Impact of Religiosity on Delirium Severity Among Critically Ill Shi'a Muslims: A Prospective Multi-Center Observational Study.

This study assesses the impact of religiosity on delirium severity and patient outcomes among Shi'a Muslim intensive care unit (ICU) patients. We conducted a prospective observational cohort study in 21 ICUs from 6 Iranian academic medical centers. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU) tool. Eligible patients were intubated, receiving mechanical ventilation (MV) for ≥ 48 h. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. A total of 4200 patients were enrolled. Patient religiosity was categorized as more (40.6%), moderate (42.3%), or less (17.1%) based on responses to patient and surrogate questionnaires. The findings suggest that lower pre-illness religiosity may be associated with greater delirium severity, MV duration, and ICU and hospital LOS. The lower mortality in the less religiosity group may be related in part to a greater proportion of female patients, but it remains unclear whether and to what extent greater religiosity impacted treatment decisions by patients and families. Further investigation is needed to validate and clarify the mechanism of the mortality findings.

Disease specific thresholds for determining extubation readiness: The optimal negative inspiratory force for chronic obstructive pulmonary disease patients.

OBJECTIVES: The negative inspiratory force (NIF) has been used to help clinicians predict a patient's likelihood of successful liberation from mechanical ventilation (MV). However, the utility of the traditional threshold of ≤-30 cmH 2O may not be appropriate for patients with chronic obstructive pulmonary disease (COPD). This study aims to define the optimal predictive NIF threshold for COPD patients. METHODS: A prospective-observational multi-center study was conducted in intensive care units of six academic medical centers. All patients had COPD and were intubated for hypercapnic respiratory failure. The process of weaning from MV was conducted according to the defined hospital protocol. NIF was measured after 120 min of spontaneous breathing trial (SBT). The sensitivity, specificity, positive, and negative predictive value (PPV, NPV), positive and negative likelihood ratios (LR+, LR-) were calculated, and the diagnostic accuracy recorded. RESULTS: A total of 90 patients with COPD (39 males and 51 females) were included. Of these, 43 patients (47.8%) were successfully extubated whereas 47 patients (52.2%) failed SBT or required re-intubation (P = 0.654). The threshold value of ≤-25 cmH2O offered the optimal performance in COPD patients: area under the receiver operating characteristic (ROC) curves ROC curves 0.836, sensitivity 95.0%, specificity 86.0%, PPV 84.4%, and NPV 95.6%., LR+ 6.79, LR- 0.06, and the diagnostic accuracy 90.7%. CONCLUSIONS: In mechanically ventilated COPD patients with hypercapnic respiratory failure, the NIF threshold of ≤-25 cmH2O was a moderate-to-good predictor for successful ventilator liberation, and outperforms the traditional threshold of ≤-30 cmH2O.

Impact of United States political sanctions on international collaborations and research in Iran.

International research collaborations improve individual, institutional and governmental capacities to respond to health crises and inequalities but may be greatly affected by political environments. Iran ranks highly in tertiary education, productivity growth, knowledge impact and successful patent applications. In many countries, economic hardship has correlated with increased international research collaborations. Some have hypothesised that financial constraint drives scholars to seek outside collaborations for cost and risk sharing, and to access funding, materials and patient populations otherwise unavailable. This paper explores the history and importance of US political sanctions on the health of Iran's academic sector. Although Iran's international research collaborations increased during periods of increased sanctions, the Pearson correlation coefficient between gross domestic product and international research collaborations was not significant (r=0.183, p=0.417). This indicates that other factors are at least in part responsible. Additionally, we found Iran's quantitative (eg, publication number) and qualitative (eg, visibility indices) publishing metrics to be discordant (two-tailed Mann-Kendall trend; p<0.0002 for both). Reasons for this are multifactorial, including increased indexing of Iranian journals, willingness of lower visibility journals to handle manuscripts with Iranian authors, widespread linkage of career advancement to science visibility indices, and others. During periods of increased sanctions, Iranian scholars were increasingly denied opportunities to publish scientific findings, attend scientific meetings, access to essential medical and laboratory supplies and information resources. We conclude that academic boycotts violate researchers' freedom and curtail progress. Free exchange of ideas irrespective of creed is needed to optimize global scientific progress.

