterizing the clinical characteristics of participants with sPIF against medium-low resistance DPIs versus those with optimal PIF (oPIF) from two phase 3 clinical trials. Methods: Baseline data were collected from two randomized, controlled, phase 3 trials (NCT03095456; NCT02518139) in participants with moderate-to-severe COPD. oPIF (60 L/min) against the medium-low resistance DPIs was used as the threshold for defining the PIF subgroups (<60 L/min (sPIF) vs ≥60 L/min (oPIF)). Results: Most participants included in this analysis were White (92%) and male (63%); the mean (range) age was 65 (43-87) years. Participants with sPIF had significantly greater dyspnea than those with oPIF as measured using the modified Medical Research Council scoring (mean (95% CI): 2.1 (2.0-2.2) vs 1.6 (1.4-1.7); P < 0.001) and baseline dyspnea index (mean (95% CI): 5.1 (4.9-5.4) vs 6.1 (5.8-6.3); P < 0.001). Based on COPD Assessment Test scores, participants with sPIF had a higher COPD symptom burden than those with oPIF (mean (95% CI): 21.5 (19.7-23.3) vs 19.5 (18.6-20.4); P = 0.05). Conclusion: In these trials, participants with COPD who had sPIF against the medium-low resistance DPIs had more dyspnea and worse health status than those with oPIF. These results demonstrate that sPIF is associated with a higher clinical burden as measured by patient-reported outcomes.

A comparative analysis of intravenous infusion methods for low-resource environments.

Introduction: Intravenous (IV) therapy is a crucial aspect of care for the critically ill patient. Barriers to IV infusion pumps in low-resource settings include high costs, lack of access to electricity, and insufficient technical support. Inaccuracy of traditional drop-counting practices places patients at risk. By conducting a comparative assessment of IV infusion methods, we analyzed the efficacy of different devices and identified one that most effectively bridges the gap between accuracy, cost, and electricity reliance in low-resource environments. Methods: In this prospective mixed methods study, nurses, residents, and medical students used drop counting, a manual flow regulator, an infusion pump, a DripAssist, and a DripAssist with manual flow regulator to collect normal saline at goal rates of 240, 120, and 60 mL/h. Participants' station setup time was recorded, and the amount of fluid collected in 10 min was recorded (in milliliters). Participants then filled out a post-trial survey to rate each method (on a scale of 1 to 5) in terms of understandability, time consumption, and operability. Cost-effectiveness for use in low-resource settings was also evaluated. Results: The manual flow regulator had the fastest setup time, was the most cost effective, and was rated as the least time consuming to use and the easiest to understand and operate. In contrast, the combination of the DripAssist and manual flow regulator was the most time consuming to use and the hardest to understand and operate. Conclusion: The manual flow regulator alone was the least time consuming and easiest to operate. The DripAssist/Manual flow regulator combination increases accuracy, but this combination was the most difficult to operate. In addition, the manual flow regulator was the most cost-effective. Healthcare providers can adapt these devices to their practice environments and improve the safety of rate-sensitive IV medications without significant strain on electricity, time, or personnel resources.

Twist and measure: characterizing the effective radius of strings and bundles under twisting contraction.

We test the standard model for the length contraction of a bundle of strings under twist, and find deviation that is significantly greater than typically appreciated and that has a different nature at medium and large twist angles. By including volume conservation, we achieve better fits to data for single-, double-, and triple-stranded bundles of nylon monofilament as an ideal test case. This gives a well-defined procedure for extracting an effective twist radius that characterizes contraction behavior. While our approach accounts for the observed faster-than-expected contraction up to medium twist angles, we also find that the contraction is nevertheless slower than expected at large twist angles for both nylon monofilament bundles and several other string types. The size of this effect varies with the individual-string braid structure and with the number of strings in the bundle. We speculate that it may be related to elastic deformation within the material. However, our first modeling attempt does not fully capture the observed behavior.

Personalizing eating disorder treatment using idiographic models: An open series trial.

