Search

Background. Atrial fibrillation (AF) is a common arrhythmia in elderly patients and is associated with increased risk of mortality. The pathogenesis of AF is complex and based on multiple genetic and environmental factors. Genome-wide association studies identified several loci in AF patients, indicating the complex genetic architecture of this disease. In rare cases, familial forms of AF have been described. Today, pathogenic variants in at least 11 different genes are associated with monogenic AF. Case presentation. The 37-year-old male patient presented to our emergency department with AF. At the age of 35, he had already been diagnosed with paroxysmal AF. Additionally, his 34-year-old brother had also been diagnosed with AF as well as nonobstructive hypertrophic cardiomyopathy. Moreover, the patient’s father was diagnosed with AF in his twenties. Transthoracic echocardiography and cardiac MRI revealed a reduced systolic left ventricular ejection without any signs of hypertrophic cardiomyopathy. Genetic testing identified the heterozygous missense variants c.3371C > T, p.(Pro1124Leu) in RYR2 (NM_001035.3) and c.2524C > A, p.(Pro842Thr) in HCN4 (NM_005477.3) in the patient’s and his brother’s DNA. Discussion. This case of familial AF helps to strengthen the role of RYR2 as a disease gene in the context of AF. Although the variant in RYR2 needs to be classified formally as variant of unknown significance, we regard it as probably disease-causing due to the previously published data. As RYR2 has already been identified as a possible target for prevention and therapy of AF, the knowledge of variants in RYR2 might become even more crucial for individual molecular therapies in the future.

Intensive Care Unit Recovery Clinics (ICU-RCs) were founded to address post-intensive care syndrome among ICU survivors. Telemedicine ICU-RCs may facilitate access for more ICU survivors, however, patient and caregiver experiences with telemedicine ICU-RCs have not been explored qualitatively.To explore patient and informal caregiver experiences with a telemedicine ICU-RC.Our qualitative exploratory cross-sectional study was guided by qualitative description methodology. Telemedicine ICU-RC visits were conducted at 3- and 12-weeks post-discharge following critical illness. Patients, and caregivers when available, met with an ICU pharmacist, ICU physician, and a neuropsychologist via Zoom. Thereafter, we conducted qualitative (1:1) telephone interviews with 14 patients and 12 caregivers recruited purposefully. Data were analyzed using conventional content analysis.Five themes were identified: (1) general impressions of the intervention; (2) intervention organization and delivery; (3) intervention substance; (4) caregiver participation; and (5) ways to improve the intervention. Participants found the telemedicine delivery acceptable, convenient, time-saving, and conducive to thorough discussions. Participants appreciated the information, reassurance, and validation. Attention to mental health during the visits was strongly endorsed. Caregiver involvement depended on patient self-management and technical ability. Suggestions included scheduling a 1-week post-discharge visit, more follow-up visits, and individualizing content for in-depth discussions, including mental health evaluation.The study results enhance the understanding of patient and caregiver experiences with a telemedicine ICU-RC. Participants' narratives helped to formulate recommendations to improve telemedicine ICU-RC delivery and content. Acceptability of this intervention indicates the potential for wider implementation of telemedicine ICU-RCs to reach more ICU survivors.

Background: Intensive Care Unit recovery clinics (ICU-RC), are multidisciplinary outpatient clinics designed to identify and treat post-intensive care syndrome impairments unique to each survivor of critical illness. Engagement is limited, thus we aimed to describe patient- and hospitalization-related sociodemographic factors associated with scheduling and attending in-person ICU-RC visits. Design: Consecutive case series of prospectively collected ICU-RC referral data. Setting: Data was collected over a 9-year period (2012–2020) for patients referred to an ICU-RC from ICUs at an academic medical center in the southeast United States. Participants: 251 adults admitted to a medical, surgical, burn, or trauma ICU referred to the ICU-RC and eligible to be scheduled for a visit. Main Outcome and Measures: The main study outcome was scheduling and completing an ICU-RC visit. Independent variables included patient demographics, ICU visit characteristics (eg, diagnosis, ventilator days), severity of illness, discharge disposition, ICU-RC referral criteria (eg, shock, delirium), and clinic scheduling administrative data (eg, referral date, clinic visit date). Results: Of 251 ICU-RC referrals eligible for a visit, 128 were scheduled, and 91 completed a visit. In univariate models older age, unspecified shock, and distance from the clinic location were associated with decreased in-person ICU-RC engagement. In a multivariable logistic regression using the same predictors and interactions, older age, unspecified shock, and home-to-clinic distance remained as factors decreasing the likelihood of ICU-RC engagement. There was a decreasing likelihood of scheduling and attending an ICU-RC visit for every additional mile of distance the patient lived from the ICU-RC. Male sex was a strong predictor of completing an ICU-RC visit. Conclusions: Older ICU survivors and those who live farther from the clinic site are less likely to engage in an in-person ICU-RC. Innovation and telemedicine strategies are needed to improve access to ICU recovery care for these populations.

