Attention Among Health Care Professionals : A Scoping Review.

BACKGROUND: The concept of attention can provide insight into the needs of clinicians and how health systems design can impact patient care quality and medical errors. PURPOSE: To conduct a scoping review to 1) identify and characterize literature relevant to clinician attention; 2) compile metrics used to measure attention; and 3) create a framework of key concepts. DATA SOURCES: Cumulated Index to Nursing and Allied Health Literature (CINAHL), Medline (PubMed), and Embase (Ovid) from 2001 to 26 February 2024. STUDY SELECTION: English-language studies addressing health care worker attention in patient care. At least dual review and data abstraction. DATA EXTRACTION: Article information, health care professional studied, practice environment, study design and intent, factor type related to attention, and metrics of attention used. DATA SYNTHESIS: Of 6448 screened articles, 585 met inclusion criteria. Most studies were descriptive (n = 469) versus investigational (n = 116). More studies focused on barriers to attention (n = 387; 342 descriptive and 45 investigational) versus facilitators to improving attention (n = 198; 112 descriptive and 86 investigational). We developed a framework, grouping studies into 6 categories: 1) definitions of attention, 2) the clinical environment and its effect on attention, 3) personal factors affecting attention, 4) relationships between interventions or factors that affect attention and patient outcomes, 5) the effect of clinical alarms and alarm fatigue on attention, and 6) health information technology's effect on attention. Eighty-two metrics were used to measure attention. LIMITATIONS: Does not synthesize answers to specific questions. Quality of studies was not assessed. CONCLUSION: This overview may be a resource for researchers, quality improvement experts, and health system leaders to improve clinical environments. Future systematic reviews may synthesize evidence on metrics to measure attention and on the effectiveness of barriers or facilitators related to attention. PRIMARY FUNDING SOURCE: None.

The Impact of Completing X-Waiver Training and Clinical Addiction Exposure on Internal Medicine Residents Treating Patients With Opioid Use Disorder.

BACKGROUND: Treating opioid use disorder (OUD) with buprenorphine or methadone significantly reduces overdose and all-cause mortality. Prior studies demonstrate that clinicians and residents reported a lack of preparedness to diagnose or treat OUD. Little is known about how clinical exposure or buprenorphine X-waiver training impacts OUD care delivery by resident physicians. OBJECTIVE: Distinguish the effects of X-waiver training and clinical exposure with OUD on resident's knowledge, attitudes, feelings of preparedness, and practices related to OUD treatment provision. METHODS: From August 2021 to April 2022, we distributed a cross-sectional survey to internal medicine residents at a large academic training program. We analyzed associations between self-reported clinical exposure and X-waiver training across 4 domains: knowledge about best practices for OUD treatment, attitudes about patients with OUD, preparedness to treat OUD, and clinical experience with OUD. RESULTS: Of the 188 residents surveyed, 91 responded (48%). A majority of respondents had not completed X-waiver training (60%, n = 55) while many had provided clinical care to patients with OUD (65%, n = 59). Most residents had favorable attitudes about OUD treatment (97%). Both residents with clinical exposure to treating OUD and X-waiver training, and residents with clinical exposure without X-waiver training, felt more prepared to treat OUD (P < .0008) compared to residents with neither clinical exposure or X-waiver training or only X-waiver training. CONCLUSIONS: Residents with clinical exposure to treating OUD are more prepared to treat patients with OUD than those without clinical exposure. Greater efforts to incorporate clinical exposure to the treatment of OUD and education in internal medicine residency programs is imperative to address the opioid epidemic.

General improvements versus interruptive or non-interruptive alerts in the blood order set: study protocol for a randomized control trial to improve packed red blood cell utilization.

BACKGROUND: Blood transfusions can serve as a life-saving treatment, but inappropriate blood product transfusions can result in patient harm and excess costs for health systems. Despite published evidence supporting restricted packed red blood cell (pRBC) usage, many providers transfuse outside of guidelines. Here, we report a novel prospective, randomized control trial to increase guideline-concordant pRBC transfusions comparing three variations of clinical decision support (CDS) in the electronic health record (EHR). METHODS: All inpatient providers at University of Colorado Hospital (UCH) who order blood transfusions were randomized in a 1:1:1 fashion to the three arms of the study: (1) general order set improvements, (2) general order set improvements plus non-interruptive in-line help text alert, and (3) general order set improvements plus interruptive alert. Transfusing providers received the same randomized order set changes for 18 months. The primary outcome of this study is the guideline-concordant rate of pRBC transfusions. The primary objective of this study is to compare the group using the new interface (arm 1) versus the two groups using the new interface with interruptive or non-interruptive alerts (arms 2 and 3, combined). The secondary objectives compare guideline-concordant transfusion rates between arm 2 and arm 3 as well as comparing all of arms of the study in aggregate to historical controls. This trial concluded after 12 months on April 5, 2022. DISCUSSION: CDS tools can increase guideline-concordant behavior. This trial will examine three different CDS tools to determine which type is most effective at increasing guideline-concordant blood transfusions. TRIAL REGISTRATION: Registered on ClinicalTrials.gov 3/20/21, NCT04823273 . Approved by University of Colorado Institutional Review Board (19-0918), protocol version 1 4/19/2019, approved 4/30/2019.

