Extracorporeal carbon dioxide removal in acute hypoxaemic respiratory failure: a systematic review, Bayesian meta-analysis and trial sequential analysis.

PURPOSE: To assess the safety and efficacy of extracorporeal carbon dioxide removal (ECCO2R) versus standard care in patients with acute hypoxaemic respiratory failure (AHRF). METHODS: MEDLINE, Embase and clinical trial registries were searched from 1994 to 31 December 2021. We included randomised controlled trials (RCTs) and observational studies. Pairs of reviewers independently extracted data and assessed the risk of bias. The primary outcome was mortality. Secondary outcomes included ventilator-free days, length of stay, safety and adverse events and physiological changes. As a primary analysis, we performed a meta-analysis of mortality until day 30 using a Bayesian random effects model. We then performed a trial sequential analysis of RCTs. RESULTS: 21 studies met inclusion criteria: three RCTs, enrolling 531 patients, and 18 observational studies. In a pooled analysis of RCTs, the posterior probability of increased mortality with the use of ECCO2R was 73% (relative risk 1.19, 95% credible interval 0.70-2.29). There was substantial heterogeneity in the reporting of safety and adverse events. However, the incidence of extra and intracranial haemorrhage was higher (relative risk 3.00, 95% credible interval 0.41-20.51) among those randomised to ECCO2R. Current trials have accumulated 80.8% of the diversity-adjusted required information size and the lack of effect reaches futility for a 10% absolute risk reduction in mortality. CONCLUSIONS: The use of ECCO2R in patients with AHRF is not associated with improvements in clinical outcomes. Furthermore, it is likely that further trials of ECCO2R aiming to achieve an absolute risk reduction in mortality of ≥10% are futile.

Intensive care unit visiting and family communication during the COVID-19 pandemic: A UK survey.

Background: Frequent visiting and communication with patients' families are embedded within normal ICU practice, however the COVID-19 pandemic has challenged this, and it is unclear how ICUs are managing. We aimed to investigate how NHS ICUs are approaching family communications and visiting during the COVID-19 pandemic. Methods: An electronic snapshot survey was delivered between 16th April and 4th May 2020 and was open to NHS ICUs. Replies from 134 individual ICUs with COVID patients were included. Results: All reported that visiting was more restricted than normal with 29 (22%) not allowing any visitors, 71 (53%) allowing visitors at the end of a patient's life (EOL) only, and 30 (22%) allowing visitors for vulnerable patients or EOL. Nearly all (n = 130, 97%) were updating families daily, with most initiating the update (n = 120, 92%). Daily telephone calls were routinely made by the medical (n = 75, 55%) or nursing team (n = 50, 37%). Video calling was used by 63 (47%), and 39 (29%) ICUs had developed a dedicated family communication team. Resuscitation and EOL discussions were most frequently via telephone (n = 129, 96%), with 24 (18%) having used video calling, and 15 (11%) reporting discussions had occurred in person. Clinicians expressed their dissatisfaction with the situation and raised concerns about the detrimental effect on patients, families, and staff. Conclusions: COVID-19 has resulted in significant changes across NHS ICUs in how they interact with families. Many units are adapting and moving toward distant and technology-assisted communication. Despite innovative solutions, challenges remain and there may be a role for local and national guidance.

Dynamic Transmission of Staphylococcus Aureus in the Intensive Care Unit.