Immunotherapy is used to treat almost all patients with advanced non-small cell lung cancer (NSCLC); however, identifying robust predictive biomarkers remains challenging. Here we show the predictive capacity of integrating medical imaging, histopathologic and genomic features to predict immunotherapy response using a cohort of 247 patients with advanced NSCLC with multimodal baseline data obtained during diagnostic clinical workup, including computed tomography scan images, digitized programmed death ligand-1 immunohistochemistry slides and known outcomes to immunotherapy. Using domain expert annotations, we developed a computational workflow to extract patient-level features and used a machine-learning approach to integrate multimodal features into a risk prediction model. Our multimodal model (area under the curve (AUC) = 0.80, 95% confidence interval (CI) 0.74–0.86) outperformed unimodal measures, including tumor mutational burden (AUC = 0.61, 95% CI 0.52–0.70) and programmed death ligand-1 immunohistochemistry score (AUC = 0.73, 95% CI 0.65–0.81). Our study therefore provides a quantitative rationale for using multimodal features to improve prediction of immunotherapy response in patients with NSCLC using expert-guided machine learning.

Funding Acknowledgements Type of funding sources: None. Background The electrophysiological inducibility of atrial fibrillation (AF) after pulmonary vein isolation (PVI) has been identified as a predictor of future AF recurrence. Stimulation protocols have not been sufficiently studied prospectively with respect to their reliability for inducing AF. Methods and results We conducted a prospective monocentric randomized clinical trial to evaluate different standardized electrical stimulation protocols on their potential to induce AF. Patients with symptomatic AF presenting in sinus rhythm scheduled for PVI were enrolled. The primary outcome was induction of AF. A total of 30 patients (age=62±2 years, 17% female, 13% persistent AF, left atrial systolic volume (LASV) 93±5 ml) were enrolled and randomized. To one of three different stimulation protocols performed at the beginning of PVI. Atrial fibrillation was induced in 4 out of 10 patients (40%) with fixed cycle length stimulation followed by up to 3 extrastimuli (protocol A), 6 out of 10 patients (60%) with burst stimulation (protocol B) and 9 out of 10 patients (90%) with fixed stimulation using the shortest cycle length with 1:1 atrial capture (protocol C), respectively. Time from start of stimulation to inducibility of AF was significantly lower in protocol C vs. protocol B and A (29±10 sec vs 40±14 sec vs 366±71 sec; p Conclusion With systematic stimulation protocols AF can be induced in up to 90%. Further studies are warranted to assess the specifity of these stimulations.

The island of Patmos, in the eastern Aegean Sea, consists almost entirely of late Miocene to Pliocene volcanic rocks. The magmatism in the Aegean is governed by subduction of the African plate below the Eurasian plate, back-arc extension, slab roll-back, slab edge processes and westward extrusion of central Anatolia to the west along the Northern Anatolian Fault into the Aegean domain, The evolution of the Aegean basin is that of a back arc setting, with a southerly trend in the locus of both convergent tectonics, and back arc stretching, allowing intermittent upwelling of arc, lithospheric and asthenospheric magmas. Here, we present new 40Ar/39Ar age data for Patmos and the nearby small island of Chilomodi to place this volcanism in a new high resolution geochronological framework. High resolution geochronology provides a key to understanding the mechanisms of both the tectonic and magmatic processes that cause the extrusion of magma locally, and sheds light on the tectonic evolution of the larger region of the back-arc basin as a whole. The volcanic series on Patmos is alkalic, consistent with a back arc extensional setting and ranges from trachybasalt, to phonolites, trachytes and rhyolites, with SiO2 ranging from 51.6–80.5 wt.% and K2O from 2–11.8 wt.% with extrusion ages ranging from 6.59 ± 0.14 Ma–5.17 ± 0.11 Ma. Volcanism on Patmos and adjacent Chilomodi can be understood by a combination of mantle and crustal tectonic processes including influence of transform faults and rotational crustal forces that also caused the opening of the south Aegean basin due to roll back of the subducting slab south of Crete.

The quantum many-body interactions in one-dimensional spin- 1 2 systems are subject to Tomonaga-Luttinger liquid (TLL) physics, which predict an array of multi-particle excitations that form continua in momentum-energy space. Here we use inelastic neutron spectroscopy to study the TLL spin dynamics in SrCo2V2O8, a compound which contains weakly coupled spin- 1 2 chains of Co atoms, at 0.05 K and in a longitudinal magnetic field up to 9.0 T. The measurements were performed above 3.9 T, where the ground state N´eel antiferromagnetic (AFM) order is completely suppressed, and the multi-particle excitations are exclusively of TLL type. In this region and below 7.0 T, the longitudinal TLL mode – psinon/antipsinon (P/AP) – is unexpectedly well described by a damped harmonic oscillator (DHO) while approaching the zone center defining the static spin-spin correlations. A non-DHO-type, continuum-like signal is seen at higher fields, but deviations from the ideal one-dimensional TLL still remain. This change in the P/AP mode coincides with the phase transition between the longitudinal spin density wave (LSDW) and transverse AFM order. Inside the LSDW state, the DHO-type P/AP spectral weight increases and the linewidth broadens as the magnetic order parameter decreases. These results reveal the impact of three-dimensional magnetic order on the TLL spin dynamics; they call for beyond the mean-field treatment for the interchain exchange interactions.