OBJECTIVE: Treatments for adults with eating disorders (EDs) only work in about 50% of individuals, and for some diagnoses (e.g., anorexia nervosa; atypical anorexia nervosa), there are no existing evidence-based treatments. Part of the reason that treatments may only work in a subset of individuals is because of the high heterogeneity present in the EDs, even within diagnoses. Manualized treatments delivered in a standard format may not always address the most relevant symptoms for a specific individual. METHOD: The current open series trial recruited participants with transdiagnostic ED diagnoses (N = 79) to investigate the feasibility, acceptability, and initial clinical efficacy of a 10-session network-informed personalized treatment for eating disorders. This treatment uses idiographic (i.e., one-person) network models of ecological momentary assessment symptom data to match participants to evidence-based modules of treatment. RESULTS: We found that network-informed personalized treatment was highly feasible with low dropout rates, was rated as highly acceptable, and had strong initial clinical efficacy. ED severity decreased from pre- to posttreatment and at 1-year follow-up with a large effect size. ED cognitions, behaviors, clinical impairment, worry, and depression also decreased from pre- to posttreatment. CONCLUSIONS: These data suggest that network-informed personalized treatment has high acceptability and feasibility and can decrease ED and related pathology, possibly serving as a feasible alternative to existing treatments. Future randomized controlled trials comparing network-informed personalized treatment for ED to existing gold standard treatments are needed. Additionally, more research is needed on this type of personalized treatment both in the EDs, as well as in additional forms of psychopathology, such as depression. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Digital Mental Health Interventions: Differences in Diet Culture Intervention Framing.

Diet culture is a societal norm that ranks thin bodies as superior to other body types and has been associated with negative outcomes, such as eating disorders. Wellness has evolved into a term that is often used to promote diet culture messages. One possible way to combat diet culture is through single-session, digital mental health interventions (DMHIs), which allow for increased access to brief public health treatments. The framing of DMHIs is critical to ensure that the target population is reached. Participants (N = 397) were enrolled in a single-session DMHI, which was framed as either a Diet Culture Intervention (n = 201) or a Wellness Resource (n = 196). Baseline group differences in eating disorder pathology, body image, weight stigma concerns, fat acceptance, and demographic characteristics were analyzed. Across groups, participants reported moderately high eating disorder pathology, low-to-moderate levels of body dissatisfaction, moderate levels of fat acceptance, and either very low or very high weight stigma concerns. Participants in the Diet Culture Intervention group reported higher levels of fat acceptance than those in the Wellness Resource group (p < 0.001). No other framing group differences were identified, though post hoc analyses revealed differences based on recruitment source (i.e., social media versus undergraduate research portal). This study found that framing a DMHI as targeting diet culture or as a Wellness Resource can result in the successful recruitment of individuals at risk of disordered eating. Framing a DMHI as a Wellness Resource may increase recruitment of individuals with low levels of fat acceptance, which may be particularly important for dismantling diet culture, disordered eating, and weight stigma concerns. Future research should assess DMHI framing in other populations, such as men and adolescents.

Resilience and Burnout Resources in Respiratory Care Departments.

BACKGROUND: Burnout is a major problem in health care, with rates of approximately 33% and 50% in nurses and physicians, respectively, prior to the COVID-19 pandemic. Respiratory therapist (RT) burnout rates and drivers have not been specifically examined. The purpose of this project was to determine resilience and burnout resources available within respiratory care departments and to provide an estimate of pre- and post-COVID-19 RT burnout rates. METHODS: A survey was developed to evaluate resilience and burnout resources in respiratory care departments. The survey was posted online to the AARConnect management, education, adult acute care, neonatal/pediatrics, COVID-19, and help line communities. Data analysis was descriptive. Key drivers of burnout among RTs were identified from qualitative answers. RESULTS: There were 221 responses, and 72% reported experiencing burnout. Ten percent of the departments that responded measured burnout; 36% utilized resilience tools, and 83% offered free employee assistance for those struggling with burnout. In January 2020, 30% of departments reported an estimated burnout rate > 40%, which increased to 44% of departments (P = .007) in the COVID-19 pandemic period. The most common drivers reported were poor leadership (32%), high work load (31%), and staffing (29%); 93% of respondents agreed that burnout is a major problem in health care, 33% agreed that burnout is primarily driven by external factors, 92% agreed that RTs have a similar risk of burnout as other health care professionals, 73% agreed that they were comfortable discussing challenging situations with colleagues, 32% agreed that their leadership provided adequate support for those suffering from burnout, and 79% agreed that they would be open to utilizing resilience tools from the AARC or other professional organizations. CONCLUSIONS: Most respondents experienced burnout and few respiratory care departments measured burnout. Resilience resources were not commonly used but employee assistance and wellness programs were common. Key drivers of burnout identified were poor leadership, staffing, and high workloads.