Staphylococcus aureus is an important bacterial pathogen. This study utilized known staphylococcal epidemiology to track S. aureus between patients, surfaces, staff hands and air in a ten-bed intensive care unit (ICU). METHODS: Patients, air and surfaces were screened for total colony counts and S. aureus using dipslides, settle plates and an MAS-100 slit-sampler once a month for 10 months. Data were modelled against proposed standards for air and surfaces, and ICU-acquired staphylococcal infection. Whole-cell genomic typing (WGS) demonstrated possible transmission pathways between reservoirs. RESULTS: Frequently touched sites were more likely to be contaminated (>12 cfu/cm2; p = 0.08). Overall, 235 of 500 (47%) sites failed the surface standard (≤2.5 cfu/cm2); 20 of 40 (50%) passive air samples failed the "Index of Microbial Air" standard (2 cfu/9 cm plate/h), and 15/40 (37.5%) air samples failed the air standard (<10 cfu/m3). Settle plate data were closer to surface counts than automated air data; the surface count most likely to reflect pass/fail rates for air was 5 cfu/cm2. Surface counts/bed were associated with staphylococcal infection rates (p = 0.012). Of 34 pairs of indistinguishable S. aureus, 20 (59%) showed autogenous transmission, with another four (12%) occurring between patients. Four (12%) pairs linked patients with hand-touch sites and six (18%) linked airborne S. aureus, staff hands and hand-touch sites. CONCLUSION: Most ICU-acquired S. aureus infection is autogenous, while staff hands and air were rarely implicated in onward transmission. Settle plates could potentially be used for routine environmental screening. ICU staphylococcal infection is best served by admission screening, systematic cleaning and hand hygiene.

Testing a Moderated Mediation Model of Mindfulness, Psychosocial Stress, and Alcohol Use among African American Smokers.

Mindfulness-based strategies have received empirical support for improving coping with stress and reducing alcohol use. The present study presents a moderated mediation model to explain how mindfulness might promote healthier drinking patterns. This model posits that mindfulness reduces perceived stress, leading to less alcohol use, and also weakens the linkage between stress and alcohol use. African American smokers (N = 399, 51% female, Mage = 42) completed measures of dispositional mindfulness, perceived stress, quantity of alcohol use, frequency of binge drinking, and alcohol use disorder symptoms. Participants with higher levels of dispositional mindfulness reported less psychosocial stress and lower alcohol use on all measures. Furthermore, mindfulness moderated the relationship between perceived stress and quantity of alcohol consumption. Specifically, higher perceived stress was associated with increased alcohol use among participants low, but not high, in mindfulness. Mindfulness may be one strategy to reduce perceived stress and associated alcohol use among African American smokers.

Social support mediates the association of health literacy and depression among racially/ethnically diverse smokers with low socioeconomic status.

Nearly half of U.S. adults have health literacy (HL) difficulties, and lack the ability to effectively obtain, process, and understand health information. Poor HL is associated with depression, yet mechanisms of this relation are unclear. This study examined whether social support mediated the relation between HL and depressive symptoms in 200 low-socioeconomic status (SES), racially/ethnically diverse smokers enrolled in cessation treatment. Mediation analyses were conducted using bootstrapping and controlling for SES and nicotine dependence. In simple mediation models, social support [Interpersonal Support Evaluation List (ISEL) total, subscales (Appraisal, Belonging, Tangible)] mediated the effect of HL on depression, such that lower HL was associated with lower perceived support, which predicted higher depressive symptoms (ps < .05). A multiple mediation model, with ISEL subscales entered simultaneously as mediators, was significant (p < .05) but only the Belonging subscale demonstrating independent significance (p < .05). Thus, social support may be a critical factor underlying the HL-depression relationship in low-SES, racially/ethnically diverse smokers.

Mindfulness predicts lower affective volatility among African Americans during smoking cessation.

Recent research suggests that mindfulness benefits emotion regulation and smoking cessation. However, the mechanisms by which mindfulness affects emotional and behavioral functioning are unclear. One potential mechanism, lower affective volatility, has not been empirically tested during smoking cessation. This study examined longitudinal associations among mindfulness and emotional responding over the course of smoking cessation treatment among predominantly low-socioeconomic status (SES) African American smokers, who are at high risk for relapse to smoking and tobacco-related health disparities. Participants (N = 399, 51% female, mean age = 42, 48% with annual income <$10,000) completed a baseline measure of trait mindfulness. Negative affect, positive affect, and depressive symptoms were assessed at five time points during smoking cessation treatment (up to 31 days postquit). Volatility indices were calculated to quantify within-person instability of emotional symptoms over time. Over and above demographic characteristics, nicotine dependence, and abstinence status, greater baseline trait mindfulness predicted lower volatility of negative affect and depressive symptoms surrounding the quit attempt and up to 1 month postquit, ps < 0.05. Although volatility did not mediate the association between greater mindfulness and smoking cessation, these results are the first to show that mindfulness is linked to lower affective volatility (or greater stability) of negative emotions during the course of smoking cessation. The present study suggests that mindfulness is linked to greater emotional stability and augments the study of mindfulness in diverse populations. Future studies should examine the effects of mindfulness-based interventions on volatility and whether lower volatility explains effects of mindfulness-based treatments on smoking cessation.