Background: Smooth muscle cell (SMC) expansion is one key morphological hallmark of pathologically altered vasculature and a characteristic feature of pulmonary vascular remodeling in pulmonary hypertension. Normal embryonal vessel maturation requires successful coverage of endothelial tubes with SMC, which is dependent on ephrin-B2 and EphB4 ligand-receptor guidance system. In this study, we investigated the potential role of ephrin-B2 and EphB4 on neomuscularization in adult pulmonary vascular disease. Methods and Results: Ephrin-B2 and EphB4 expression is preserved in smooth muscle and endothelial cells of remodeled pulmonary arteries. Chronic hypoxia-induced pulmonary hypertension was not ameliorated in mice with SMC-specific conditional ephrin-B2 knockout. In mice with global inducible ephrin-B2 knockout, pulmonary vascular remodeling and right ventricular hypertrophy upon chronic hypoxia exposure were significantly diminished compared to hypoxic controls, while right ventricular systolic pressure was unaffected. In contrast, EphB4 receptor kinase activity inhibition reduced right ventricular systolic pressure in hypoxia-induced pulmonary hypertension without affecting pulmonary vascular remodeling. Genetic deletion of ephrin-B2 in murine pulmonary artery SMC, and pharmacological inhibition of EphB4 in human pulmonary artery smooth muscle cells, blunted mitogen-induced cell proliferation. Loss of EphB4 signaling additionally reduced RhoA expression and weakened the interaction between human pulmonary artery smooth muscle cells and endothelial cells in a three-dimensional coculture model. Conclusions: In sum, pulmonary vascular remodeling was dependent on ephrin-B2-induced Eph receptor (erythropoietin-producing hepatocellular carcinoma receptor) forward signaling in SMC, while EphB4 receptor activity was necessary for RhoA expression in SMC, interaction with endothelial cells and vasoconstrictive components of pulmonary hypertension.

Background Emergency department visits due to head injury in the United States have increased significantly over the past decade, and parallel the increasing use of direct oral anticoagulants (DOACs). Objective We investigated the incidence of delayed intracranial hemorrhage (DICH) in patients with head injury who were taking DOACs. Methods We conducted a single-center retrospective study at a level II trauma center. All patients with head injury and using DOACs with an initial negative head computed tomography (HCT) scan from March 1, 2014 to December 31, 2017 were included. DICH was identified as a positive finding on repeat HCT performed within 24 h. Each case of DICH underwent blinded review by two additional neuroradiologists. Demographic data were collected; independent t-tests were used to compare group means and linear regression for variable correlations. Results Two hundred and eighty-seven patients with mean age of 80 years (interquartile range 14 years) met inclusion criteria. Repeat HCT was performed in 224 study participants (78%). Five (1.7%) resulted in DICH, three of which might have been present on initial HCT, with an incidence rate ranging from 0.7% to 1.7%. Only two initial HCTs were read as negative by all three neuroradiologists; 60% disagreed on the initial read. Independent t-test procedures showed an association between DICH and higher Injury Severity Score (ISS). Conclusions We found a DICH incidence rate of 0.7–1.7%. ISS was statistically significant between the two groups. It is possible that in patients with a subjective estimation of low injury severity, a low mechanism of injury and reasonable outpatient follow-up, patients can be discharged home with standard head injury precautions and no repeat HCT, but further prospective studies are needed.