User-Centered Design to Reduce Inappropriate Blood Transfusion Orders.

BACKGROUND: To improve blood transfusion practices, we applied user-centered design (UCD) to evaluate potential changes to blood transfusion orders. OBJECTIVES: The aim of the study is to build effective transfusion orders with different designs to improve guideline adherence. METHODS: We developed three different versions of transfusion orders that varied how information was presented to clinicians ordering blood transfusions. We engaged 14 clinicians (residents, advanced practice providers [APPs], and attending physicians) from different specialties. We used the think aloud technique and rapid qualitative analysis to generate themes to incorporate into our modified orders. RESULTS: Most end-users who participated in the semi-structured interviews preferred the interruptive alert design plus behavioral nudges (n = 8/14, 57%). The predominant rationale was that the in-line alert was not visually effective in capturing the end-user's attention, while the interruptive alert forced a brief stop in the workflow to consider the guidelines. All users supported the general improvements, though for different reasons, and as a result, the general improvements remained in the designs for the forthcoming trial. CONCLUSION: The user experience uncovered through the think aloud approach produced a clear and rich understanding of potentially confounding factors in the initial design of different intervention versions. Input from end-users guided the creation of all three designs so each was addressing human factors with parity, which ensured that the results of our study reflected differences in interruptive properties of the alerts and not differences in design.

Concepts and metrics of clinician attention: a scoping review protocol.

INTRODUCTION: There is growing emphasis on the importance of both the cognitive and behavioural phenomenon of attention for clinicians engaged in patient care. Aspects of attention such as cognitive load, distraction and task switching have been studied in various settings with different methodologies. Using the protocol described here, we aim to systematically review the medical literature in order to map the concept of attention and to synthesise diverse concepts and methods under the broader category of research focused on 'attention'. METHODS AND ANALYSIS: Following the methodology described by the Joanna Briggs Institute and Arksey and O'Malley, our scoping review conducts an iterative search of Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline (PubMed) and EMBASE (Ovid). An initial limited search based on key concepts and terminology will generate relevant articles which in turn will be mined for additional keywords and index terms to guide a formal literature search. Our multidisciplinary team will extract data into a matrix, including a small random sample of the same studies (to ensure concordance), and present the results in a descriptive narrative format. ETHICS AND DISSEMINATION: As a secondary analysis, our study does not require ethics approval, and we will ensure that included studies have appropriate approval. We anticipate results will identify diverse ways of conceptualising clinician attention and will provide a foundation for developing additional metrics and study methods to optimise attention in the clinical environment. We will disseminate results through journals and conferences and coordinate with colleagues doing work in adjacent fields.

Histone Modifications in Papillomavirus Virion Minichromosomes.

An unusual feature of papillomaviruses is that their genomes are packaged into virions along with host histones. Viral minichromosomes were visualized as "beads on a string" by electron microscopy in the 1970s but, to date, little is known about the posttranslational modifications of these histones. To investigate this, we analyzed the histone modifications in HPV16/18 quasivirions, wart-derived bovine papillomavirus (BPV1), and wart-derived human papillomavirus type 1 (HPV1) using quantitative mass spectrometry. The chromatin from all three virion samples had abundant posttranslational modifications (acetylation, methylation, and phosphorylation). These histone modifications were verified by acid urea polyacrylamide electrophoresis and immunoblot analysis. Compared to matched host cell controls, the virion minichromosome was enriched in histone modifications associated with active chromatin and depleted for those commonly found in repressed chromatin. We propose that the viral minichromosome acquires specific histone modifications late in infection that are coupled to the mechanisms of viral replication, late gene expression, and encapsidation. We predict that, in turn, these same modifications benefit early stages of infection by helping to evade detection, promoting localization of the viral chromosome to beneficial regions of the nucleus, and promoting early transcription and replication.IMPORTANCE A relatively unique feature of papillomaviruses is that the viral genome is associated with host histones inside the virion. However, little is known about the nature of the epigenome within papillomavirions or its biological relevance to the infectious viral cycle. Here, we define the epigenetic signature of the H3 and H4 histones from HPV16 virions generated in cell culture and native human papillomavirus type 1 (HPV1) and bovine papillomavirus 1 (BPV1) virions isolated from bovine and human wart tissue. We show that native virions are enriched in posttranslational modifications associated with active chromatin and depleted with those associated with repressed chromatin compared to cellular chromatin. Native virions were also enriched in the histone variant H3.3 compared to the canonical histone H3.1. We propose that the composition of virion-packaged chromatin reflects the late stages of the viral life cycle and promotes the early stages of infection by being primed for viral transcription.