A rapid shallow breathing index threshold of 85 best predicts extubation success in chronic obstructive pulmonary disease patients with hypercapnic respiratory failure.

BACKGROUND: The rapid shallow breathing index (RSBI) is used clinically to help predict a patient's likelihood of successful liberation from mechanical ventilation (MV). However, the traditional threshold (<105 breaths/min/L) may underperform in patients with chronic obstructive pulmonary disease (COPD). We sought to determine the optimal RSBI threshold for COPD patients to improve the diagnostic accuracy for predicting successful ventilator liberation. METHODS: This was a prospective observational multicenter study of COPD patients [according to Global initiative for Chronic Obstructive Lung Disease (GOLD) criteria] admitted to the Medical ICUs of eight academic medical centers. All patients were intubated for hypercapnic respiratory failure and met the American Thoracic Society/European Respiratory Society guidelines to participate in a weaning trial. Ventilator weaning was conducted according to a defined protocol. RSBI was measured through the ventilator after 120 minutes of spontaneous breathing trial (SBT). RESULTS: Ninety patients were included (39 males and 51 females). Forty-three patients (48%) were successfully extubated whereas 47 patients (52%) failed extubation. Significant differences were observed between groups for duration-of-intubation [duration of intubation (DoI); P<0.0001], spontaneous tidal volume (VT) (P=0.03), and the ratio of dynamic-to-static compliance (P=0.005). The RSBI threshold of ≤85 breaths/min/L performed best: area under curve (AUC) receiver operating characteristic (ROC) curves 0.91, sensitivity 95.6%, specificity 90.4%, positive predictive value (PPV) 95.5%, and negative predictive value (NPV) 90.6%., positive likelihood ratio (LR+) 5.48, negative likelihood ratio (LR-) 0.25, and the diagnostic accuracy 91.7%. In post-ROC analyses, DoI and hospital length-of-stay (LOS) did not impact performance. CONCLUSIONS: In COPD patients intubated with hypercapnia, RSBI ≤85 breaths/min/L outperformed the widely used threshold <105 breaths/min/L, yielding a 95.5% probability of extubation success, independent of ventilation duration or hospital LOS.

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial.

OBJECTIVE: To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA). METHODS: We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical-surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge. RESULTS: One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones. CONCLUSION: Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge. TRIAL REGISTRATION: The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.

Comparison of non-invasive to invasive oxygenation ratios for diagnosing acute respiratory distress syndrome following coronary artery bypass graft surgery: a prospective derivation-validation cohort study.

OBJECTIVE: To determine if non-invasive oxygenation indices, namely peripheral capillary oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) and partial pressure of alveolar oxygen (PAO2)/FiO2 may be used as effective surrogates for the partial pressure of arterial oxygen (PaO2)/FiO2. Also, to determine the SpO2/FiO2 and PAO2/FiO2 values that correspond to PaO2/FiO2 thresholds for identifying acute respiratory distress syndrome (ARDS) in patients following coronary artery bypass graft (CABG) surgery. METHODS: A prospective derivation-validation cohort study in the Open-Heart ICU of an academic teaching hospital. Recorded variables included patient demographics, ventilator settings, chest radiograph results, and SPO2, PaO2, PAO2, SaO2, and FiO2. Linear regression modeling was used to quantify the relationship between indices. Receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of the threshold values. RESULTS: One-hundred seventy-five patients were enrolled in the derivation cohort, and 358 in the validation cohort. The SPO2/FiO2 and PAO2/FiO2 ratios could be predicted well from PaO2/FiO2, described by the linear regression models SPO2/FiO2 = 71.149 + 0.8PF and PAO2/FiO2 = 38.098 + 2.312PF, respectively. According to the linear regression equation, a PaO2/FiO2 ratio of 300 equaled an SPO2/FiO2 ratio of 311 (R2 0.857, F 1035.742, < 0.0001) and a PAO2/FiO2 ratio of 732 (R2 0.576, F 234.887, < 0.0001). The SPO2/FiO2 threshold of 311 had 90% sensitivity, 80% specificity, LR+ 4.50, LR- 0.13, PPV 98, and NPV 42.1 for the diagnosis of mild ARDS. The PAO2/FiO2 threshold of 732 had 86% sensitivity, 90% specificity, LR+ 8.45, LR- 0.16, PPV 98.9, and NPV 36 for the diagnosis of mild ARDS. SPO2/FiO2 had excellent discrimination ability for mild ARDS (AUC ± SE = 0.92 ± 0.017; 95% CI 0.889 to 0.947) as did PAO2/FiO2 (AUC ± SE = 0.915 ± 0.018; 95% CI 0.881 to0.942). CONCLUSIONS: PaO2 and SaO2 correlated in the diagnosis of ARDS, with a PaO2/FiO2 of 300 correlating to an SPO2/ FiO2 of 311 (Sensitivity 90%, Specificity 80%). The SPO2/ FiO2 ratio may allow for early real-time rapid identification of ARDS, while decreasing the cost, phlebotomy, blood loss, pain, skin breaks, and vascular punctures associated with serial arterial blood gas measurements.