Introduction Peripartum cardiomyopathy (PPCM) remains a major contributor to maternal morbidity and mortality worldwide. The disease is associated with various complications mainly occurring early during its course. Reported adverse outcomes include decompensated heart failure, thromboembolic complications, arrhythmias and death. Purpose We aimed to systematically summarize the outcomes of women with PPCM across different geographical regions and to identify possible predictors of adverse outcomes. Methods For this systematic review and meta-analysis, we performed a comprehensive search of all articles published between January 2000 and June 2021 on PubMed/MEDLINE, Web of Science, Scopus and EBSCO Host, including Academic Search Premier, Africa-Wide Information, CINAHL. All cohort, case-control and cross-sectional studies, as well as control arms of randomized controlled trials (RCTs) reporting on the in-hospital complications and 6- and/or 12-month outcomes of PPCM were considered eligible. Results Forty-seven studies (4875 participants across 60 countries) met the eligibility criteria. Hemodynamic and echocardiographic parameters were similar across all continents. In-hospital mortality was reported as 1.9% [95% CI 0.5–4.0] across all regions. About 10% of patients received invasive ventilation, 21.5% inotropic and 3.1% received mechanical support, respectively. Left ventricular (LV) thrombus complicated 9.0% [95% CI 6.5–11.9] of patients and all-cause embolic events (i.e., stroke, arterial embolism, deep vein thrombosis, pulmonary embolus) occurred in 6.1% [95% CI 3.8–8.9]. Arrhythmias were seldomly reported. All-cause mortality was 8.0% [95% CI 5.5–10.8, I2=79,1%) at 6 months and 9.8% [95% CI 6.2–14.0], I2=80.48%) at 12 months respectively. Overall, 44.4% ([95% CI 36.2–52.8], I2=91.7%) of patients recovered their LV function within 6 months and 58.7% ([95% CI 48.1–68.9], I2=75.8%) within 12 months, respectively. The lowest rate of LV recovery was reported by studies conducted in the Middle East (13.6% [95% CI 9.5–18.1], 3 studies), whereas the highest rate of LV recovery was reported for patients from Europe (56.8% [95% CI 38.1–74.7], 6 studies, I2=93.3%). All-cause mortality was highest in Africa and Asia/Pacific. Europe and North America reported the highest prevalence of LV recovery. (Figure 1) Frequent prescription of beta-blockers, ACE-I/ARB and bromocriptine/cabergoline treatment was associated with significantly lower all-cause mortality and better LV recovery (Figure 2). Conclusion We identified significant global differences in prescribed treatment, prevalence of in-hospital complications and six- and 12-month outcomes. Frequent prescription of guideline-directed heart failure therapy was associated with better LV recovery and lower all-cause mortality. Timely initiation and up-titration of heart failure therapy should therefore be strongly encouraged to improve outcome in women with PPCM. Funding Acknowledgement Type of funding sources: None.

Background and objective High resting heart rate (HR) associates with cardiovascular death (CVD) and heart failure hospitalisation (HFH) in patients with reduced ejection fraction (HFrEF), but data are sparse in patients with preserved (HFpEF) or mildly reduced (HFmrEF) ejection fraction. Empagliflozin reduced the risk of CVD and HFH in HFpEF in the EMPEROR-Preserved trial. This study analyses the influence of HR on outcomes in patients with left ventricular ejection fraction (LVEF) >40% in EMPEROR-Preserved and evaluates the effects of empagliflozin across HR categories. Methods Patients (n=5988) with HFpEF (LVEF >40%) were categorised to HR 75 bpm. The composite of CVD or HFH (primary outcome), first HFH, CVD, recurrent HFH and all-cause mortality were studied in the HR groups and in patients separated by sinus rhythm (SR) or atrial fibrillation (AF) and true HFpEF (EF ≥50%) or HFmrEF (EF 40–49%). Results Empagliflozin did not influence HR over time. At HR >75 bpm, the primary outcome (hazard ratio: 1.31, 1.13–1.52, p=0.0003), time to first HFH (hazard ratio: 1.25, 1.04–1.49, p=0.02), recurrent HFH (hazard ratio: 1.29, 1.05–1.60, p=0.02), CVD (hazard ratio: 1.49, 1.21–1.84, p=0.0001) and all-cause mortality (hazard ratio: 1.49, 1.28–1.73, p Conclusions HR in SR, but not in AF, predicts heart failure outcomes in HFpEF and HFmrEF, but the effects of empagliflozin were not modified by HR. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance

Objective Current guidelines for the management of arterial hypertension, dyslipidemia, or secondary cardiovascular (CV) prevention recommend combination drug treatments with single pill combinations (SPC). This concept is expected to improve adherence to treatment and, as a consequence, to reduce the risk of adverse CV outcomes associated with these clinical conditions. Aim of our study was to assess whether SPC are clinically superior to multi pill combination (MPC) with identical drugs in reducing CV events and al-cause mortality in a huge population under real world conditions in daily practice. Methods We analyzed an anonymized claims dataset (AOK PLUS, a statutory German sickness fund) including patients with hypertension and other CV diseases in the years 2012–2017; minimum follow-up was 1 year or until date of death, After 1:1-Propensity Score Matching (PSM), selected CV outcomes (myocardial infarction, stroke, transitory ischemic attack, coronary artery disease, heart failure, acute renal failure, cardiovascular hospitalization, all cause hospitalization) as well as all-cause mortality were compared using Incidence Rate Ratios (IRRs) and non-parametric tests. Results 50,622 patients (25,311 patients in SPC versus MPC group) aged ≥18 years treated with SPC or identical MPC were followed up for at least 1 year or until death. No significant differences in baseline characteristics were observed after PSM. Nine different clinical outcomes were compared for each group. In all comparisons, significantly lower incidence rate ratios (IRR) were identified for SPC, confirmed by comparison of Kaplan-Meier estimates: stroke (IRR=0.77; 95% CI 0.67–0.88; p Conclusion In clinical practice, the SPC regimen is associated with a lower incidence of CV events and lower all-cause mortality. Time to the event is also significantly longer in the SPC group compared to MPC. These results strongly support the concept of SPC and the implementation into daily practice to improve patient's prognosis. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): APONTIS PHARMA GmbH & Co. KG