Human Papillomavirus Quasivirus Production and Infection of Primary Human Keratinocytes.

This protocol describes the production of human papillomavirus (HPV)-derived quasiviruses. Quasiviruses are infectious particles that are produced in 293TT packaging cells and contain a complete viral genome. We describe methods for infection of primary human keratinocytes with HPV quasiviruses, as well as assays to measure early viral DNA replication and transcription. Published 2020. U.S. Government. Basic Protocol 1: Transfection, harvest, and isolation of HPV quasiviruses Alternate Protocol 1: Packaging HPV DNA replicated in 293TT cells Alternate Protocol 2: Production of higher-purity quasivirus using the "Ripcord" method Support Protocol 1: Production of HPV minicircles Support Protocol 2: Production of recircularized HPV genomes Support Protocol 3: Screening of fractions for viral proteins Support Protocol 4: Screening of fractions for viral DNA Support Protocol 5: Measuring viral titer Support Protocol 6: Quantitation of quasivirions Basic Protocol 2: Infection of primary human foreskin keratinocytes with quasivirus Basic Protocol 3: HPV quasivirus transcription assay Basic Protocol 4: HPV quasivirus replication assay.

No Camphor Toxicity in Cambodian Infants.

Thiamine deficiency and beriberi are prevalent in Cambodia, although most infants with nonspecific clinical symptoms of beriberi, including tachypnea, lack echocardiographic evidence diagnostic of the disease. Camphor activates transient receptor potential vanilloid 3 (TRPV3), a nonselective ion channel expressed in the medial preoptic nucleus of the hypothalamus and thought to be important for thermo-sensitivity. Because camphorated ointments are used commonly among Cambodian infants, we hypothesized that topical camphor modulates thermoregulatory behaviors, causing beriberi-simulating tachypnea, separate from any influence of thiamine deficiency. We assessed 9 tachypneic and 10 healthy infants for Tiger Balm use and for presence of camphor in whole blood. However, no camphor was found in blood from any infants, indicating that camphor is unrelated to tachypneic illness in Cambodian infants.

The Columbia-Bronx VA amalgamative clerkship: an effective, 12-week, integrated, longitudinal clinical experience.

BACKGROUND: Many medical schools have adopted the longitudinal integrated clerkship (LIC) model in response to calls for increased continuity in clinical learning environments. However, because of implementation challenges, such programs are not feasible at some institutions or are limited to a small number of students. OBJECTIVE: In January 2014, Columbia University College of Physicians and Surgeons (P&S) recognized the need to explore different LIC formats and began offering four, 12-week amalgamative clerkships (AC). Students within this curricular track experienced primary care, internal medicine 'away', orthopedic surgery, urology, and an elective in an integrated format. DESIGN: P&S developed the AC in partnership with the James J. Peters VA Medical Center in Bronx, NY (BVA). All patient care and educational conferences took place at the BVA during the 12-week experience. The learning objectives of the AC were aligned to the learning objectives of a 52-week20 LIC also offered at Columbia. An evaluation process was developed to determine studentlearning experiences and preliminary outcomes, including how well the LIC-related objectivescould be achieved in a shorter period of time. RESULTS: In 2015, P&S collected AC evaluation data through three student feedback sessions. Students reported that the AC provided opportunity for patient continuity, patient-centered care approaches, meaningful roles for students, career development opportunities, and health systems awareness. CONCLUSIONS: Early outcomes indicate that the BVA AC provides a degree of longitudinality that can influence student perceptions of patient care, career development, and health systems, consistent with the larger LIC. The team continues to gather additional data on students' experiences and investigate additional sites that have potential to serve as future AC learning environments.

