Future scenarios of palliative care in health system of Iran: a multi-method study.

Background: Paying attention to palliative care has accelerated in Iran in the last 10 years. Considering the trend of aging, increasing burden of chronic diseases and increasing health costs, planning and development of palliative care is necessary in the future. This study was conducted with the aim of explaining the alternative scenarios of palliative care in the health system of Iran until the horizon of 2030. Methods: This study was a multi-method scenario planning with a qualitative using multiple methods design, which was conducted in 3 phases in 2018-2020. In the first phase, a list of driving forces was extracted using qualitative interviews and literature review. In the second phase, all factors identified in the previous phase were examined in terms of degree of uncertainty and cross-impact analysis, and two key uncertainties were extracted. In the third phase, based on two key uncertainties, four future scenarios of palliative care were formulated, validated and scenario strategies were presented. Results: The results indicate two uncertainties, including "governance of palliative care in the health system" and "acceptance of palliative care by society," based on which, four scenarios with the names "climbing to the top," "excruciating climb," "edge of the abyss" and "The bottom of the valley" were compiled. Conclusion: The development of palliative care in health system of Iran is faced with serious uncertainties that it is necessary to focus the developmental activities of palliative care on the two axes of acceptance by society and need for coherent governance by considering all the dimensions and influential components by ministry of health. The application of the results of this research can provide reasonable options for effective interventions and implementation of this category of services to the beneficiaries of palliative care.

Association of norepinephrine with pressure ulcer development in critically ill patients with COVID-19-related acute respiratory distress syndrome: A dose-response analysis.

OBJECTIVES: To investigate the correlation between varying doses of norepinephrine (NE) and the incidence of pressure injuries (PIs) in COVID-19 patients in intensive care units (ICUs). DESIGN: A retrospective multicenter study was conducted on 1,078 COVID-19 patients admitted to ICUs with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. The research spanned from March 2020 to April 2021 across five university-affiliated hospitals in Iran. Univariate and multivariate binary logistic regression analyses, along with linear and non-linear dose-response assessments, were utilized to evaluate the relationship between NE dosages and the probability of PI development. FINDINGS: The multivariate analysis revealed a significant association between higher doses of NE administered over 24 h (OR: 1.832, 95 % CI: 1.218-2.754, P=0.004) and cumulative doses (OR: 1.408, 95 % CI: 1.204-1.975, P=0.048) with the occurrence of PIs. Moreover, patients receiving high NE doses had a nearly fourfold increased risk of developing PIs, regardless of PIs stage, compared to those on low or moderate doses (>15 µg/min vs. ≤ 15 µg/min; OR: 4.401, 95 % CI: 3.339-5.801, P=0.001). Although the linear dose-response analysis did not show a significant correlation between NE doses (µg/min) and PI development (P>0.05), the non-linear analysis indicated that NE doses ≤ 9 µg/min were associated with a reduced risk of PI development. CONCLUSION: Maintaining NE infusion within the range of 1-9 µg/min appears to be most effective in reducing the likelihood of PIs in ICU patients with COVID-19. Lower NE doses (≤9 µg/min) were associated with a lower risk of PI development, suggesting that factors beyond NE dosage or the use of other vasopressors may play a crucial role in PI formation in this patient cohort. IMPLICATIONS FOR CLINICAL PRACTICE: Rather than suggesting a specific threshold, clinicians should consider further studies to determine the optimal dose that balances microvascular perfusion and patient outcomes. It is crucial to comprehensively evaluate additional factors and selectively use vasopressors. Individualized care, including regular monitoring and personalized treatment plans, is essential for achieving the best outcomes in this patient population.

Transitions from Aerobic to Anaerobic Metabolism and Oxygen Debt during Elective Major and Emergency Non-Cardiac Surgery.