Background/Introduction The Global SYMPLICITY Registry (GSR) was designed to evaluate the safety and efficacy of renal denervation (RDN) in real-world patients. Inclusion and exclusion criteria are limited to allow assessment of the effects of RDN on patients with a wide range of comorbidities. The current analysis examines blood pressure (BP) reduction after RDN in higher cardiovascular risk patients. Purpose To evaluate blood pressure reduction after RDN in higher cardiovascular risk patients in GSR. Methods GSR is a prospective all-comers registry to evaluate the safety and efficacy of RDN. Patients are enrolled in GSR and receive radiofrequency RDN using the Symplicity Flex or Symplicity Spyral catheter. Office and ambulatory BP are measured at each follow-up (3, 6, 12, 24, and 36 months). In this post-hoc analysis, changes from baseline in office and 24-hour ambulatory systolic blood pressure were assessed in patients at higher cardiovascular risk. Higher risk was defined using baseline office systolic or diastolic BP as well as additional risk factors (Figure 1). Results As of March 2021, there were 2621 patients characterized as higher cardiovascular risk in GSR. Baseline characteristics included mean age 60.7±12.1 years, 57.6% male, 37.9% type 2 diabetes, 35.8% hypocholesterolemia, 19.7% eGFR Conclusions Higher risk patients in GSR had sustained office and ambulatory systolic BP reductions out to 3 years after catheter-based radiofrequency RDN. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic

Purpose Hypertension represents the most common cardiovascular risk factor for premature death worldwide. Hydrochlorothiazide (HCTZ) is one of the most commonly used antihypertensive and diuretic drug worldwide. Recently, pharmacoepidemiologic studies associated the use of HCTZ with increased risk of skin cancer. As a result, prescriptions of HCTZ decreased, leading to worsening of blood pressure therapy in a significant proportion of patients. However, whether HCTZ causes skin cancer remains elusive. We aimed to examine the photosensitive potential of HCTZ in vivo. To further enlighten the pathophysiologic mechanisms of carcinogenesis and phototoxicity caused by HCTZ in vitro, we conducted a series of laboratory experiments. Methods This randomized, double-blinded, placebo-controlled clinical trial assessed the phototoxic properties of HCTZ. We randomly assigned 30 healthy adult volunteers in a 2:1 ratio to either HCTZ 25 mg daily or placebo once daily for 15 days. Skin photosensitivity by phototesting for UV-A and UV-B radiation, office blood pressure, serum-vitamin-D status and urinary excretion of thymidine-dimers were measured. To further assess the pathophysiologic mechanisms of possibly HCTZ induced photosensitivity, human keratinocytes (HaCaT) were incubated with HCTZ and then irradiated with UV-B radiation (311 nm one burst of 100 J/cm2). rt-PCR-testing and western blots were performed to analyze reactive oxygen species, inflammation and carcinogenesis. Results All 30 participants were adherent to the protocol, as confirmed by toxicological analysis of serum and urine. Skin photosensitivity to exposure of UV-A and UV-B radiation remained unchanged in both groups (UVB-MED: HCTZ Δ = 0.0 J/cm2 vs. placebo Δ = −0.2 J/cm2; p=0.06). No thymidine-dimers were detected in urine of either group. Systolic blood pressure decreased in both groups but was not different between HCTZ and placebo (HCTZ Δ = −5.2 mmHg vs. placebo Δ = −5.4 mmHg; p=0.94). The same was found for diastolic blood pressure (HCTZ Δ = −1.9 mmHg vs. placebo Δ = −4.3 mmHg; p=0.34). Serum-vitamin-D increased in both groups (HCTZ Δ = +2.7 ng/ml vs. placebo Δ = 0.9 ng/ml; p=0.56). In addition, combination of HCTZ and a high intensity burst of UV-B radiation did not increase expression of inflammatory proteins or increase formation of reactive oxygen species (SOD-1, SOD-2, and catalase). Conclusions HCTZ did not significantly increase photosensitivity for UV-A or UV-B radiation in healthy volunteers compared with placebo. Moreover, no relevant DNA-damages were detected in either group. HCTZ alone did not increase inflammation, formation of reactive oxygen species or carcinogenesis in human keratinocytes. Furthermore, the combination of a UV-B burst of 100 J/cm2 and HCTZ was not associated with additive effects on inflammation, reactive oxygen species or carcinogenisis. HCTZ in a cumulative dose of 375 did not increase photosensitivity or DNA-damages in vivo. Funding Acknowledgement Type of funding sources: None.

Pig bronchi are rare anomalies, in which the right upper lobe bronchus originates above the carina. During surgery, this can lead to technical challenges associated with the bronchial anastomosis, especially during lung transplantation. We herein report the case of a combined liver-lung transplantation with a pig bronchus in both, the organ donor and the transplant recipient. In both cases the bronchi originated slightly above the level of the carina facilitating an oblique resection and a single tracheobronchial anastomosis with a running suture. Follow-up bronchoscopy showed a completely healed anastomosis with no evidence of malacia or stenosis.