Host cell restriction factors that limit transcription and replication of human papillomavirus.

The life cycle of human papillomaviruses (HPV) is tightly regulated by the differentiation state of mucosal and cutaneous keratinocytes. To counteract viral infection, constitutively expressed cellular factors, which are defined herein as restriction factors, directly mitigate viral gene expression and replication. In turn, some HPV gene products target these restriction factors and abrogate their anti-viral effects to establish efficient gene expression and replication programs. Ironically, in certain circumstances, this delicate counterbalance between viral gene products and restriction factors facilitates persistent infection by HPVs. This review serves to recapitulate the current knowledge of nuclear restriction factors that directly affect the HPV infectious cycle.

Novel recombinant papillomavirus genomes expressing selectable genes.

Papillomaviruses infect and replicate in keratinocytes, but viral proteins are initially expressed at low levels and there is no effective and quantitative method to determine the efficiency of infection on a cell-to-cell basis. Here we describe human papillomavirus (HPV) genomes that express marker proteins (antibiotic resistance genes and Green Fluorescent Protein), and can be used to elucidate early stages in HPV infection of primary keratinocytes. To generate these recombinant genomes, the late region of the oncogenic HPV18 genome was replaced by CpG free marker genes. Insertion of these exogenous genes did not affect early replication, and had only minimal effects on early viral transcription. When introduced into primary keratinocytes, the recombinant marker genomes gave rise to drug-resistant keratinocyte colonies and cell lines, which maintained the extrachromosomal recombinant genome long-term. Furthermore, the HPV18 "marker" genomes could be packaged into viral particles (quasivirions) and used to infect primary human keratinocytes in culture. This resulted in the outgrowth of drug-resistant keratinocyte colonies containing replicating HPV18 genomes. In summary, we describe HPV18 marker genomes that can be used to quantitatively investigate many aspects of the viral life cycle.

Diagnosis and Treatment of Polycystic Ovary Syndrome.

Polycystic ovary syndrome is the most common endocrinopathy among reproductive-aged women in the United States, affecting approximately 7% of female patients. Although the pathophysiology of the syndrome is complex and there is no single defect from which it is known to result, it is hypothesized that insulin resistance is a key factor. Metabolic syndrome is twice as common in patients with polycystic ovary syndrome compared with the general population, and patients with polycystic ovary syndrome are four times more likely than the general population to develop type 2 diabetes mellitus. Patient presentation is variable, ranging from asymptomatic to having multiple gynecologic, dermatologic, or metabolic manifestations. Guidelines from the Endocrine Society recommend using the Rotterdam criteria for diagnosis, which mandate the presence of two of the following three findings- hyperandrogenism, ovulatory dysfunction, and polycystic ovaries-plus the exclusion of other diagnoses that could result in hyperandrogenism or ovulatory dysfunction. It is reasonable to delay evaluation for polycystic ovary syndrome in adolescent patients until two years after menarche. For this age group, it is also recommended that all three Rotterdam criteria be met before the diagnosis is made. Patients who have marked virilization or rapid onset of symptoms require immediate evaluation for a potential androgen-secreting tumor. Treatment of polycystic ovary syndrome is individualized based on the patient's presentation and desire for pregnancy. For patients who are overweight, weight loss is recommended. Clomiphene and letrozole are first-line medications for infertility. Metformin is the first-line medication for metabolic manifestations, such as hyperglycemia. Hormonal contraceptives are first-line therapy for irregular menses and dermatologic manifestations.

Utility of double inversion recovery MRI in paediatric epilepsy.

Detecting focal abnormalities in MRI examinations of children with epilepsy can be a challenging task given the frequently subtle appearance of cortical dysplasia, mesial temporal sclerosis and similar lesions. In this report, we demonstrate the utility of double inversion recovery MRI in the detection of paediatric epileptogenic abnormalities, promoted primarily by increased lesion conspicuity due to complementary suppression of both cerebrospinal fluid and normal white matter signal.

Does emotional intelligence change during medical school gross anatomy course? Correlations with students' performance and team cohesion.

Emotional intelligence (EI) has been associated with increased academic achievement, but its impact on medical education is relatively unexplored. This study sought to evaluate change in EI, performance outcomes, and team cohesion within a team-based medical school anatomy course. Forty-two medical students completed a pre-course and post-course Schutte Self-Report Emotional Intelligence Test (SSEIT). Individual EI scores were then compared with composite course performance grade and team cohesion survey results. Mean pre-course EI score was 140.3 out of a possible 160. During the course, mean individual EI scores did not change significantly (P = 0.17) and no correlation between EI scores and academic performance was noted (P = 0.31). In addition, EI did not correlate with team cohesion (P = 0.16). While business has found significant utility for EI in increasing performance and productivity, its role in medical education is still uncertain.