INTRODUCTION: Intraoperative hemodynamic and metabolic optimization of both the high-risk surgical patients and critically ill patients remains challenging. Reductions in oxygen delivery or increases in oxygen consumption can initiate complex cellular processes precipitating oxygen debt (OXD). METHODS: This study tested the hypothesis that intraoperative changes in sublingual microcirculatory flow reflect clinically relevant transitions from aerobic to anaerobic metabolism (TRANAM). We included patients undergoing elective major and emergency non-cardiac surgery. Macro- and microcirculatory variables, oxygen extraction, and transitions of metabolism were assessed in both cohorts. RESULTS: In the elective group, OXD was progressively increased over time, with an estimated 2.24 unit increase every 30 min (adjusted p < 0.001). Also, OXD was negatively correlated with central venous pressure (ρ = -0.247, adjusted p = 0.006) and positively correlated with stroke volume variation (ρ = 0.185, adjusted p = 0.041). However, it was not significantly correlated with sublingual microcirculation variables. In the emergency surgery group, OXD increased during the first two intraoperative hours and then gradually decreased until the end of surgery. In that cohort, OXD was positively correlated with diastolic arterial pressure (ρ = 0.338, adjpatients and the critically ill patients remains challengingsted p = 0.015). Also, OXD was negatively correlated with cardiac index (ρ = -0.352, adjusted p = 0.003), Consensus Proportion of Perfused Vessels (PPV) (ρ = -0.438, adjusted p < 0.001), and Consensus PPV (small) (ρ = -0.434, adjusted p < 0.001). CONCLUSIONS: TRANAM were evident in both the elective major and emergency non-cardiac surgery cohorts independent of underlying alterations in the sublingual microcirculation.

Effect of Ozone Therapy on Diabetes-related Foot Ulcer Outcomes: A Systematic Review and Meta-analysis.

PURPOSE: This study aimed to assess the effectiveness of ozone therapy in treating Diabetes-related Foot Ulcer (DFU) and its outcomes. METHODS: A systematic search was conducted in PubMed/MEDLINE, Scopus, Web of Science, and ProQuest databases for published studies evaluating the use of ozone as an adjunct treatment for DFU, from inception to December 21, 2022. The primary outcome measure was the change in wound size after the intervention compared to pretreatment. Secondary outcomes included time to complete ulcer healing, number of healed patients, adverse events, amputation rates, and hospital length of stay. Quantitative data synthesis for the meta-analysis was performed using a random-effects model and generic inverse variance method, while overall heterogeneity analysis was conducted using a fixed-effects model. Interstudy heterogeneity was assessed using the I2 index (>50%) and the Cochrane Q statistic test. Sensitivity analysis was performed using the leave-one-out method. RESULTS: The meta-analysis included 11 studies comprising 960 patients with DFU. The results demonstrated a significant positive effect of ozone therapy on reducing foot ulcer size (Standardized Mean Difference (SMD): -25.84, 95% CI: -51.65 to -0.04, p = 0.05), shortening mean healing time (SMD: -38.59, 95% CI: -51.81 to -25.37, p < 0.001), decreasing hospital length of stay (SMD: -8.75, 95% CI: -14.81 to -2.69, p < 0.001), and reducing amputation rates (Relative Risk (RR): 0.46, 95% CI: 0.30-0.71, p < 0.001), compared to standard treatment. CONCLUSION: This meta-analysis indicates that ozone therapy has additional benefits in expediting complete DFU healing, reducing the amputation rates, and decreasing hospital length of stay, though its effects do not differ from standard treatments for complete ulcer resolution. Further research is needed to address the heterogeneity among studies and to better understand the potential beneficial effects of ozone therapy.

Effect of peri-intubation non-pharmacological interventions on postoperative laryngeal symptoms: A systematic review with meta-analysis and meta-regression.

