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Background: We followed prolonged mechanically ventilated (PMV) patients for weaning attempts and explored factors associated with successful weaning and long-term survival., Methods: This historical cohort study included all adult PMV patients admitted to a single rehabilitation hospital during 2015-2018 and followed for survival according to weaning success up to 3 years or the end of 2021., Results: The study included 223 PMV patients. Of them, 124 (55.6 %) underwent weaning attempts, with 69 (55.6 %) successfully weaned, 55 (44.4 %) unsuccessfully weaned, and 99 patients with no weaning attempts. The mean age was 67 ± 20 years, with 39 % female patients. Age, sex distributions and albumin levels at admission were not significantly different among the groups. The successful weaning group had a 6 % higher proportion of conscious patients than the failed weaning group (55 % vs. 49 %, respectively, p = 0.45). Patients successfully weaned were less frequently treated with antibiotics for 5 days or more than those unsuccessfully weaned (74 % vs 80 %, respectively, p = 0.07). They also had a lower proportion of time from intubation to tracheostomy greater than 14 days (45 % vs 66 %, p = 0.02). The age, sex, antibiotic treatment, time to tracheostomy exceeding 14 days and time from admission to first weaning attempt adjusted one-year mortality risk of successful vs. failed weaning was somewhat lower, HR = 0.75, 95%CI: 0.33-1.60, p = 0.45, with the same trend by the end of 3 years, HR = 0.77, 95%CI: 0.42-1.39, p = 0.38., Conclusion: Successful weaning from PMV may be associated with better survival and allows chronically ventilated patients to become independent on a ventilator. A larger study is needed to further validate our findings., Competing Interests: Declaration of competing interest All authors have no conflicts of interest to declare, (Copyright © 2024. Published by Elsevier Ltd.)

Background & Aims: Mechanically ventilated patients are weaned during acute care hospitalization when it is determined that they are ready for withdrawal. If weaning fails, patients are admitted to a rehabilitation medical center for continued supportive care and additional weaning attempts. This study's objective is to increase the success rate of weaning from prolonged mechanical ventilation (PMV), and to shorten the overall weaning period by tailoring the patient's caloric intake according to their individually measured energy needs., Methods: We designed a randomized, controlled, double-blinded trial to be conducted among PMV patients undergoing routine ventilation-weaning attempts. Patients in the intervention arm will be fed according to energy needs determined by calorimetry. Patients in the control arm will be fed according to the standard of care, namely the Recommended Dietary Allowance (RDA) guidelines. Each patient will undergo up to five weaning attempts. Study outcomes will include successful weaning rate, time to successful weaning, and 3-12 months survival rate., Discussion: This trial aims to examine the safety and efficacy of a nutritional diet based on an individual's measured caloric needs in terms of weaning rates and weaning time. We hypothesize that calorimetry-based nutrition plan will prove to be superior in both success rate and time to successful weaning compared to the standard nutrition plan based on the resting energy expenditure (REE) formula during the weaning process., Trial Registration: ClinicalTrials.gov identifier: NCT04825717., Competing Interests: Declaration of competing interest None., (Copyright © 2023 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Death or prolonged disorders of consciousness (DOC) of a loved one are both considered relational-losses that severely disrupt attachment-bonds. Grief in both conditions was compared by exploring the impact of familial-role and attachment-orientation. In DOC, caregivers' grief was found significantly intensified relative to Death. Familial-role impacted grief in both conditions alike, with partners' heightened grief in DOC reflecting the complexity of their stagnant bonds. In Death, avoidance-attachment mitigated grief, while in DOC anxiety-attachment accentuated grief, we suggest that while physical-separation in death facilitates the modification of continuing attachment-schema, in DOC, modification may be required while the patient is still alive.