Background: Delirium is an acute syndrome of organ dysfunction with long-term consequences which commonly occurs in the Intensive Care Unit (ICU). The incidence of delirium ranges from 30% - 50% in low severity ICU patients and up to 80% in mechanically ventilated patients. This condition is frequently under-recognized and daily routine screening is a key strategy to early intervention. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most recommended assessment tools for detecting delirium in the critical ill patient. Objective: The main objective of this study is to educate ICU staff about delirium. In addition, nurses were trained to use the CAM-ICU as a standard screening tool. The intervention was evaluated through a survey aimed at ICU staff. Methods: An educational intervention was started in 2014 in our ICU. An educational package for ICU staff consisted of a didactic brochure and explanatory videos. One-on-one teaching, case based scenarios and didactic teaching were strategies used in the implementation process. The entire intervention was evaluated by means of a survey directed to the professionals. Results: The structure of the didactic brochure was simple in order to have an easy understanding of the CAM-ICU tool. We also created 10-minute videos. According to the results of the satisfaction survey (N=62), disorganized thinking was the most difficult feature of CAM-ICU to interpret. When in doubt, consultation between co-workers was the primary resource selected by unit staff. Conclusion: This initiative achieved the objective of training health care professionals in the application of the CAM-ICU tool with a good level of satisfaction from them. Therefore, ICU staff consider delirium management in the broader picture of critically ill patient care as a major activity of daily practice.

Background Telehealth-based intensive care unit recovery clinics (ICU-RCs) can increase access to post-ICU recovery care for patients and their families. It is crucial to understand patients’ and caregivers’ experience of illness and recovery to build patient- and family-centered ICU-RCs. Objective To explore patients’ and caregivers’ perceptions of ICU hospitalization and recovery. Methods Individual semistructured telephone interviews were conducted with 14 patients and 12 caregivers who participated in a telehealth ICU-RC. This study was guided by qualitative description methodology. Conventional content analysis was used to analyze the data. Results Patients described their ICU hospitalization as scary, traumatic, and lonely. Participants’ feedback on hospitalization ranged from praise to criticism. Patients wanted more realistic and detailed prognostication about post-ICU recovery and more physical therapy after discharge. Patients strongly valued the mental health component of ICU-RC visits, which contrasted with the scant attention paid to mental health in other postdischarge health care settings. Their knowledge about post-ICU recovery and connectedness to a primary care provider varied. Conclusions Examining patients’ and caregivers’ perceptions of ICU hospitalization and recovery highlights ICU-RC components that can be strengthened to support patient- and family-centered recovery. The ICU-RC staff should invite patients to share feedback about their ICU stay; give a timely, realistic prognosis for recovery; offer mental health consultations; provide physical therapy; and partner with patients and their caregivers to develop and deliver post-ICU care.

Rationale: There are limited data on the impact of the COVID-19 pandemic on intensive care unit (ICU) recovery clinic care delivery practices. Objectives: We sought to better understand the patient-level factors affecting ICU recovery clinic care and changing clinical thinking during the COVID-19 pandemic. We also sought to understand how the COVID-19 pandemic sparked innovation within ICU recovery clinics. Methods: A multicenter qualitative study was conducted with ICU recovery clinic interprofessional clinicians involved with the Critical and Acute Illness Recovery Organization (CAIRO) between February and March 2021. Data were collected using semi-structured interviews and were analyzed using thematic analysis. Key themes were organized in a working analytical framework. Results: Twenty-nine participants from fifteen international sites participated in the study. Participants identified three patient-level key themes which influenced care delivery in ICU recovery programs: 1) social isolation; 2) decreased emotional reserve in patients and families; and 3) substantial social care needs. Changes in ICU recovery clinic care delivery occurred at both clinician-level (e.g., growing awareness of healthcare disparities and inequities, recognition of financial effects of illness, refinement of communication skills, increased focus on reconstructing the illness narrative) and practice-level (e.g., expansion of care delivery modes, efforts to integrate social care) in response to each of the patient-level themes. Identified gaps in ICU recovery clinic care delivery during the COVID-19 pandemic included a need for multidisciplinary team members, access to care issues (e.g., digital poverty, health insurance coverage, language barriers), and altered family engagement. Conclusion: Our study demonstrated that addressing patient-level factors such as efforts to integrate social care, address financial needs, refine provider communication skills (e.g., empathic listening), and enhance focus on reconstructing the illness narrative became important priorities during the ICU recovery clinic visit during the COVID-19 pandemic. We also identified several ongoing gaps in ICU recovery clinic care delivery which highlight the need for interventions focused on the integration of social and clinic services for critical care survivors.