Positive smoking outcome expectancies mediate the association between negative affect and smoking urge among women during a quit attempt.

Ecological momentary assessment was used to examine associations between negative affect, positive smoking outcome expectancies, and smoking urge during the first 7 days of a smoking quit attempt. Participants were 302 female smokers who enrolled in an individually tailored smoking cessation treatment study. Multilevel mediation analysis was used to examine the temporal relationship among the following: (a) the effects of negative affect and positive smoking outcome expectancies at 1 assessment point (e.g., time j) on smoking urge at the subsequent time point (e.g., time j + 1) in Model 1; and, (b) the effects of negative affect and smoking urge at time j on positive smoking outcome expectancies at time j + 1 in Model 2. The results from Model 1 showed a statistically significant effect of negative affect at time j on smoking urge at time j + 1, and this effect was mediated by positive smoking outcome expectancies at time j, both within- and between-participants. In Model 2, the within-participant indirect effect of negative affect at time j on positive smoking outcome expectancies at time j + 1 through smoking urge at time j was nonsignificant. However, a statistically significant indirect between-participants effect was found in Model 2. The findings support the hypothesis that urge and positive smoking outcome expectancies increase as a function of negative affect, and suggest a stronger effect of expectancies on urge as opposed to the effect of urge on expectancies.

Mindfulness Ameliorates the Relationship between Weight Concerns and Smoking Behavior in Female Smokers: A Cross-Sectional Investigation.

Weight concerns are common among female smokers and may interfere with smoking cessation. It is imperative to identify protective factors to lessen the likelihood that smoking-related weight concerns prompt smoking and hinder cessation efforts. Mindfulness is one potential protective factor that might prevent weight concerns from triggering smoking. In the current study, relationships among facets of trait mindfulness, smoking-related weight concerns, and smoking behavior were examined among 112 young adult female smokers (70.5% daily smokers; 83% Caucasian; mean age 20 [SD = 1.69]). After controlling for demographic variables, the Describing facet of trait mindfulness predicted lower smoking-related weight concerns. The mindfulness characteristics of Acting with Awareness, Nonreactivity, and Describing moderated the relationship between smoking-related weight concerns and smoking frequency, such that smoking-related weight concerns predicted greater smoking frequency in female smokers with low and medium levels of these mindfulness characteristics but did not in those with higher levels of mindfulness. These results suggest that mindfulness-based interventions may be effective for weight-concerned smokers.

The influence of discrimination on smoking cessation among Latinos.

BACKGROUND: Although studies have shown a cross-sectional link between discrimination and smoking, the prospective influence of discrimination on smoking cessation has yet to be evaluated. Thus, the purpose of the current study was to determine the influence of everyday and major discrimination on smoking cessation among Latinos making a quit attempt. METHODS: Participants were 190 Spanish speaking smokers of Mexican Heritage recruited from the Houston, TX metropolitan area who participated in the study between 2009 and 2012. Logistic regression analyses were conducted to evaluate the associations of everyday and major discrimination with smoking abstinence at 26 weeks post-quit. RESULTS: Most participants reported at least some everyday discrimination (64.4%), and at least one major discrimination event (56%) in their lifetimes. Race/ethnicity/nationality was the most commonly perceived reason for both everyday and major discrimination. Everyday discrimination was not associated with post-quit smoking status. However, experiencing a greater number of major discrimination events was associated with a reduced likelihood of achieving 7-day point prevalence smoking abstinence, OR=.51, p=.004, and continuous smoking abstinence, OR=.29, p=.018, at 26 weeks post-quit. CONCLUSIONS: Findings highlight the high frequency of exposure to discrimination among Latinos, and demonstrate the negative impact of major discrimination events on a smoking cessation attempt. Efforts are needed to attenuate the detrimental effects of major discrimination events on smoking cessation outcomes.