Objectives:: To trace the psychological mechanism underlying caregivers' emotional experience in prolonged disorders of consciousness, by examining the mediating role of boundary ambiguity in the relationship between ambiguous loss and grief., Design:: Cross-sectional design., Setting:: The Respiratory Rehabilitation Division of a long-term medical and rehabilitation institute., Subjects:: A total of 64 primary caregivers (69% female) of patients in a vegetative state ( n = 49) or minimally conscious state ( n = 15), with a mean age of 55.5 (SD = 12.3) years. Participants were mostly the patient's children (62%) or partners (27%). The mean caregiving duration was 4.9 (SD = 5.1) years., Main Measures:: The Boundary Ambiguity Scale, the Revised Need for Closure Scale, an adapted version of the multifactor Two-Track Bereavement Questionnaire, and a sociodemographic questionnaire, which included items regarding caregiving: frequency of visits and perception of the patient's psychological presence., Results:: (1) Caregivers' grief scores (total TTBQ: mean = 2.97; SD = 0.55) did not significantly differ from those exhibited by a normative bereavement sample. (2) Time since injury did not affect caregivers' grief scores (three-year cut-point; P > .05). (3) Mediation analyses revealed that boundary ambiguity (mean = 34.03; SD = 7.55) significantly mediates the relationship between need for closure ( B = .11; confidence interval (CI) = .04-.23) and grief; frequency of visits ( B = .05, CI = .02-.10) and grief and perception of psychological presence ( B = .26, CI = .00-.61) and grief in three separate models., Conclusion:: Ambiguity concerning relational boundaries hinders caregivers' ongoing grief reaction and impedes their ability to integrate the loss. High frequency of visits, belief in the patient's psychological presence and difficulties in tolerating uncertainty are all clinical manifestations of caregivers' entangled experience.

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The results of studies on determination of the ignition delay time of hypergolic low-toxicity ("green") propellants with high-test hydrogen peroxide as an oxidizer are discussed. The use of liquid and solid fuels containing compounds that catalyze the hydrogen peroxide decomposition (manganese and copper salts) or actively react with hydrogen peroxide (e.g., NaBH4) allows preparation of propellants with the ignition delay time shorter than 20 ms, which allows using these propellants in liquid or hybrid rocket engines. The use of ionic liquids as a fuel in most cases also requires introducing promoters. [ABSTRACT FROM AUTHOR]

The article aims to extend our understanding of physical and psychological types of ambiguous loss through a systematic review based on content and psycholinguistic analysis. The study encompassed articles aligned with ambiguous loss published between 2019-2023, retrieved from PsycINFO, Web of Science (WoS), and Scopus. To eliminate the bias in the literature review, the study extracted published articles, dissertations, book chapters, and preprints with titles containing the search term "ambiguous loss". Two reviewers (the first and the third authors worked independently) examined titles and abstracts and identified papers highlighting physical (n=34) or psychological (n=23) types of ambiguous loss. The physical type results from physical absence of meaningful persons (e.g. abducted, missing, adopted), while the psychological type results from psychological absence of meaningful persons (e.g. dementia, mental illness, addiction). The study applies the conceptual and relational content analysis of Leximancer (version 4.5) to develop three cluster maps and lists of concepts separately for physical and psychological types and all selected papers published between 2019-2023. The results show that the physical type primarily encompasses situations related to adoption, potentially leading to the ambiguous loss experienced by both biological parents and children when facing forced separation. Psychological type includes parents of children with disabilities, shaken baby syndrome, and caregivers of individuals with brain injuries and cancer. The present study indicates that the conceptual boundaries between physical and psychological types of ambiguous loss are not only expanding but also erasing, giving way to new applications in settings such as the COVID-19 pandemic, organ donor families, and sexual and gender minority. [ABSTRACT FROM AUTHOR]