OBJECTIVES: To evaluate the effectiveness of peri-intubation non-pharmacological interventions in reducing postoperative sore throat (POST), cough (PEC), and hoarseness in surgical patients. DESIGN: A systematic review with meta-analysis and meta-regression. SETTING: Elective surgery under general anesthesia in operating rooms. MAIN OUTCOME MEASURES: Evaluate the impact of non-pharmacological interventions, including pre-intubation (gargling with Sodium Azulene Sulfonate, licorice, or using Strepsils tablets of honey and lemon lozenge), during-intubation (inflating the TT cuff with normal saline and softening the ETT cuff with warm normal saline), and post-intubation (cold vapor therapy, gargling with honey lemon water, and using green tea gargle), on the occurrence of POST, PEC, and hoarseness. RESULTS: Nineteen trials with 2,136 participants were included. Pre-intubation intervention significantly reduced POST immediately after extubation (n = 861; OR: 0.28, 95 % CI: 0.20-0.38, P < 0.001), and 24 h post-extubation (n = 1006; OR: 0.21, 95 % CI: 0.16-0.28, P < 0.001). During-intubation intervention did not show significant effects on POST. Pre-intubation intervention also reduced POST-associated pain score at 24 h post-extubation (n = 440; MD: -0.50, 95 % CI: -0.81 to -0.18, P < 0.001). Post-intubation interventions were effective in reducing POST-associated pain scores at different time points post-extubation (P < 0.05). Pre-intubation intervention significantly reduced PEC (OR: 0.13, 95 % CI: 0.02-0.70, P = 0.02) and hoarseness (OR: 0.36, 95 %CI: 0.15-0.86, P = 0.02) at 24 h post-extubation. However, during-intubation interventions did not reduce hoarseness at 24 h post-extubation. CONCLUSION: Pre-intubation non-pharmacological interventions were found to be the most effective in reducing the incidence and severity of POST, PEC, and hoarseness. IMPLICATIONS FOR CLINICAL PRACTICE: Implementing pre-intubation non-pharmacological interventions can be beneficial for bedside nurses and healthcare professionals in reducing postoperative complications and nurses can contribute to improving patient comfort and recovery outcomes following surgery. SYSTEMATIC REVIEW PROTOCOL: The protocol was registered in the PROSPERO international prospective register of systematic reviews on 2 January 2024 (CRD42023492813).

Correlation between socio-demographic characteristics, metabolic control factors and personality traits with self-perceived health status in patients with diabetes: A cross-sectional study.

Purpose: This study aimed to assess the relationship between metabolic control factors, socio-demographic characteristics, personality traits, and self-perceived health status in diabetes. Methods: This cross-sectional study included 318 patients with type 1 and 2 diabetes (DM). Participants completed a questionnaire-based survey, which included the NEO Personality Inventory-Revised to measure five personality dimensions and the SF-12 survey to assess self-perceived health status. Binary logistic regression was performed to analyze the data, with socio-demographic characteristics, clinical data, and nutrition status as independent variables, and self-perceived health status (categorized as poor or good condition) as the dependent variable. Unadjusted and adjusted binary logistic regression analyses were used to examine the association between personality traits (high vs. low) and metabolic control factors (good control vs. bad control) with health status scores. Results: 60.7% of the participants with diabetes in the study described their health as "good." The results indicated that female gender (OR: 0.314, 95%CI: 0.105-0.938, P = 0.038), age > 60 years (OR: 0.263, 95%CI: 0.117-0.592, P = 0.001), comorbidities (OR: 0.314, 95%CI: 0.178-0.556, P = 0.001), DM complications (OR: 0.531, 95%CI: 0.337-0.838, P = 0.007), diabetic neuropathy (OR: 0.562, 95%CI: 0.356-0.886, P = 0.013), and diabetic ulcer (OR: 0.130, 95%CI: 0.023-0.747, P = 0.022) were independent variables associated with a "poor" health status. However, regular physical activity (OR: 3.144, 95%CI: 1.209-8.175, P = 0.019) and a healthy nutritional diet (OR: 2.456, 95%CI: 1.421-4.245, P < 0.001) were associated with a higher likelihood of a "good" self-perceived health status. Conclusion: Preventive programs and interventions aimed at improving self-perceived health among patients with diabetes should focus on increasing regular physical activity and promoting a healthy nutritional status. These actions should be particularly targeted towards female and older patients with higher neuroticism traits.

Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysis.

BACKGROUND: An increasing number of patients requires extracorporeal membrane oxygenation (ECMO) for life support. This supportive modality is associated with nosocomial infections (NIs). This systematic review and meta-analysis aim to assess the incidence and risk factors of NIs in adult. METHODS: We searched PubMed, Scopus, Web of Science, and ProQuest databases up to 2022. The primary endpoint was incidence of NI. Secondary endpoints included time to infection, source of infection, ECMO duration, Intensive care and hospital length of stay (LOS), ECMO survival and overall survival. Incidence of NI was reported as pooled proportions and 95% confidence intervals (CIs), while dichotomous outcomes were presented as risk ratios (RR) as the effective index and 95% CIs using a random-effects model. RESULTS: Among the 4,733 adult patients who received ECMO support in the 30 included studies, 1,249 ECMO-related NIs per 1000 ECMO-days was observed. The pooled incidence of NIs across 18 studies involving 3424 patients was 26% (95% CI 14-38%).Ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) were the most common NI sources. Infected patients had lower ECMO survival and overall survival rates compared to non-infected patients, with risk ratio values of 0.84 (95% CI 0.74-0.96, P = 0.01) and 0.80 (95% CI 0.71-0.90, P < 0.001), respectively. CONCLUSION: Results showed that 16% and 20% lower of ECMO survival and overall survival in patients with NI than patients without NI, respectively. However, NI increased the risk of in-hospital mortality by 37% in infected patients compared with non-infected patients. In addition, this study identified the significant positive correlation between ECMO duration and ECMO-related NI.

What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) is an alternative method for patients with reversible causes of cardiac arrest (CA) after conventional cardiopulmonary resuscitation (CCPR). However, cardiopulmonary resuscitation (CPR) duration during ECPR can vary due to multiple factors. Healthcare providers need to understand these factors to optimize the resuscitation process and improve outcomes. The aim of this study was to examine the different variables impacting the duration of CPR in patients undergoing ECPR. METHODS: This retrospective, single-center, observational study was conducted on adult patients who underwent ECPR due to in-hospital CA (IHCA) or out-of-hospital CA (OHCA) at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. Univariate and multivariate binary logistic regression analyses were performed to identify the prognostic factors associated with CPR duration, including demographic and clinical variables, as well as laboratory tests. RESULTS: The mean ± standard division age of the 48 participants who underwent ECPR was 41.50 ± 13.15 years, and 75% being male. OHCA and IHCA were reported in 77.1% and 22.9% of the cases, respectively. The multivariate analysis revealed that several factors were significantly associated with an increased CPR duration: higher age (OR: 1.981, 95%CI: 1.021-3.364, P = 0.025), SOFA score (OR: 3.389, 95%CI: 1.289-4.911, P = 0.013), presence of comorbidities (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), OHCA (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), and prolonged collapse-to-CPR time (OR: 1.446, 95%CI:1.092-3.014, P = 0.001). Additionally, the study found that the initial shockable rhythm was inversely associated with the duration of CPR (OR: 0.271, 95%CI: 0.161-0.922, P = 0.045). However, no significant associations were found between laboratory tests and CPR duration. CONCLUSION: These findings suggest that age, SOFA score, comorbidities, OHCA, collapse-to-CPR time, and initial shockable rhythm are important factors influencing the duration of CPR in patients undergoing ECPR. Understanding these factors can help healthcare providers better predict and manage CPR duration, potentially improving patient outcomes. Further research is warranted to validate these findings and explore additional factors that may impact CPR duration in this population.