Arginine/Asymmetric Dimethylarginine Ratio in Colorectal Surgery.

BACKGROUND: Asymmetric dimethylarginine (ADMA) is a naturally occurring amino acid that inhibits the effects of nitric oxide synthetases, producing considerable effects on the vascular system. Recent studies have suggested that increased ADMA is a major contributor to endothelial dysfunction, resulting in significant effects on cardiovascular and renal function. METHODS: The study sample consisted of five male and 11 female patients scheduled for elective laparoscopic colorectal surgery; patients were between 41 and 77 years of age. Venous whole blood (8 - 10 mL) was collected from patients prior to colorectal surgery, as well as on postoperative day 1 and 2. Arginine, citrulline, ADMA, and symmetric dimethylarginine levels were measured in collected blood using liquid chromatography coupled to mass spectrometry. RESULTS: Data from the amino-acid blood analysis demonstrated that the levels of L-citrulline and L-arginine decreased on postoperative days 1, coinciding with an increase of ADMA levels. The overall result of these changes was a decrease in the arginine to ADMA ratio by 21% from the preoperative period to postoperative day 2 (P = 0.02). CONCLUSIONS: The data collected through this study demonstrate a significant increase in systemic ADMA levels following major laparoscopic colorectal surgery.

Management of Pain in Complex Nerve Injuries.

Traumatic nerve injuries can be devastating and life-changing events, leading to functional morbidity and psychological stress and social constraints. Even in the event of a successful surgical repair with recovered motor function, pain can result in continued disability and poor quality of life. Pain after nerve injury can also prevent recovery and return to preinjury life. It is difficult to predict which patients will develop persistent pain; once incurred, pain can be even challenging to manage. This review seeks to define the types of pain following peripheral nerve injuries, investigate the pathophysiology and causative factors, and evaluate potential treatment options.

Reporting of problematic drinkers and the harm they cause: Assessing the role of alcohol use, sex, and age of those affected by a problematic drinker.

This study explores survey respondents' reports of alcohol-related harm created by another person's drinking and whether the experience of harm was influenced by the respondent's own risky drinking behavior and other relevant personal demographics (age and sex). Drawing from a cross-sectional survey of Australian adults, the study analyzes the likelihood that frequent risky drinkers, infrequent risky drinkers, nonrisky drinkers, and nondrinkers would report a problematic drinker and the different harms experienced as a result of the problematic drinker. The study also examines the type of harms experienced and the number of different harms experienced. Both unadjusted and adjusted models (accounting for age and sex) are reported. Results showed that respondents' own drinking behavior influenced their reporting of a problematic drinker and the breadth of harms reported. More frequent risky drinkers reported a problematic drinker than did nonrisky drinkers, but the difference in odds was not significant between nondrinkers and nonrisky drinkers, nor between infrequent risky drinkers and frequent risky drinkers. The reported average number of harms for infrequent and frequent risky drinking categories was less than that for nondrinkers but was not significant. There was a nonlinear negative relationship between the age of the respondent and the probability of reporting a problematic drinker, and, after accounting for age, compared to men, women were significantly more likely to report a problematic drinker. The study highlights some evidence for the effect that individuals who drink at riskier levels may experience more harms due to their heavier drinking social networks but downplay these experiences that others cause.

Assessment of three-dimensional high-definition visualization technology to perform microvascular anastomosis.