As recent reviews of the literature have shown, a growing number of studies have focused on the burden of caregivers of people living with a prolonged disorder of consciousness. However, none of these reviews have focused specifically on caregivers in the home care setting. It is therefore difficult to have a state of knowledge specific to this setting, even though many POCD patients live at home once their condition has stabilized. For this reason, we decided, after completing recent literature reviews, to conduct a quantitative and qualitative analysis of publications presenting data on the quality of life of caregivers whose relative with PDOC lives at home. While all the studies agree that the presence of a person with PDOC is a heavy burden for the caregiver, some authors refute the idea defended by others that this burden is the same whether the patient lives at home or in care facilities. All the studies also stress the need for public material and organisational assistance, without which caregivers find themselves in a state of great financial and psychological distress. Such support would also help to strengthen internal resilience factors. [ABSTRACT FROM AUTHOR]

Multiple and two‐way reversible shape memory polymers (M/2W‐SMPs) are highly promising for many fields due to large deformation, lightweight, strong recovery stress, and fast response rates. Herein, a semi‐crystalline block poly(urethane‐urea‐amide) elastomers (PUUAs) are prepared by the copolymerization of isocyanate‐terminated polyurethane (OPU) and amino‐terminated oligomeric polyamide‐1212 (OPA). PUUAs, composed of OPA as stationary phase and PTMEG as reversible phase, exhibit excellent rigidity, flexibility, and resilience, and cPUUA‐C7‐S25 exhibits the best tensile property with strength of 10.3 MPa and elongation at break of 360.2%. Besides, all the PUUAs possess two crystallization/melting temperatures and a glass transition temperature, which endow PUUAs with multiple and reversible two‐way shape memory effect (M/2W‐SME). Physically crosslinked PUUA‐C0‐S25 exhibits excellent dual and triple shape memory, and micro chemically crosslinked cPUUA‐C7‐S25 further shows quadruple shape memory behavior. Additionally, both PUUA‐C0‐S25 and cPUUA‐C7‐S25 have 2W‐SME. Intriguingly, cPUUA‐C7‐S25 can achieve a higher temperature (up to 165 °C) SME, which makes it suitable for more complex and changeable applications. Based on the advantages of M/2W‐SME, a temperature‐responsive application scenario where PUUAs can transform spontaneously among different shapes is designed. These unique M/2W‐SME and high‐temperature SME will enable the applications of high‐temperature sensors, actuators, and aerospace equipment. [ABSTRACT FROM AUTHOR]

This review provides an ethical analysis of disorders of consciousness (DoC) along the care continuum, from preinjury to injury, acute care to subacute care and early rehabilitation, and finally transitioning to chronic rehabilitation and societal reintegration. We provide an actionable, chronological assessment of ethical issues related to DoC care. This expands upon established ethics literature, which focuses almost exclusively on the clinical encounter for DoC. Our goal is to broaden the aperture of ethical analysis to address how social and environmental conditions predispose some persons to brain injury, and how such conditions might also pose barriers to meaningful societal reintegration after recovery. [ABSTRACT FROM AUTHOR]

This cross-sectional study explored caregivers' views on patient prognosis, alongside dispositional optimism and grief in prolonged disorders of consciousness. Participants were 64 primary family caregivers (aged 34–80 years) of patients diagnosed with either persistent vegetative state or minimal conscious state, all hospitalized in a long-term medical–rehabilitative institute. Caregivers' views on prognosis were derived from questions designed to assess belief in improvement (Question 1) and medical prospect 5 years forward (Question 2). Grief was assessed using selected scales from the Two-Track Bereavement Questionnaire and dispositional optimism by the Life Orientation Test-Revised. While caregivers' optimism was significantly higher than the normative population, their grief levels resembled death. Classification based on belief in improvement (Question 1) indicated that despite an equivalent time since injury, caregivers conveying a positive prognosis exhibited intensified grief and were more optimistic, religious, and patient-oriented, relative to those conveying a negative prognosis. Our findings point to caregivers' utilization of optimism and highlight the importance of seeing hope as a dynamic process in such continuous medical states of uncertainty. Thus, clinical interventions should be attuned to the role dispositional versus unrealistic optimism plays in caregivers' hope-related goal setting, while working through mitigating their grief. [ABSTRACT FROM AUTHOR]