Cardiac Rehabilitation Using the Family-Centered Empowerment Model is Effective in Improving Long-term Mortality in Patients with Myocardial Infarction: A 10-year Follow-Up Randomized Clinical Trial.

INTRODUCTION: Cardiac rehabilitation (CR) play a critical role in reducing the risk of future cardiovascular events and enhancing the quality of life for individuals who have survived a heart attack. AIM: To assess the mortality rates and stability of the effects in myocardial infarction (MI) survivors after implementing a Family-Centered Empowerment Model (FCEM)-focused hybrid cardiac rehabilitation program. METHODS: This double-blind randomized controlled clinical trial, conducted at Shariati Hospital, an academic teaching hospital in Tehran, Iran (2012-2023), involved 70 MI patients and their families. Participants were randomly assigned to an FCEM intervention group or standard CR control group. The intervention commenced after the MI patient's safe discharge from the CCU and continued for the entire 10-year follow-up period. Various questionnaires were utilized to collect data on mortality rates and health-related quality of life (HRQoL). RESULTS: The 10-year follow-up period revealed lower mortality rates in the intervention group (5.7%, 11.4%, and 17.1% at 5, 7, and 10 years, respectively) compared to the control group (20%, 37.1%, and 48.9%). After adjusting for age, gender, and BMI, the control group had a four times higher mortality risk (HR: 4.346, 95% CI 1.671-7.307, P = 0.003). The FCEM-focused program demonstrated a significant and sustained positive impact on participants' quality of life for 48 months, with greater improvement compared to the control group. CONCLUSION: This study highlights the effectiveness of FCEM-based hybrid CR programs in enhancing long-term patient outcomes and reducing mortality rates among MI survivors. Further research is needed to explore the potential benefits in larger samples and diverse populations. TRIAL REGISTRATION: This study (Identifier: NCT02402582) was registered in the ClinicalTrials.gov on 03/30/2015.

Risk factors for neurological disability outcomes in patients under extracorporeal membrane oxygenation following cardiac arrest: An observational study.

OBJECTIVES: This study aimed to identify factors associated with neurological and disability outcomes in patients who underwent ECMO following cardiac arrest. METHODS: This retrospective, single-center, observational study included adult patients who received ECMO treatment for in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) between February 2016 and March 2020. Factors associated with neurological and disability outcomes in these patients who underwent ECMO were assessed. SETTING: Hamad General Hospital, Qatar. MAIN OUTCOME MEASURES: Neurological disability outcomes were assessed using the Modified Rankin Scale (mRS) and the Cerebral Performance Category (CPC) scale. RESULTS: Among the 48 patients included, 37 (77 %) experienced OHCA, and 11 (23 %) had IHCA. The 28-day survival rate was 14 (29.2 %). Of the survivors, 9 (64.3 %) achieved a good neurological outcome, while 5 (35.7 %) experienced poor neurological outcomes. Regarding disability, 5 (35.7 %) of survivors had no disability, while 9 (64.3 %) had some form of disability. The results showed significantly shorter median time intervals in minutes, including collapse to cardiopulmonary resuscitation (CPR) (3 vs. 6, P = 0.001), CPR duration (12 vs. 35, P = 0.001), CPR to extracorporeal cardiopulmonary resuscitation (ECPR) (20 vs. 40, P = 0.001), and collapse-to-ECPR (23 vs. 45, P = 0.001), in the good outcome group compared to the poor outcome group. CONCLUSION: This study emphasizes the importance of minimizing the time between collapse and CPR/ECMO initiation to improve neurological outcomes and reduce disability in cardiac arrest patients. However, no significant associations were found between outcomes and other demographic or clinical variables in this study. Further research with a larger sample size is needed to validate these findings. IMPLICATIONS FOR CLINICAL PRACTICE: The study underscores the significance of reducing the time between collapse and the initiation of CPR and ECMO. Shorter time intervals were associated with improved neurological outcomes and reduced disability in cardiac arrest patients.

Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study.