Discrimination, affect, and cancer risk factors among African Americans.

OBJECTIVES: To examine whether stress or depressive symptoms mediated associations between perceived discrimination and multiple modifiable behavioral risk factors for cancer among 1363 African American adults. METHODS: Nonparametric bootstrapping procedures, adjusted for sociodemographics, were used to assess mediation. RESULTS: Stress and depressive symptoms each mediated associations between discrimination and current smoking, and discrimination and the total number of behavioral risk factors for cancer. Depressive symptoms also mediated the association between discrimination and overweight/obesity (p values < .05). CONCLUSIONS: Discrimination may influence certain behavioral risk factors for cancer through heightened levels of stress and depressive symptoms. Interventions to reduce cancer risk may need to address experiences of discrimination, as well as the stress and depression they engender.

Mediators of discrimination and self-rated health among African Americans.

OBJECTIVES: To examine whether stress and depressive symptoms mediated relationships of perceived discrimination and self-rated health among African Americans. METHODS: A nonparametric bootstrapping procedure was used to assess mediation, controlling for sociodemographic variables, among 1406 cohort study adults (age=45.5±12.6, 25.1% male). RESULTS: Greater discrimination was associated with poorer self-rated health (ß =-.010, SE=.003, p = .001). Stress and depressive symptoms were each significant mediators of this relationship in single and multiple mediator models (ps ≤ 05). CONCLUSIONS: Perceived discrimination may contribute to poorer self-rated health among African Americans through heightened levels of stress and depression. Interventions addressing these mechanisms might help reduce the impact of discrimination on health. Definitive results await longitudinal study designs to assess causal pathways.

Androgen receptor phosphorylation at serine 308 and serine 791 predicts enhanced survival in castrate resistant prostate cancer patients.

We previously reported that AR phosphorylation at serine 213 was associated with poor outcome and may contribute to prostate cancer development and progression. This study investigates if specific AR phosphorylation sites have differing roles in the progression of hormone naïve prostate cancer (HNPC) to castrate resistant disease (CRPC). A panel of phosphospecific antibodies were employed to study AR phosphorylation in 84 matched HNPC and CRPC tumours. Immunohistochemistry measured Androgen receptor expression phosphorylated at serine residues 94 (pAR94), 308 (pAR308), 650(pAR650) and 791 (pAR791). No correlations with clinical parameters were observed for pAR94 or pAR650 in HNPC or CRPC tumours. In contrast to our previous observation with serine 213, high pAR308 is significantly associated with a longer time to disease specific death (p = 0.011) and high pAR791 expression significantly associated with a longer time to disease recurrence (p = 0.018) in HNPC tumours and longer time to death from disease recurrence (p = 0.040) in CRPC tumours. This observation in CRPC tumours was attenuated in high apoptotic tumours (p = 0.022) and low proliferating tumours (p = 0.004). These results demonstrate that understanding the differing roles of AR phosphorylation is necessary before this can be exploited as a target for castrate resistant prostate cancer.

Associations between health literacy and established predictors of smoking cessation.

OBJECTIVES: We examined associations between health literacy and predictors of smoking cessation among 402 low-socioeconomic status (SES), racially/ethnically diverse smokers. METHODS: Data were collected as part of a larger study evaluating smoking health risk messages. We conducted multiple linear regression analyses to examine relations between health literacy and predictors of smoking cessation (i.e., nicotine dependence, smoking outcome expectancies, smoking risk perceptions and knowledge, self-efficacy, intentions to quit or reduce smoking). RESULTS: Lower health literacy was associated with higher nicotine dependence, more positive and less negative smoking outcome expectancies, less knowledge about smoking health risks, and lower risk perceptions. Associations remained significant (P < .05) after controlling for demographics and SES-related factors. CONCLUSIONS: These results provide the first evidence that low health literacy may serve as a critical and independent risk factor for poor cessation outcomes among low-socioeconomic status, racially/ethnically diverse smokers. Research is needed to investigate potential mechanisms underlying this relationship.