Postnatal care in Brazil: opportunities and challenges / Cuidado pós-natal no Brasil: oportunidades e desafios / Cuidado post-natal en Brasil: oportunidades y desafíos

ABSTRACT Aim: in this paper the authors described the experience in proposition and realization of a workshop in a partnership between UK and Brazilian researchers. The aim was plan out a strategy for the successful implementation of interventions to improve the health and wellbeing of women's postnatal care in Brazil. Method: this is an experience report about the implementation of that workshop. It was held in the Universidade Federal de Santa Catarina, from 7 to 10 March 2016, under the auspices of the British Council Researcher Links Scheme, funded through the Newton Fund and Brazilian Council of the State Foundations of Research, Sciences and Innovation represented in Santa Catarina by Foundation for Research and Innovation of Santa Catarina. Results: during the workshop were presented health and social care experiences of women in Brazil from pregnancy through to the months after birth, integrated review of social technology in health, the importance of specific public health initiatives and good health surveillance in a country as large and multi-cultured as Brazil. It was also carried out a meeting between health professionals and women and their partners who had received postnatal care. Each day we worked in small groups to identify the research areas that we were interested in moving forward with as a Brazil-UK research network. Conclusions: a number of perceived opportunities and challenges were identified during the workshop from researchers, practitioners, parents and policy makers. The success of social technology interventions depends on their appropriate introduction within Brazil's social and healthcare context.

RESUMO Objetivo: neste artigo os autores descreveram a experiência de propor e realizar um workshop colaborativo com pesquisadores brasileiro e do reino unido. O objetivo foi planejar uma estratégia que garantisse o sucesso na implementação de intervenções para melhorar a saúde e o bem-estar de mulheres em cuidado pós-natal no Brasil. Método: relato de experiência sobre a implementação de um workshop. Foi desenvolvido na Universidade Federal de Santa Catarina do dia 7 ao dia 10 de março 2016, com o patrocínio do British Council Researcher Links Scheme, fundado através do Fundo Newton e do Conselho Brasileiro de Fundações Estaduais de Amparo à Pesquisa, Ciência e Inovação representado em Santa Catarina pela Fundação de Pesquisa e Inovação de Santa Catarina. Resultados: durante o workshop foram apresentadas experiências sociais e de saúde de mulheres brasileiras, desde a gravidez ate alguns meses pós-natais. Integraram-se discussões sobre tecnologia social em saúde, sobre a importância de inovações específicas na saúde pública e vigilância em saúde, em um país tão grande e multicultural como Brasil. Desenvolveu-se uma reunião entre profissionais de saúde, mulheres e acompanhantes que tem recebido cuidado pós-natal. Trabalhamos em grupos pequenos com o intuito de identificar as áreas que nos interessavam desenvolver na rede Brasil-Reino Unido. Conclusões: o número de oportunidades e desafios percebido foram identificados durante o workshop pelos pesquisadores, profissionais atuantes, pais e formuladores de politicas. O sucesso das intervenções tecnológicas e sociais depende da sua introdução apropriada no contexto social e da saúde brasileira.

RESUMEN Objetivo: en este artículo los autores describieron la experiencia de proponer y realizar un taller colaborativo con investigadores brasileños y británicos. El objetivo fue planear una estrategia que garantizara el éxito en la implementación de intervenciones para mejorar la salud y el bienestar de mujeres en cuidado post-natal, en Brasil. Método: relato de experiencia sobre la implementación de un taller. Fue llevado a cabo en la Universidad Federal de Santa Catarina, del 7 al 10 de Marzo del 2016, con el auspicio del British Council Researcher Links Scheme, fundado a través del Fondo Newton y el Consejo Brasileño de Fundaciones Estatales de Amparo a la investigación, ciencia e innovación representado en Santa Catarina por la Fundación de Investigación e Innovación de Santa Catarina. Resultados: durante el taller fueron presentadas experiencias sociales y de salud de mujeres brasileñas, desde el embarazo hasta algunos meses post-natales. Se integrarondiscusiones sobre tecnología social en salud, la importancia de innovaciones especificas en salud pública y vigilancia en salud, en un país tan grande y multicultural como Brasil. Se llevó a cabo una reunión entre profesionales de salud, mujeres y sus acompañantes que han recibido cuidado post-natal. Cada día, trabajamos en grupos pequeños para identificar las áreas que nos interesaban en desarrollar en la red Brasil-Gran Bretaña. Conclusiones: El número de oportunidades y desafíos percibidos fueron identificados durante el taller, por los investigadores, profesionales de salud actuantes, padres y formuladores de políticas. El éxito de las intervenciones tecnológicas y sociales depende de su introducción apropiada en el contexto social y de salud brasileño.