BACKGROUND AND AIM: Traditional visualization techniques in microsurgery require strict positioning in order to maintain the field of visualization. However, static posturing over time may lead to musculoskeletal strain and injury. Three-dimensional high-definition (3DHD) visualization technology may be a useful adjunct to limiting static posturing and improving ergonomics in microsurgery. In this study, we aimed to investigate the benefits of using the 3DHD technology over traditional techniques. METHODS: A total of 14 volunteers consisting of novice and experienced microsurgeons performed femoral anastomoses on male Sprague-Dawley retired breeder rats using traditional techniques as well as the 3DHD technology and compared the two techniques. Participants subsequently completed a questionnaire regarding their preference in terms of operational parameters, ergonomics, overall quality, and educational benefits. Efficiency was also evaluated by mean times to complete the anastomosis with each technique. RESULTS: A total of 27 anastomoses were performed, 14 of 14 using the traditional microscope and 13 of 14 using the 3DHD technology. Preference toward the traditional modality was noted with respect to the parameters of precision, field adjustments, zoom and focus, depth perception, and overall quality. The 3DHD technique was preferred for improved stamina and less back and eye strain. Participants believed that the 3DHD technique was the better method for learning microsurgery. Longer mean time of anastomosis completion was noted in participants utilizing the 3DHD technique. CONCLUSIONS: The 3DHD technology may prove to be valuable in improving proper ergonomics in microsurgery. In addition, it may be useful in medical education when applied to the learning of new microsurgical skills. More studies are warranted to determine its efficacy and safety in a clinical setting.

Breast reconstruction satisfaction rates at a large county hospital.

BACKGROUND: It has been previously reported that the indigent patient population is less likely to seek breast reconstruction. It has also been reported that lower income women who do chose to undergo reconstruction are less satisfied with the results. This study assesses the level of breast reconstruction satisfaction in women treated at Los Angeles County Medical Center (LAC). For those women with lower satisfaction, we seek to identify the root source of this dissatisfaction. METHODS: Patients who underwent breast reconstruction at LAC from 2007 to 2012 were identified by Current Procedural Terminology codes. Eligible participants were administered the BREAST-Q postreconstruction module. Demographic data were obtained from the patient and/or their medical records. RESULTS: A total of 65 patients completed the surveys. The satisfaction scores for the appearance of the breast were 61 (24) and satisfaction with overall outcome was 80 (26). The occurrence of major complications was associated with lower satisfaction scores with respect to the appearance of the breast (P<0.0001) and overall outcome (P=0.02). In addition, patients with delayed reconstruction were also noted to be more satisfied with respect to appearance of the breast (P=0.03). CONCLUSIONS: Despite suggestions that the indigent and the underserved patient population are less satisfied with the results of their breast reconstruction procedures, patients at LAC demonstrated comparable satisfaction levels to other published reports. The occurrence of major complications and immediate reconstruction were significantly associated with lower levels of satisfaction.

Novel biomarkers of arterial and venous ischemia in microvascular flaps.

The field of reconstructive microsurgery is experiencing tremendous growth, as evidenced by recent advances in face and hand transplantation, lower limb salvage after trauma, and breast reconstruction. Common to all of these procedures is the creation of a nutrient vascular supply by microsurgical anastomosis between a single artery and vein. Complications related to occluded arterial inflow and obstructed venous outflow are not uncommon, and can result in irreversible tissue injury, necrosis, and flap loss. At times, these complications are challenging to clinically determine. Since early intervention with return to the operating room to re-establish arterial inflow or venous outflow is key to flap salvage, the accurate diagnosis of early stage complications is essential. To date, there are no biochemical markers or serum assays that can predict these complications. In this study, we utilized a rat model of flap ischemia in order to identify the transcriptional signatures of venous congestion and arterial ischemia. We found that the critical ischemia time for the superficial inferior epigastric fasciocutaneus flap was four hours and therefore performed detailed analyses at this time point. Histolgical analysis confirmed significant differences between arterial and venous ischemia. The transcriptome of ischemic, congested, and control flap tissues was deciphered by performing Affymetrix microarray analysis and verified by qRT-PCR. Principal component analysis revealed that arterial ischemia and venous congestion were characterized by distinct transcriptomes. Arterial ischemia and venous congestion was characterized by 408 and 1536>2-fold differentially expressed genes, respectively. qRT-PCR was used to identify five candidate genes Prol1, Muc1, Fcnb, Il1b, and Vcsa1 to serve as biomarkers for flap failure in both arterial ischemia and venous congestion. Our data suggests that Prol1 and Vcsa1 may be specific indicators of venous congestion and allow clinicians to both diagnose and successfully treat microvascular complications before irreversible tissue damage and flap loss occurs.