The number of family members caring and caregiving for a loved one undergoing physical and mental changes continues to increase dramatically. For many, this ongoing experience not only involves the "burden of caregiving" but also the "burden of grief" as their loved-one's newfound medical condition can result in the loss of the person they previously knew. Dramatic cognitive, behavioral, and personality changes, often leave caregivers bereft of the significant relationship they shared with the affected person prior to the illness or injury. This results in what we term conditions of acquired "non-death interpersonal loss" (NoDIL). Current approaches to these losses use an amalgam of models drawn from both death and non-death loss. Despite their utility, these frameworks have not adequately addressed the unique processes occurring in the interpersonal sphere where the grieving caregiver needs to reach some modus vivendi regarding the triad of "who the person was," "who they are now," and "who they will yet become." In this paper we propose a process-based model which addresses cognitive-emotional-behavioral challenges caregivers meet in the face of their new reality. These require a revision of the interpersonal schemas and the relationships that takes into account the ongoing interactions with the affected family member. The model and its utility to identify adaptive and maladaptive responses to NoDIL is elaborated upon with clinical material obtained from caregivers of people diagnosed with major neuro-cognitive disorder and pediatric traumatic brain injury. The article concludes with implications for theory, research and clinical intervention. [ABSTRACT FROM AUTHOR]

Background: Prolonged disorders of consciousness (PDOC) are amongst the severest sequelae of acquired brain injury. Evidence regarding epidemiology and rehabilitation outcomes is scarce. These knowledge gaps and psychological distress in families of PDOC patients may complicate clinical decision-making. The complex PDOC care and associated moral dilemmas result in high workload in healthcare professionals. Since 2019, all PDOC patients in the Netherlands have access to intensive neurorehabilitation up to 2 years post-injury provided by one rehabilitation center and four specialized nursing homes. Systematic monitoring of quantitative rehabilitation data within this novel chain of care is done in a study called DOCTOR. The optimization of tailored PDOC care, however, demands a better understanding of the impact of PDOC on patients, their families and healthcare professionals and their views on rehabilitation outcomes, end-of-life decisions and quality of dying. The True Outcomes of PDOC (TOPDOC) study aims to gain insight in the qualitative outcomes of PDOC rehabilitation and impact of PDOC on patients, their families and healthcare professionals.Methods: Nationwide multicenter prospective cohort study in the settings of early and prolonged intensive neurorehabilitation with a two-year follow-up period, involving three study populations: PDOC patients > 16 years, patients' family members and healthcare professionals involved in PDOC care. Families' and healthcare professionals' views on quality of rehabilitation outcomes, end-of-life decisions and dying will be qualitatively assessed using comprehensive questionnaires and in-depth interviews. Ethical dilemmas will be explored by studying moral deliberations. The impact of providing care to PDOC patients on healthcare professionals will be studied in focus groups.Discussion: To our knowledge, this is the first nationwide study exploring quality of outcomes, end-of-life decisions and dying in PDOC patients and the impact of PDOC in a novel chain of care spanning the first 24 months post-injury in specialized rehabilitation and nursing home settings. Newly acquired knowledge in TOPDOC concerning quality of outcomes in PDOC rehabilitation, ethical aspects and the impact of PDOC will enrich quantitative epidemiological knowledge and outcomes arising from DOCTOR. Together, these projects will contribute to the optimization of centralized PDOC care providing support to PDOC patients, families and healthcare professionals. [ABSTRACT FROM AUTHOR]

Objective: To understand the multiple and sometimes conflicting roles substitute decision makers (SDMs) of individuals in a vegetative state (VS), minimally conscious state (MCS), or with locked-in syndrome (LIS) perform while caring for a loved one and the competing priorities derived from these roles. Methods: We conducted semi-structured qualitative interviews using a constructive-grounded theory design. Twelve SDMs, who were also family members for 11 patients, were interviewed at two time points (except one) for a total of 21 in-depth interviews. Results: Participants described that caregiving is often the central role which they identify as their top priority and around which they coordinate and to some extent subordinate their other roles. In addition to caregiving, they participated in a wide variety of roles, which were sometimes in conflict, as they became caregivers for a loved one with chronic and complex needs. SDMs described the caregiver role as complex and intense that lead to physical, emotional, social, and economic burdens. Conclusion: SDMs report high levels of burdens in caring for a person with a prolonged disorder of consciousness. Lack of health system support that recognized the broader context of SDMs lives, including their multiple competing priorities, was a major contributing factor. [ABSTRACT FROM AUTHOR]