Smoking topography and outcome expectancies among individuals with schizotypy.

Compared to smokers in the general population, smokers with schizophrenia smoke more cigarettes per day and have higher nicotine dependence and biochemical indicators of nicotine intake. They also have more intense smoking topography and greater positive smoking expectancies. Little is known about the relationship between smoking and schizotypy, defined as the personality organization reflecting a vulnerability to schizophrenia-spectrum pathology. This study assessed schizotypy symptoms, smoking characteristics and behaviors, and smoking expectancies in young adults with psychometrically defined schizotypy and demographically matched controls without schizotypy. Smokers with schizotypy had higher nicotine dependence and smoked more cigarettes per week compared to control smokers. They were also more likely to endorse greater positive consequences (i.e., improved state enhancement, stimulation, social facilitation, taste/sensorimotor manipulation, reduced negative affect and boredom) and fewer negative consequences of smoking. Smokers with schizotypy and control smokers did not differ on smoking topography or carbon monoxide levels. This is the first known study to investigate relationships between these smoking-related variables in smokers with schizotypy. Individuals with schizotypy possessed certain smoking-related characteristics and smoking expectancies similar to those with schizophrenia. This offers preliminary insight into unique smoking-related factors among individuals with schizotypy and highlights the importance of continued research in this area.

Effects of brief mindfulness instructions on reactions to body image stimuli among female smokers: an experimental study.

INTRODUCTION: Recent research has shown that body image stimuli increase negative affect and smoking urges among female smokers. Mindfulness (paying attention to present-moment experience with an attitude of nonjudgmental acceptance) may be a useful technique to minimize the influence of body dissatisfaction on negative affect, smoking urges, and smoking behavior. METHODS: This study investigated whether mindfulness influences how female college smokers respond to a body image challenge. The study used a 2 × 2 factorial design with body image challenge (trying on a bathing suit vs. looking at a purse) crossed with instructions (mindfulness vs. silence). Female smokers (n = 64; M (age) = 20.03 [± 1.77], 87.5% Caucasian) were randomly assigned to one of four conditions: Purse + Silence (n = 16), Body Image + Silence (n = 15), Purse + Mindfulness (n = 15), and Body Image + Mindfulness (n = 18).

Unique relationships between facets of mindfulness and eating pathology among female smokers.

Female smokers often have higher levels of eating disorder symptoms than non-smokers, and concerns about eating and weight might interfere with smoking cessation. Thus, it is critical to identify factors to promote healthier eating and body image in this population. Initial research suggests that specific aspects of trait mindfulness predict lower body dissatisfaction and eating disorder symptoms among non-smokers. However, these relationships are unknown among smokers. The current study examined associations between facets of trait mindfulness and eating disorder symptoms in 112 college female smokers (83% Caucasian; mean age 20 years, SD=1.69). After controlling for relevant sociodemographic variables, Describing and Nonjudging facets of mindfulness predicted lower bulimic symptoms and body dissatisfaction (ps<.05), while Acting with Awareness predicted lower bulimic and anorexic symptoms, ps<.05. Observing predicted higher anorexic symptoms, p<.05. These results suggest that specific mindfulness facets are related to lower eating disorder symptoms among smokers, whereas other facets are not associated or have a positive relationship with these symptoms. Mindfulness-based interventions focusing on Describing, Nonjudging, and Acting with Awareness may help to reduce eating pathology among female smokers, which could potentially improve smoking cessation rates in this population.

Actual medical and pharmacy costs for bariatric surgery: 6-year follow-up.