Incidence of surgical-site infection is not affected by method of immediate breast reconstruction.

BACKGROUND: To date, few large-scale studies have reported the incidence of surgical-site infection in women undergoing mastectomy with respect to the various methods of immediate breast reconstruction. This study assessed whether the reconstruction method was associated with the risk of surgical-site infection in these patients. METHODS: Using the National Surgical Quality Improvement Program database, 9230 female patients undergoing mastectomy with immediate reconstruction from 2005 to 2009 were identified. Reconstruction was classified as autologous, prosthetic, or hybrid. The primary outcome was the incidence of surgical-site infection within 30 days of operation. Univariate and multivariate analyses were performed to derive the unadjusted and adjusted risk of surgical-site infection according to reconstruction method. RESULTS: The overall rate of surgical-site infection was 3.53 percent (95 percent CI, 3.15 to 3.94 percent), with individual rates of 3.33 percent (95 percent CI, 2.93 to 3.76 percent) for prosthetic reconstruction, 4.88 percent (95 percent CI, 3.48 to 6.11 percent) for autologous reconstruction, and 2.19 percent (95 percent CI, 0.88 to 4.45 percent) for hybrid reconstruction. The adjusted odds ratio of surgical-site infection was 1.14 (95 percent CI, 0.83 to 1.58; p = 0.42) for autologous versus prosthetic methods and 0.59 (95 percent CI, 0.27 to 1.27; p = 0.18) for hybrid versus prosthetic methods. CONCLUSIONS: Although the risk of surgical-site infection in patients undergoing immediate reconstruction is highest with autologous and lowest with hybrid methods of reconstruction, the difference in infection risk was not statistically significant after adjustment for confounding factors. Thus, all methods of reconstruction are viable options with regard to risk for surgical-site infection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Risk factors associated with venous thromboembolism in 49,028 mastectomy patients.

Venous thromboembolism (VTE) is a potentially preventable disease that carries significant morbidity and mortality. Although malignancy is associated with increased risk for VTE, it varies according to cancer type. Despite the fact that breast cancer is the most common form of cancer in women, the incidence and risk factors associated with VTE in patients undergoing mastectomy have not been well characterized. To address this we utilized the ACS-NSQIP database to identify and characterize independent risk factors for VTE in 49,028 mastectomy patients. We identified 116 cases of VTE in the 49,028 cases analyzed (0.23%). Obesity (BMI > 30, OR = 1.91, p < 0.001), inpatient status (OR = 3.75, p < 0.001), venous catheterization (OR = 2.67, p = 0.012), prolonged operative time >3 h (OR = 4.36, p < 0.001), and immediate reconstruction (OR = 3.23, p < 0.001) were found to be independent risk factors for VTE. While the incidence of VTE is rare in mastectomy patients, the heightened awareness and increased VTE prophylaxis should be considered in high risk groups.

Identifying risk factors for surgical site infections in mastectomy patients using the National Surgical Quality Improvement Program database.

BACKGROUND: The Centers for Disease Control and Prevention reported that surgical site infections (SSIs) create a significant hospital burden. To date, few multi-institutional studies have been performed to evaluate the risk factors for SSIs in mastectomy patients. METHODS: By using the American College of Surgeons' National Surgical Quality Improvement Program database, all patients undergoing mastectomy from 2005 to 2009 were identified. The outcome was to determine the incidence rate and identify significant independent risk factors of SSIs. RESULTS: The incidence of SSI was 2.3% (891 of 38,739; 95% confidence interval, 2.2%-2.5%) in patients undergoing mastectomy without reconstruction. Significant (P < .05) risk factors for SSI included a body mass index greater than 25, American Society of Anesthesiology classification of 3 or higher, diabetes mellitus, surgical time of 2 hours or longer (75th percentile), and current smoking status. CONCLUSIONS: Before this study, there was wide variation in the incidence rate of surgical site infections in this patient population. This was a large-scale study to address these inconsistencies.