BACKGROUND: The impact of the chronological sequence of events, including cardiac arrest (CA), initial cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) implementation, on clinical outcomes in patients with both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), is still not clear. The aim of this study was to investigate the prognostic effects of the time interval from collapse to start of CPR (no-flow time, NFT) and the time interval from start of CPR to implementation of ECPR (low-flow time, LFT) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO). METHODS: This single-center, retrospective observational study was conducted on 48 patients with OHCA or IHCA who underwent ECMO at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. We investigated the impact of prognostic factors such as NFT and LFT on various clinical outcomes following cardiac arrest, including 24-hour survival, 28-day survival, CPR duration, ECMO length of stay (LOS), ICU LOS, hospital LOS, disability (assessed using the modified Rankin Scale, mRS), and neurological status (evaluated based on the Cerebral Performance Category, CPC) at 28 days after the CA. RESULTS: The results of the adjusted logistic regression analysis showed that a longer NFT was associated with unfavorable clinical outcomes. These outcomes included longer CPR duration (OR: 1.779, 95%CI: 1.218-2.605, P = 0.034) and decreased survival rates for ECMO at 24 h (OR: 0.561, 95%CI: 0.183-0.903, P = 0.009) and 28 days (OR: 0.498, 95%CI: 0.106-0.802, P = 0.011). Additionally, a longer LFT was found to be associated only with a higher probability of prolonged CPR (OR: 1.818, 95%CI: 1.332-3.312, P = 0.006). However, there was no statistically significant connection between either the NFT or the LFT and the improvement of disability or neurologically favorable survival after 28 days of cardiac arrest. CONCLUSIONS: Based on our findings, it has been determined that the NFT is a more effective predictor than the LFT in assessing clinical outcomes for patients with OHCA or IHCA who underwent ECMO. This understanding of their distinct predictive abilities enables medical professionals to identify high-risk patients more accurately and customize their interventions accordingly.

A 39 Year mortality study of survivors exposed to sulfur mustard agent: A survival analysis.

Background: The primary objective of this study was to analyze the long-term survival of 48,067 chemical warfare survivors who suffered from pulmonary, cutaneous, and ocular lesions in the decades following the Iran-Iraq war. Methods: The data for this study were obtained from the Veterans and Martyr Affair Foundation (VMAF) database. The survivors were divided into two groups based on whether they were evacuated/admitted (EA) to a hospital or not evacuated/admitted (NEA) to a hospital. The proportional hazard (PH) assumption for age categories, gender, exposure statuses, and eye severity was not satisfied. Therefore, we used a Generalized Gamma (GG) distribution with an Accelerated Failure Time (AFT) model for analysis. Results: The study included a total of 48,067 observations, and among them, 4342 (9.03 %) died during the study period. The mean (SD) age of the survivors was 55.99 (7.9) years. The mortality rate increased with age, and higher rates were observed in males. Survival probabilities differed significantly among age categories, provinces, lung severity, and eye severity based on log-rank tests (p-value<0.05 for all). The GG model results showed that higher age and being male were associated with a shorter time to death. The study also found that the mortality rate was significantly higher in the EA group compared to the NEA group. Conclusion: The present study showed no significant difference in survival time between the EA and NEA groups. The findings suggest that pulmonary lesions caused by mustard gas are more likely to be fatal compared to skin and eye lesions. The results also indicate a potential association between survival time and the severity of lung damage.

A respiratory critical care nurse training program for settings without a registered respiratory therapists: A protocol for a multimethod study.