Objectives: Caregivers of patients diagnosed with disorders of consciousness (DoCs) play a pivotal role in the care pathway of these patients. Due to the high costs of care, among other symptoms and disorders previously described in the literature, they can manifest also mood and stress-related disorders which greatly impact their life and increase their burden. It is noteworthy to identify which factors are better related to the manifestation of mood and stress-related disorders to care for the caregivers in time. However, no studies have explored which factors are related to the manifestation of these disorders within this population yet. Materials and methods: We explored with different questionnaires whether patient-, caregiver-, and caregiving environment-related factors are associated with mood and stress-related disorders on 114 caregivers of patients with DoCs. Results: Our results showed that female caregivers manifested higher levels of both depression and prolonged grief disorder; furthermore, the presence of economic problems increased the levels of depression. Moreover, different levels of caregivers' depression, anxiety, anger expression, and prolonged grief disorder were closely linked to the degree of behavioural responsiveness of the patients. Conclusions: Our results highlighted the need to consider also caregivers' mood and stress-related disorders when defining the care pathway of patients with DoCs; indeed, caregivers constitute the main environment of DoC patients and they need tailored interventions aimed at reducing their burden due to caregiving. [ABSTRACT FROM AUTHOR]

Bereavements that occur under external traumatic circumstances increase the risk for dysfunction, trauma symptomatology, as well as disordered and prolonged grief. While the majority of individuals who have experienced traumatic bereavements do not meet formal criteria for posttraumatic stress disorder (PTSD), persistent complex bereavement disorder (PCBD), or prolonged grief disorder (PGD), the degree of distress and dysfunction for these bereaved can be quite significant. The assessment and intervention paradigms in use with traumatic bereavements often prioritize the trauma and bypass the centrality of the interpersonal loss. By using a bifocal approach in conceptualizing bereavement, the Two-Track Model of Bereavement (TTMB) rebalances the approach to the class of traumatic bereavements. Track I examines biopsychosocial functioning and symptoms of trauma, and track II focuses on the nature of the ongoing relationship with the deceased and the death story that may also have elements of traumatic response. The model and its application serve to identify both adaptive and maladaptive responses to loss along both axes to optimally focus interventions where needed. The story of the death, the psychological relationship with the deceased, and the presence of biopsychosocial difficulties each have a part to play in assessment and intervention. A case study of assessment and intervention following traumatic bereavement due to suicide illustrates how attention to each of these factors in the TTMB can facilitate change. Ultimately, the relational bond with the deceased is a major vector in grief and mourning. Assessment and intervention with traumatic bereavements require attention to dysfunction and symptoms of trauma as well as to the death story and the state of the relationship to the deceased. [ABSTRACT FROM AUTHOR]

This essay will examine the viability of a kabbalistic ethics from the vantage point of what I have identified in previously published studies as the hypernomian foundation of the nomos, the grounding of the law in the ground that exceeds the law of the ground. Contrary to Scholem, who put the emphasis on an antinomian impulse that is in conflict with the tenets of the tradition, I argue that the hallmark of religious nihilism is the promulgation of the belief that impiety is the gesture of supreme piety. In the ensuing analysis, I will explore the subject of hypernomianism by a close analysis of what may be called in Derridean terms the law beyond the law, which he identified further as the nonjuridical ideal of justice, the gift of forgiveness, the aspect of pure mercy in relation to which it is no longer viable to distinguish guilt and innocence. [ABSTRACT FROM AUTHOR]