Physicians' perceptions of barriers to cardiovascular disease risk factor control among patients with diabetes: results from the translating research into action for diabetes (TRIAD) study.

INTRODUCTION: Many patients with diabetes have poorly controlled blood glucose, lipid, or blood pressure levels, increasing their risk for cardiovascular disease (CVD) and other complications. Relatively little is known about what physicians perceive to be barriers to good CVD risk factor control or their own role in helping patients achieve good control. METHODS: We interviewed 34 primary care physicians in 4 states to assess their perceptions of patients' barriers to CVD risk factor control. Interviews were coded and analyzed for emergent themes. RESULTS: Physicians attributed barriers primarily to patients (socioeconomic issues, competing medical conditions, and lack of motivation) or to health system barriers (cost of care or lack of a multidisciplinary team). Physicians also expressed high levels of frustration with their efforts to address barriers. CONCLUSIONS: Physicians felt that barriers to CVD risk factor control often were beyond their abilities to address. Training physicians or other members of the primary health care team to address patients' personal barriers and health system barriers to good control could help alleviate high frustration levels, improve relationships with patients, and improve the treatment of diabetes. Supporting such efforts with adequate reimbursement should be a focus of health care reform.

The effect of blood pressure on hematoma formation with perioperative Lovenox in excisional body contouring surgery.

BACKGROUND: Prophylactic use of low molecular weight heparin (LMWH) has been shown to be efficacious in decreasing thromboembolism. LMWHs are associated with increased rates of bleeding. OBJECTIVE: We reviewed perioperative blood pressure dynamics for patients who experienced hematomas while undergoing body contouring procedures while receiving enoxaparin (Lovenox), compared with similar patients who did not have development of a postoperative hematoma. METHODS: A retrospective chart review was performed examining 2 patient groups: 10 patients who experienced a hematoma after excisional body contouring surgery with perioperative Lovenox; and 10 similar patients with respect to sex, surgery type, massive weight loss status, and Lovenox administration, who did not have a hematoma. Preoperative and postoperative blood pressures were recorded, as were blood pressures during the last 2 hours of surgery. Mean arterial pressures (MAPs) were calculated for all time points, and mean intraoperative MAP was statistically compared with preoperative and postoperative MAP, for the two groups. RESULTS: The mean preoperative MAP for each group was the same (97.5 mm Hg vs 95.8 mm Hg; P = .61). The mean MAP for the last 2 hours of each case was significantly lower in the hematoma group (66.7 mm Hg vs 82.4 mm Hg; P < .0001), and a higher mean postoperative MAP reached significance in the hematoma group (96.3 mm Hg vs 88.5 mm Hg; P = .05). Both the difference between intraoperative and preoperative blood pressure (30.7 mm Hg vs 13.4 mm Hg; P < .0001) and between intraoperative and postoperative blood pressure (29.6 mm Hg vs 7.0 mm Hg; P < .0001) were increased in the hematoma group versus the non-hematoma group. CONCLUSIONS: Many patients undergoing excisional body contouring surgery are at risk for VTE and may need perioperative chemoprophylaxis. However, maintaining a normal intraoperative blood pressure and vigilance in recognizing and treating postoperative hypertension may reduce the hematoma rate seen with perioperative administration of LMWH.

Domestic violence: court case conviction and recidivism.

This article examines the effect of convictions for domestic violence or a related charge on the recidivism of batterers. Findings indicate that convictions reduce the likelihood of domestic violence recidivism. The variance explained by the conviction variable is modest; however, conviction remains significant when the batterers' histories of domestic violence charges and other background variables are introduced. The article also explores the associations between batterers' background characteristics and court convictions, as well as the effect of sanctions on the recidivism of convicted batterers.