BACKGROUND: The increasing elderly population and prevalence of chronic diseases have raised the need for ICU beds. However, limited bed availability often causes delays in admission, leading to wasted treatment time. OBJECTIVES: This study aims to create and implement a training program for respiratory critical care nurses (RCCNs) in settings without registered respiratory therapists (RRTs). METHODOLOGY/DESIGN: The study will use a multimethod sequential research design, including a scoping review, content analysis, Delphi methods, and a randomized clinical trial. The scoping review will gather extensive information on respiratory care for critically ill patients and the responsibilities of RCCNs. Content analysis and expert interviews will identify opportunities and challenges in RCCNs' provision of respiratory care. The Delphi method will integrate the results to develop a comprehensive training program for RCCNs. Subsequently, five RCCNs will undergo theoretical and practical examinations after completing the three-month training program, and the impact of RCCNs on critically ill patients' outcomes will be evaluated through a clinical trial. ANTICIPATED FINDINGS: The study aims to provide a comprehensive training program for RCCNs and investigate its impact on the outcomes of critically ill patients through a clinical trial. CONCLUSION: The training program will equip RCCNs with the necessary skills and knowledge to provide respiratory critical care from the emergency department to hospital discharge. This pioneering study aims to improve patient outcomes in settings without RRTs by offering a unique program for RCCNs. IMPLICATIONS FOR CLINICAL PRACTICE: The development and implementation of this training program for RCCNs in settings without RRTs will address the gap in respiratory care and potentially improve patient outcomes. By empowering RCCNs with specialized training, healthcare facilities can ensure the provision of high-quality respiratory care throughout a patient's critical illness journey, enhancing the efficiency and effectiveness of healthcare teams, especially in resource-limited settings.

Evaluation of psychological distress, burnout and structural empowerment status of healthcare workers during the outbreak of coronavirus disease (COVID-19): a cross-sectional questionnaire-based study.

BACKGROUND: In light of several recent studies, there is evidence that the coronavirus disease 2019 (COVID-19) pandemic has caused various mental health concerns in the general population, as well as among healthcare workers (HCWs). The main aim of this study was to assess the psychological distress, burnout and structural empowerment status of HCWs during the COVID-19 outbreak, and to evaluate its predictors. METHODS: This multi-center, cross-sectional web-based questionnaire survey was conducted on HCWs during the outbreak of COVID-19 from August 2020 to January 2021. HCWs working in hospitals from 48 different countries were invited to participate in an online anonymous survey that investigated sociodemographic data, psychological distress, burnout and structural empowerment (SE) based on Depression Anxiety and Stress Scale 21 (DASS-21), Maslach Burnout Inventory (MBI) and Conditions for work effectiveness questionnaire (CWEQ_II), respectively. Predictors of the total scores of DASS-21, MBI and CWEQ-II were assessed using unadjusted and adjusted binary logistic regression analysis. RESULTS: Out of the 1030 HCWs enrolled in this survey, all completed the sociodemographic section (response rate 100%) A total of 730 (70.9%) HCWs completed the DASS-21 questionnaire, 852 (82.6%) completed the MBI questionnaire, and 712 (69.1%) completed the CWEQ-II questionnaire. The results indicate that 360 out of 730 responders (49.3%) reported severe or extremely severe levels of stress, anxiety, and depression. Additionally, 422 out of 851 responders (49.6%) reported a high level of burnout, while 268 out of 712 responders (37.6%) reported a high level of structural empowerment based on the DASS-21, MBI, and CWEQ-II scales, respectively. In addition, the analysis showed that HCWs working in the COVID-19 areas experienced significantly higher symptoms of severe stress, anxiety, depression and higher levels of burnout compared to those working in other areas. The results also revealed that direct work with COVID-19 patients, lower work experience, and high workload during the outbreak of COVID-19 increase the risks of negative psychological consequences. CONCLUSION: Health professionals had high levels of burnout and psychological symptoms during the COVID-19 emergency. Monitoring and timely treatment of these conditions is needed.

The feasibility of using acoustic measures for predicting the Total Opacity Scores of chest computed tomography scans in patients with COVID-19.