Spiritual Health and Outcomes in Muslim ICU Patients: A Nationwide Cross-Sectional Study.

The aim of the present study is to describe how religiosity and spirituality affect the psychiatric morbidity of Muslim intensive care unit (ICU) patients. We conducted a prospective nationwide cross-sectional study of ICU patients discharged from 45 medical centers spanning 31 proivinces in Iran. Adults (age ≥ 18 years) admitted to the ICU and treated with invasive mechanical ventilation were eligible. Nine validated survey tools were administered to detect direct and indirect associations between spiritual health (SH) and depression, anxiety, and post-traumatic disorder. The Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale-Revised (IES-R), Post-Traumatic Stress Syndrome 14 question (PTSS-14) quality-of-life (QoL), and quality of patient to physician or nurse communication (PP-QoC and PN-QoC) scales were modeled through two mediators by structural equation modeling (SEM). Sex, ICU type, LOS, and APACHE II score were added in the independent variable list. 338 eligible patients were discharged from the ICUs during the study period. 56 were excluded (clinical status), and 282 were administered the survey. 278 returned it, with 272 complete and 6 partial responses. SH displayed no direct or indirect association to QoL. SH was indirectly associated with decreased depression and anxiety (B = - 0.081, p < 0.05) via PP-QoC mediator. Both direct and indirect positive associations were observed between SH and IES-R (B = 0.293, p < 0.05; via PP-QoC) and PTSS-14 scores (B = 0.267, p < 0.001; via PP-QoC). Medical ICU location was associated with decreased PTSS-14 scores via the same mediator. In this survey of Muslim ICU patients treated with invasive mechanical ventilation, SH correlated with decreased depression and anxiety, but paradoxically increased post-traumatic stress. The most influential mediator was patient-physician quality-of-communication.

Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium.

PURPOSE: We investigated the impact of delirium on illness severity, psychological state, and memory in acute respiratory distress syndrome patients with very long ICU stay. MATERIALS AND METHODS: Prospective cohort study in the medical-surgical ICUs of 2 teaching hospitals. Very long ICU stay (>75days) and prolonged delirium (≥40days) thresholds were determined by ROC analysis. Subjects were ≥18years, full-code, and provided informed consent. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation IV, Simplified Acute Physiology Score-3, and Sequential Organ Failure Assessment scores. Psychological impact was assessed using the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, and the 14-question Post-Traumatic Stress Syndrome (PTSS-14). Memory was assessed using the ICU Memory Tool survey. RESULTS: 181 subjects were included. Illness severity did not correlate with delirium duration. On logistic regression, only PTSS-14<49 correlated with delirium (p=0.001; 95% CI 1.011, 1.041). 49% remembered their ICU stay clearly. 47% had delusional memories, 50% reported intrusive memories, and 44% reported unexplained feelings of panic or apprehension. CONCLUSION: Delirium was associated with memory impairment and PTSS-14 scores suggestive of PTSD, but not illness severity.