OBJECTIVE: To determine the change in total medical expenditures, total pharmacy expenditures, and subcategories of medical and pharmacy expenditures in obese individuals following weight loss surgery (WLS), and to compare these costs with expenditures in obese individuals not receiving WLS. METHODS: Louisiana Office of Group Benefits (OGB), the state-managed health insurer, invited members to be evaluated for insurance-covered WLS. Of 951 obese members who provided written consent to begin the WLS screening process, 40 were selected for surgery. Medical and pharmaceutical claims cost data of the 911 patients who did not have surgery and the 39 individuals who completed surgery were compared over a 2-year presurgical and 6-year postsurgical period. RESULTS: Total nonpharmacy medical costs were lower for WLS patients compared with non-WLS patients beginning 4 years postsurgery and lasting through 6 years postsurgery. No differences were found between WLS and non-WLS patients in expenditures for most medical subcategories examined, including emergency department, physical and occupational therapy, office visits, and laboratory/pathology; whereas sleep facility and all remaining medical expenditures not represented by a subcategory were lower for WLS patients during some postsurgery years. Total pharmacy costs were lower for WLS participants at 2 and 3 years postsurgery, but these lower costs were not maintained; however, costs remained lower for antidiabetic agents, antihypertensive agents, and dyslipidemic agents through all 6 postsurgery years under study. CONCLUSIONS: The cost of WLS may begin to be recouped within the first 4 years postsurgery with continued effects 6 years postsurgery.

Contingency management for patients with cooccurring disorders: evaluation of a case study and recommendations for practitioners.

Research indicates that contingency management (CM) has potential to improve a number of outcomes (e.g. substance use, treatment attendance, quality of life) among individuals with substance use and cooccurring disorders. However, multiple factors must be considered on a case-by-case basis in order to promote optimal treatment effects. The present study describes an individualized CM protocol for a US Veteran with substance dependence and cooccurring severe mental illness. CM targeted attendance at outpatient appointments and appropriate use of hospital resources. Effects of CM were assessed by comparing the 3-month baseline and CM periods. The CM intervention marginally reduced unnecessary hospital admissions, resulting in cost savings to the medical center of over $5,000 in three months for this individual. However, CM did not affect outpatient attendance. Several complications arose, highlighting challenges in using CM in populations with substance use and cooccurring disorders. Practical suggestions are offered for maximizing the effects of CM.

The role of emotional nonacceptance in the relation between depression and recent cigarette smoking.

Evidence that smokers have heightened depressive symptoms and report smoking in response to negative affect has led to an interest in mindfulness- and acceptance-based strategies to help smokers respond more adaptively to depressive symptoms. More research is needed to examine the role of emotional nonacceptance (ie, the tendency to judge or negatively evaluate one's emotions) in the relation between depression and smoking, particularly among populations with elevated smoking rates (eg, individuals with substance use disorders). This study examined the mediating role of emotional nonacceptance in the relation between depression and smoking among 125 smokers in residential substance abuse treatment. Participants (mean age = 35 ± 10; 60% male; 63% White) reported how many cigarettes they smoked in the past hour and completed self-report measures of emotion dysregulation (including nonacceptance) and depression. Major depressive disorder was assessed through clinical interview. Results supported the hypothesized relevance of emotional nonacceptance to recent smoking. Specifically, emotional nonacceptance was the only dimension of emotion dysregulation uniquely associated with recent smoking and mediated the relationship between depression and recent smoking. Results suggest that depression may interfere with emotional acceptance, increasing urges to smoke to escape negative affect. Targeting emotional nonacceptance may improve smoking cessation treatments for depressed individuals.

The contribution of emotion regulation difficulties to risky sexual behavior within a sample of patients in residential substance abuse treatment.

The present study examined the unique contribution of emotion regulation difficulties to past-year risky sexual behavior (RSB) among substance use disorder (SUD) patients (above and beyond other known RSB risk factors). A sample of 177 SUD patients completed a series of questionnaires. At the zero-order level, emotion regulation difficulties, were significantly positively associated with the number of commercial sexual (i.e., the exchange of sex for drugs or money) partners with which penetrative sex occurred and significantly negatively associated with the likelihood of using a condom when having sex with a commercial partner under the influence of drugs. Emotion regulation difficulties also significantly predicted these RSB indices above and beyond other RSB risk factors, including demographics, depression, sensation seeking, traumatic exposure, and substance use severity. The specific emotion regulation difficulty of lack of emotional clarity emerged as a unique predictor of RSB. The implications of these findings for understanding motivations for RSB and developing targeted interventions for RSB among SUD patients are discussed.