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BackgroundDespite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting. ObjectiveThis trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention. MethodsTo address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor’s office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis. ResultsThis trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020. ConclusionsData generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study’s findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery. Trial RegistrationClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021 International Registered Report Identifier (IRRID)DERR1-10.2196/21350

Employing two alternative measures of state failure, we investigate how state weakness influences resident terrorist groups' survival. Theoretically, state failure favors resident terrorist groups' survival, while state territorial control fosters resident groups' termination until some control threshold. Empirically, we uncover a robust negative relationship between a country's weakness and its control of terrorism through the lens of the resident terrorist groups' survival prospects. The discovered relationship withstands a host of robustness tests – e.g., alternative estimates and samples. We apply an instrument designed to address endogeneity concerns. In particular, our novel instrument for failed states consists of the interaction between natural disasters and ethnic fractionalization. As a state's percentage of territorial control increases, resident terrorist groups are more prone to ending until some threshold control percent. Our analysis can guide counterterrorism policy by exploiting the nuanced theoretical determinants identified here that foster resident groups' termination in failing states. [ABSTRACT FROM AUTHOR]

This study examines the effect of foreign military interventions on the incidence of suicide attacks. It presents three theoretical explanations. Foreign military interventions may boost insurgent use of suicide attacks by (a) fomenting a nationalist backlash that sanctions the use of more extreme and unconventional tactics like suicide attacks, (b) providing more and better targets against which suicide attacks can be launched, or (c) prompting insurgents to use suicide tactics in order to overcome their power asymmetries and to confront better defended targets that are enhanced by interventions. We test these competing explanations using a battery of statistical tests on cross-national, time-series data for 138 countries during the period from 1981 to 2005. We find that only foreign interventions with specific features -- pro-government interventions involving larger numbers of ground troops -- boost suicide attacks in countries experiencing interventions. This finding suggests that by tipping the balance of power against insurgents and hardening targets in the context of assisting a local government, foreign military interventions are likely to increase the use of suicide attacks by regime challengers. [ABSTRACT FROM AUTHOR]

The article presents the author's view concerning the move of the American government in countering terrorism as well as in promoting human rights in the U.S. The author discusses the negative effects of the terrorism in political and governmental stability and notes the actions of the government in preventing such subversive activities. Meanwhile, the author cites the strategies of the government in upholding and promoting the rights of every American citizen while fighting insurgencies. Furthermore, the government's decision in implementing counterterrorism policy is also mentioned.