Objective: To explore the ways in which health care professionals and families understand terms and concepts associated with disorders of consciousness. Methods: Open-ended, semi-structured interviews were conducted with 20 health care professionals and 18 family caregivers affiliated with a disorders of consciousness program within a nationally ranked rehabilitation facility in the United States. Results: Analysis revealed that: (1) disagreement between some health care professionals and family caregivers regarding the presence of consciousness can arise due to differing beliefs about a patient experiencing pain, and differences in the length of time family caregivers spend with patients relative to clinical staff; (2) some health care professionals and family caregivers use nonclinical terms and concepts to describe consciousness; and (3) some family caregivers might attribute complex mental capacities to patients, which extend beyond the clinical evidence. Conclusion: The beliefs of health care professionals and families regarding disorders of consciousness are complex and could be influenced by broader psychological proclivities to "see minds" in patients who have a liminal neurological status. Awareness of these dynamics may assist health care professionals when interacting with family caregivers. [ABSTRACT FROM AUTHOR]

Electrospray ionization chromatography-mass spectrometry was used to study transarylation and disproportionation reactions of di(4-methoxyphenyl) and di(4-dimethylaminophenyl) telluroxides in refluxing toluene. The reaction mixture compositions were established based on the mass spectrometry data and relative retention times. General schemes for fragmentation of the reaction mixture components were suggested. [ABSTRACT FROM AUTHOR]

An author index for the 2015 issue of ''Multiple Sclerosis Journal" is presented.

Although ephemeral streams constitute critical natural resources in dryland environments, water regulations and monitoring protocols typically focus on perennial streams, and may not always be appropriate for characterizing intermittent systems. The article presents findings from a comprehensive evaluation of environmental conditions in two ephemeral transboundary streams: the Hebron/Besor and Zomar/Alexander. The streams are representative of numerous watersheds which originate in Palestinian land and flow into Israel. Transboundary streams in the region exhibit high concentrations of point and non-point sources of pollution. Many of the region's streams that in the past had no flow except for isolated storm incidents have emerged as perennial streams, channelling raw or partially treated industrial or municipal wastes. Management of these natural resources constitutes a unique challenge because of the complex local political circumstances. The article presents chemical and biological monitoring results, identifying high levels of non-point source nutrient runoff during rainfall events and high percolation of contaminated stream water during its flow that should be addressed in future restoration strategies. The practical challenges associated with the monitoring of ephemeral streams are also discussed with suggestions for future studies and management efforts. [ABSTRACT FROM AUTHOR]

Background Flu-like symptoms are common adverse events associated with interferon beta relapsing multiple sclerosis therapies. Objectives To evaluate the incidence and severity of flu-like symptoms after transitioning from non-pegylated interferons to peginterferon beta-1a and assess flu-like symptom mitigation using naproxen. Methods ALLOW was a phase 3b open-label study in relapsing multiple sclerosis patients. Patients had received non-pegylated interferon for 4 or more months immediately before beginning a 4-week screening period. At baseline, patients switched to peginterferon beta-1a and were randomly assigned (1:1) to continue their current flu-like symptoms management regimen or start twice-daily naproxen 500 mg for 8 weeks. Patients then switched to their preferred regimen and were followed for 48 weeks in total. Results Of 201 patients, 89.6% did not experience new/worsening flu-like symptoms during their first 8 weeks on peginterferon beta-1a. Flu-like symptom severity remained low in current-regimen and naproxen patients, with no significant between-group differences. Median flu-like symptom duration per injection was 3.2 hours longer with peginterferon beta-1a versus prior interferon, but the 4-week cumulative duration was reduced 49–78%. No new safety signals were identified. Conclusion Most patients who switched from non-pegylated interferon to peginterferon beta-1a did not experience new/worsening flu-like symptoms. Flu-like symptom duration per injection increased, but the cumulative duration significantly decreased. These data may inform flu-like symptom management guidance. [ABSTRACT FROM AUTHOR]