A multidisciplinary approach to prolonged extracorporeal membrane oxygenation for acute respiratory distress syndrome due to coronavirus 2019-case report.

Patients with novel coronavirus 2019 (COVID-19) may develop acute respiratory distress syndrome (ARDS) and require extracorporeal membrane oxygenation (ECMO) support. Currently there is no specific treatment for COVID-19 available; thus, for patients with severe ARDS, the respiratory condition needs to improve while on ECMO support. Here we present a multidisciplinary team approach to the care of a patient with COVID-related ARDS requiring three months of veno-venous (VV) ECMO which lead to recovery. A 35-year-old male was transferred to us with ARDS due to COVID-19 infection with a lactate 13.7 mmol/L and an arterial-blood gas oxygenation of 75 mmHg on maximum ventilator settings. He was placed on VV ECMO during which he developed pneumonia, bacteremia, and pneumothoraces; however, his other organ functions were preserved. During his time in the Intensive Care Unit (ICU), multiple subspecialist teams participated in his care including physicians, pharmacists, nurses, nutritionists, case management, and social work. The VV ECMO was weaned off after 91 days of support, after which he had a prolonged hospital course due to inflammatory bowel disease, and aspiration pneumonia. CT scan performed six weeks prior to discharge showed mild improvement in diffuse airspace opacities superimposed on extensive chronic cystic changes. He was eventually discharged to a rehabilitation facility 68 days after ECMO removal. He was then seen in our outpatient pulmonary clinic one month and our Post-Intensive Care Syndrome clinic three months after discharge on two liters of nasal cannula oxygen. Pulmonary function testing done at this time demonstrated severe restrictive lung disease and severely reduced diffusion capacity. This case highlights the need for multidisciplinary collaboration among hospital teams to ensure success and patient survival in the setting of COVID ARDS. In those COVID ARDS patients with intact renal, metabolic, hematologic, and cardiovascular function, ECMO should be strongly considered.

The effects of drinking water service fragmentation on drought-related water security.

Drought is a critical stressor that contributes to water insecurity. In the United States, an important pathway by which drought affects households' access to clean, reliable drinking water for basic needs is through the organization and activities of community water systems. Research on the local political economy of drinking water provision reveals the constraints on community water systems that affect their performance when confronting drought hazards. Fragmentation in responsibility for drinking water contributes to disparities in drought vulnerability, preparation, and response across households and across communities. The nature and extent of these disparities require further investigation to identify strategies for expanding water security in the face of drought and other water hazards.

What Is the Optimal Blood Pressure on Veno-Arterial Extracorporeal Membrane Oxygenation? Impact of Mean Arterial Pressure on Survival.

Blood pressure management is crucial for patients on veno-arterial extracorporeal membrane oxygenation (VA ECMO). Lower pressure can lead to end-organ malperfusion, whereas higher pressure may compete with ECMO flow and cardiac output. The impact of mean arterial pressure (MAP) on outcomes of patients on VA ECMO was evaluated. Patients who were supported on VA ECMO from September 2010 to March 2016 were retrospectively analyzed for average MAP throughout their course on ECMO, excluding the first and last day. Survival and complications observed during ECMO were investigated by classifying patients into groups based on their average MAP. A total of 116 patients were identified. Average MAP was significantly higher in patients who survived to discharge (82 ± 5.6 vs. 78 ± 5.5 mm Hg, p = 0.0003). There was a positive association between MAP and survival. Survival was best with MAP higher than 90 mm Hg (71%) and worst with MAP less than 70 mm Hg, where no patient survived. MAP was an independent predictor of survival to discharge by multivariate analysis (odds ratio 1.17, p = 0.013). Vasopressors were used more frequently in patients with lower pressure (coefficient -3.14, p = 0.005) without affecting survival (odds ratio 0.95, p = 0.95). Although the MAP did not affect the probability of strokes or bleeding complications, patients with a higher MAP had a lower incidence of kidney injury (p = 0.007). In conclusion, survival of patients on VA ECMO was significantly greater with a higher MAP, without being affected by prolonged vasopressor use.

Recent improvement and projected worsening of weather in the United States.

As climate change unfolds, weather systems in the United States have been shifting in patterns that vary across regions and seasons. Climate science research typically assesses these changes by examining individual weather indicators, such as temperature or precipitation, in isolation, and averaging their values across the spatial surface. As a result, little is known about population exposure to changes in weather and how people experience and evaluate these changes considered together. Here we show that in the United States from 1974 to 2013, the weather conditions experienced by the vast majority of the population improved. Using previous research on how weather affects local population growth to develop an index of people's weather preferences, we find that 80% of Americans live in counties that are experiencing more pleasant weather than they did four decades ago. Virtually all Americans are now experiencing the much milder winters that they typically prefer, and these mild winters have not been offset by markedly more uncomfortable summers or other negative changes. Climate change models predict that this trend is temporary, however, because US summers will eventually warm more than winters. Under a scenario in which greenhouse gas emissions proceed at an unabated rate (Representative Concentration Pathway 8.5), we estimate that 88% of the US public will experience weather at the end of the century that is less preferable than weather in the recent past. Our results have implications for the public's understanding of the climate change problem, which is shaped in part by experiences with local weather. Whereas weather patterns in recent decades have served as a poor source of motivation for Americans to demand a policy response to climate change, public concern may rise once people's everyday experiences of climate change effects start to become less pleasant.

Transradial approach versus transfemoral approach for coronary angiography and coronary angioplasty.

In the United States, approximately 1.7 million cardiac catheterizations are performed each year, making it the fifth most common procedure. In this article, the author reviews the literature on the alternative transradial approach versus the traditional transfemoral approach for cardiac catheterization. Through a meta-analysis, clinical trials were thoroughly analyzed. The clinical and procedural outcomes are compared to provide evidence that the transradial approach for coronary angiography and angioplasty is associated with lower risks of adverse outcomes compared with the traditional transfemoral approach. An educational focus highlights the role of the nurse practitioner to ensure proper assessment and management of patients after transradial access.