Thiamine deficiency and cardiac dysfunction in Cambodian infants.

OBJECTIVES: To compare blood thiamine concentrations, echocardiography findings, and plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in infants with clinically diagnosed beriberi and healthy matched controls, and to evaluate changes after thiamine treatment. STUDY DESIGN: Sixty-two Cambodian infants (20 cases and 42 controls), aged 2-47 weeks, were enrolled in this prospective study. Echocardiography and phlebotomy were performed at baseline and after thiamine treatment. RESULTS: Both cases and controls were thiamine-deficient, with median blood thiamine diphosphate (TDP) concentrations of 47.6 and 55.1 nmol/L, respectively (P = .23). All subjects had normal left ventricular ejection fraction. The median NT-proBNP concentration in cases (340 pg/mL [40.1 pmol/L]) was higher than previously reported normal ranges, but not statistically significantly different from that in controls (175 pg/mL [20.7 pmol/L]) (P = .10), and was not correlated with TDP concentration (P = .13). Two cases with the lowest baseline TDP concentrations (24 and 21 nmol/L) had right ventricular enlargement and elevated NT-proBNP levels that improved dramatically by 48 hours after thiamine administration. CONCLUSION: Only a minority of thiamine-deficient Cambodian infants demonstrate abnormal echocardiography findings. Thiamine deficiency produces echocardiographic evidence of right ventricular dysfunction, but this evidence is not apparent until deficiency is severe. NT-proBNP concentrations are mildly elevated in sick infants with normal echocardiography findings, indicating possible physiological changes not yet associated with echocardiographic abnormalities.

Sustained improvements in dyspnea and pulmonary function 3 to 5 years after lung volume reduction surgery.

OBJECTIVES: To determine long-term survival rates of patients who underwent lung volume reduction surgery (LVRS) for emphysema and the factors associated with longer survival, and to evaluate levels of perceived dyspnea and health-related quality of life (HRQL) after a follow-up period of 3 to 5.5 years. DESIGN: Retrospective observational study. SETTING: Academic medical center METHODS: Telephone and postal surveys were used to obtain patient dyspnea scores and HRQL scores. Hospital databases and state registries were searched to determine patient survival and pulmonary function. RESULTS: Of 54 patients undergoing LVRS, 29 patients (18 men and 11 women) were available for follow-up, which ranged from 36 to 66 months (mean +/- SE, 51 +/- 1.5 months). There was significant sustained improvement in modified Medical Research Council scores compared to pre-LVRS: 2.19 +/- 0.19 vs 2.88 +/- 0.14 (p = 0.0000). Eleven of 22 patients demonstrated an increase in all three Mahler baseline dyspnea index grades of at least one level. Baseline body mass index (BMI) and post-LVRS length of stay (LOS) were significantly associated with survival: survivor vs deceased baseline BMI, 24.2 +/- 0.6 vs 21.4 +/- 0.5 (p = 0.002), and post-LVRS LOS, 15.4 +/- 1.7 days vs 28.7 +/- 5.3 days (p = 0.015). Compared to pre-LVRS, 20 patients with mean follow-up time of 45 months demonstrated significant sustained improvements in FEV(1) percentage of predicted (31.4 +/- 2.1% vs 39.8 +/- 3.5%, p = 0.038), total lung capacity percentage of predicted (136 +/- 4% vs 122 +/- 3%, p = 0.0004), and residual volume percentage of predicted (237 +/- 14% vs 172 +/- 11%, p = 0.0001). Patient HRQL measured using the Dartmouth Primary Care Co-operative Quality of Life questionnaire was more favorable than that reported in aged-care settings. Caregiver burden scale scores indicate caring for a recipient of LVRS carries similar burden to that for caring for individuals with other chronic illnesses. CONCLUSIONS: In this population, a majority of the LVRS patients survived for >/= 3 years. Among survivors, dyspnea and lung function benefits were seen. Baseline BMI and postoperative LOS were significantly associated with survival.