To study the possibility of using acoustic parameters, i.e., Acoustic Voice Quality Index (AVQI) and Maximum Phonation Time (MPT) for predicting the degree of lung involvement in COVID-19 patients. This cross-sectional case-control study was conducted on the voice samples collected from 163 healthy individuals and 181 patients with COVID-19. Each participant produced a sustained vowel/a/, and a phonetically balanced Persian text containing 36 syllables. AVQI and MPT were measured using Praat scripts. Each patient underwent a non-enhanced chest computed tomographic scan and the Total Opacity score was rated to assess the degree of lung involvement. The results revealed significant differences between patients with COVID-19 and healthy individuals in terms of AVQI and MPT. A significant difference was also observed between male and female participants in AVQI and MPT. The results from the receiver operating characteristic curve analysis and area under the curve indicated that MPT (0.909) had higher diagnostic accuracy than AVQI (0.771). A significant relationship was observed between AVQI and TO scores. In the case of MPT, however, no such relationship was observed. The findings indicated that MPT was a better classifier in differentiating patients from healthy individuals, in comparison with AVQI. The results also showed that AVQI can be used as a predictor of the degree of patients' and recovered individuals' lung involvement. A formula is suggested for calculating the degree of lung involvement using AVQI.

Effects of Iranian herbal Zofa® syrup for the management of clinical symptoms in patients with COVID-19: A randomized clinical trial.

Objective: The objective of this study was to determine the role of Iranian herbal Zofa® syrup in improving the clinical symptoms of patients with COVID-19. Materials and Methods: This randomized clinical trial was conducted on 105 patients with COVID-19. Patients were randomly assigned to the intervention (n=35) group (received 10 ml of Zofa® syrup every 8 hours/seven days plus standard treatment) or the control (n=70) group (received only standard treatment). Assessments were performed before and after treatment. Results: The groups were comparable regarding age (p=0.980), gender (p=0.584), comorbidities (p=0.318), or drug history (p=0.771). There was no difference between patients' recovery status at the time of discharge (p=0.327) or two weeks post-discharge (p=0.165) in the intervention and control groups. No patient was hospitalized to the intensive care unit (ICU) for supplemental oxygen therapy and no patient died in the intervention group. However, in the control group, three (4.5%) patients were transferred to the ICU, and two (3.03%) patients died. Conclusion: Considering the better recovery status of the patients at the time of discharge and the absence of patient deaths in the intervention group, more additional studies are needed to confirm these findings and elucidate the role of Zofa® in COVID-19.

Impact of spirituality on patient memories of intensive care unit stays: A nationwide cross-sectional study.

Background: Absent or delusional memories are experienced by many patients following an intensive care unit (ICU) stay. Up to 70% may have delusional or hallucinatory intrusive memories, which may persist long term. This study aims to investigate how spiritual health (SH) impacts ICU patients' memories and quality of communication (QoC) between patients and physicians (PP) or nurses (PN). Methods: This cross-sectional study was conducted across the country on ICU patients discharged from 45 medical centers in 31 provinces of Iran, to evaluate the direct and indirect effects of SH and ICU characteristics on patients' memory. Two valid and standard ICU memory tools (ICU-MT) and SH questionnaires were administered to patients 1 day post-ICU discharge used. Results: No significant direct effect of SH scores on ICU-MT items was observed. No significant correlation was observed between PP-QoC and PN-QoC variables and primary items of the ICU-MT. Female sex positively correlated with the development of delusional memories (odds ratio [OR]: 1.730, 95% confidence interval [CI]: 1.025-2.915, P < 0.05). Subjects admitted to the medical ICU were less likely to remember being in the ICU (OR: 0.398, 95% CI: 0.159-0.996, P < 0.05), and were less likely to report intrusive memories from their time in the hospital or events that led to their admission (OR: 0.19, 95% CI: 0.086-0.419, P < 0.001). Conclusions: The results of this study indicate that the spiritual health indirectly increased coping with intrusive memories, however, no direct effect was observed on ICU-MT items. The quality of communication between patients and physicians and nurses significantly mediated development of intrusive memories.