Research confirms the heterogeneous nature of patient challenges during recovery from the ICU and supports the need for modifying care experiences, but few data are available to guide clinicians seeking to support patients' individual recovery trajectories.What is the content of patient-provider dialogues in a telemedicine multidisciplinary ICU recovery clinic (ICU-RC)?We conducted a qualitative descriptive study in a telemedicine multidisciplinary ICU-RC at a tertiary academic medical center in the southeastern United States. The sample included 19 patients and 13 caregivers (≥ 18 years of age) attending a telemedicine ICU-RC visit after critical illness resulting from septic shock or ARDS. Patients and caregivers met with an ICU pharmacist, ICU physician, and a psychologist via a secure web-conferencing platform for 33 ICU-RC visits within 12 weeks of hospital discharge. Telemedicine ICU-RC visits were audio-recorded and transcribed verbatim for analysis. A coding system was developed using iterative inductive and deductive approaches.Two themes were identified from the patient-provider dialogue: (1) problem identification and (2) problem-solving strategies. We identified five subthemes that capture the types of problems identified: health status, mental health and cognition, medication management, health-care access and navigation, and quality of life. Problem-solving subthemes included facilitating care coordination and transitions, providing education, and giving constructive feedback and guidance.Patients surviving a critical illness experience a complexity of problems that may be addressed best by a multidisciplinary ICU-RC. Through analysis of our telemedicine ICU-RC dialogues, we were able to identify problems and solutions to address challenges during a critical transitional phase of ICU recovery.ClinicalTrials.gov; No.: NCT03926533; URL: www.gov.

The newly developed Spline Analysis at Mesoscale Utilizing Radar and Aircraft Instrumentation–Thermodynamic Retrieval (SAMURAI-TR) is used to estimate three-dimensional temperature and pressure perturbations in Hurricane Rita on 23 September 2005 from multi–Doppler radar data during the RAINEX field campaign. These are believed to be the first fully three-dimensional gridded thermodynamic observations from a TC. Rita was a major hurricane at this time and was affected by 13 m s−1 deep-layer vertical wind shear. Analysis of the contributions of the kinematic and retrieved thermodynamic fields to different azimuthal wavenumbers suggests the interpretation of eyewall convective forcing within a three-level framework of balanced, quasi-balanced, and unbalanced motions. The axisymmetric, wavenumber-0 structure was approximately in thermal-wind balance, resulting in a large pressure drop and temperature increase toward the center. The wavenumber-1 structure was determined by the interaction of the storm with environmental vertical wind shear resulting in a quasi balance between shear and shear-induced kinematic and thermodynamic perturbations. The observed wavenumber-1 thermodynamic asymmetries corroborate results of previous studies on the response of a vortex tilted by shear, and add new evidence that the vertical motion is nearly hydrostatic on the wavenumber-1 scale. Higher-order wavenumbers were associated with unbalanced motions and convective cells within the eyewall. The unbalanced vertical acceleration was positively correlated with buoyant forcing from thermal perturbations and negatively correlated with perturbation pressure gradients relative to the balanced vortex.

The COVID-19 pandemic will require health systems to test interventions to improve the recovery and social integration of adult survivors of COVID-19. Peer support is a complex intervention that allows COVID-19 survivors to give and receive practical and emotional support in relationship with other survivors of acute illness. The growing expertise within CAIRO can be leveraged by stakeholders interested in starting and sustaining a peer support program for COVID-19 survivors.

Background After critical illness, patients are often left with impairments in physical, social, emotional, and cognitive functioning. Peer support interventions have been implemented internationally to ameliorate these issues. Objective To explore what patients believed to be the key mechanisms of effectiveness of peer support programs implemented during critical care recovery. Methods In a secondary analysis of an international qualitative data set, 66 telephone interviews with patients were undertaken across 14 sites in Australia, the United Kingdom, and the United States to understand the effect of peer support during recovery from critical illness. Prevalent themes were documented with framework analysis. Results Most patients who had been involved in peer support programs reported benefit. Patients described 3 primary mechanisms: (1) sharing experiences, (2) care debriefing, and (3) altruism. Conclusion Peer support is a relatively simple intervention that could be implemented to support patients during recovery from critical illness. However, more research is required into how these programs can be implemented in a safe and sustainable way in clinical practice.

Purpose To analyze and describe the use and usefulness of the ICU diary to support family members of critically ill patients. Materials and methods A socio-technical systems model (SEIPS 2.0) guided data collection and analysis in this study aimed to gain a holistic understanding of factors that shape ICU diary processes and family requirements for support. Triangulated data sources, including interviews, observations, and photographs, were content analyzed for person, task, tool, and context attributes determining the use and usefulness of ICU diaries. Researchers recruited family members of critically ill patients admitted to ICUs in two hospitals (urban, rural) in the southeastern United States. Results Nineteen female (100%) family members participated in this study. ICU diaries were used and adapted by family members to cope with the ICU experience in multiple ways. Results indicate that staff support, easy access, embedded instructional format, early initiation, and family ownership facilitated ICU diary use by family members. The ICU diary was useful as a medium to process emotions and gain insights, reduce stress, track information, and communicate with the staff and the patient. Conclusions The ICU diary is useful to family members as a stress reduction, information management, and communication tool. The design of ICU diary implementations must address system factors to assure family members receive benefits from diary use. Further research is needed to expand our understanding of the optimal structure, process, and content of ICU diary implementations.

OBJECTIVE: To engage critical care end-users (survivors and caregivers) to describe their emotions and experiences across their recovery trajectory, and elicit their ideas and solutions for health service improvements to improve the ICU recovery experience. DESIGN: End-user engagement as part of a qualitative design using the Framework Analysis method. SETTING: The Society of Critical Care Medicine’s THRIVE international collaborative sites (follow-up clinics and peer support groups). SUBJECTS: Patients and caregivers following critical illness and identified through the collaboratives. INTERVENTIONS: Nil. MEASUREMENTS AND MAIN RESULTS: Eighty-six interviews were conducted. The following themes were identified: 1. Emotions and experiences of patients – Loss of former self; Experiences of disability and adaptation; 2. Emotions and experiences of caregivers – Emotional impacts, adopting new roles, and caregiver burden; Influence of gender roles; Adaptation, adjustment, recalibration; and 3. Patient and caregiver-generated solutions to improve recovery across the arc of care - Family-targeted education; Expectation management; Rehabilitation for patients and caregivers; Peer support groups; Reconnecting with ICU post discharge; Access to community based supports post discharge; Psychological support; Education of issues of ICU survivorship for health professionals; Support across recovery trajectory. Themes were mapped to a previously published recovery framework (Timing it Right) that captures patient and caregiver experiences, and their support needs across the phases of care from the event/diagnosis to adaptation post-discharge home. CONCLUSIONS: Patients and caregivers reported a range of emotions and experiences across the recovery trajectory from ICU to home. Through end-user engagement strategies many potential solutions were identified that could be implemented by health services and tested to support the delivery of higher-quality care for ICU survivors and their caregivers that extend from tertiary to primary care settings.

Objective: The impact of previous lung volume reduction surgery (LVRS) or endoscopic lung volume reduction (ELVR) on lung transplantation (LuTX) remains unclear. This study assesses the risk of previous lung volume reduction on the outcome of a later LuTX. Methods: Patients suffering from emphysema who underwent bilateral LuTX were included in this multicenter analysis. Study groups were defined as: previous LVRS, previous ELVR, controls. Imbalances were corrected by coarsened exact matching for center, gender, age, diagnosis, and BMI. A comparative analysis of intraoperative characteristics, perioperative outcome and long-term survival was performed. Results: 615 patients were included (LVRS = 26; ELVR = 60). Compared to controls, LVRS patients had a higher rate of postoperative ECMO (15.4 vs. 3.9%; p = 0.006), whereas ELVR patients suffered more often from wound infections (8.9% vs. 2.5%; p = 0.018). Perioperative outcome, duration of ventilation, ICU stay, and hospital stay were comparable between groups. Bacterial colonization of the airway differed significantly between both LVR groups and controls in pre- and post-LuTX cultures. Survival was not impacted (1-/3-/5-year survival for LVRS: 92.3%/85.7%/77.1%; controls: 91.3%/82.4%/76.3%; p = 0.58 | ELVR: 93.1%/91%/91%; controls 91.2%/81.7%/75.3%; p = 0.17). Conclusion: Lung volume reduction does not impact short and long-time survival after bilateral LuTX. Due to differences in airway colonization after LVR, caution to prevent infectious complications is warranted. ispartof: Transpl Int vol:35 pages:10048-10048 ispartof: location:Switzerland status: Published online

Background Although diaries are an evidence-based practice that improves the quality of life of patients in an intensive care unit and their loved ones, centers in the United States are struggling to successfully implement diary programs in intensive care units. Currently, few published recommendations address how to facilitate implementation of a diary program, and how to effectively sustain it, in an intensive care unit. Objectives To discuss challenges with implementing diary programs in intensive care units at 2 institutions in the United States, and to identify solutions that were operationalized to overcome these perceived difficulties. Methods The teams from the 2 institutions identified local barriers to implementing diaries in their intensive care units. Both groups developed standard operating procedures that outlined the execution and evaluation phases of their implementation projects. Results Barriers to implementation include liability and patient privacy, diary program development, and implementation and sustainability concerns. Various strategies can help maintain clinical and family member engagement. Conclusion Through a team’s sustained dedication and a diligent assessment of perceived obstacles, a diary program can indeed be implemented within an intensive care unit.

BACKGROUND: Intensive care unit (ICU) diaries are recommended to address psychological sequelae following critical illness. Diaries are correlated with reduced prevalence of post- traumatic stress disorder in survivors of critical illness and their families. LOCAL PROBLEM: Our ICU was not adequately meeting the psychological needs of patients and families. METHODS: We established an interprofessional team to implement an ICU diary program in partnership with implementation of the ABCDEF (Assess, prevent, and manage pain; Both awakening and breathing trials; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment) bundle and peer support programs. Staff knowledge and perception of ICU diaries were obtained. INTERVENTIONS: Diaries were initiated for patients at high risk for post-intensive care syndrome, and entries by all ICU disciplines and family members/visitors were encouraged. RESULTS: A total of 75 diaries were initiated between January 2017 and January 2019. The ICU diaries have been received positively by patients, family members, and staff. CONCLUSIONS: The ICU diary is a cost-effective and efficient intervention to help patients and family members cope with the burden of critical illness.