Clinician perceptions of the impact of ICU family visiting restrictions during the COVID-19 pandemic: an international investigation.

PURPOSE: To guarantee the safety of the public, clinicians and patients during the COVID-19 pandemic, hospital visits were severely restricted internationally. There are limited data on the precise impact of these visiting restrictions on Intensive Care Unit clinicians. Our objectives therefore were to explore the impact of family visitation restrictions on clinicians and care delivery and describe innovation alongside areas for potential improvement. METHODS: A qualitative approach using focus groups was employed. We recruited members of the multi-disciplinary team from Spain, France and the UK. Framework analysis was used to synthesize and interpret data. RESULTS: In total, 28 staff from multiple international sites contributed to data across six focus groups: 12 from the UK, 9 from France and 7 from Spain. In relation to the key aims, we derived four themes: the emergence of new technologies, relationships and rapport establishment, communication challenges and end-of-life care provision. Across each theme, the overarching concepts of clinician emotional exhaustion and emotional distress emerged alongside the negative impact on job satisfaction. CONCLUSION: The impact of COVID-19 family visitation restrictions is far reaching. Future research should examine the wider impact of family presence in the ICU.

Recovery of platelet reactivity following cessation of either aspirin or ticagrelor in patients treated with dual antiplatelet therapy following percutaneous coronary intervention: a GLOBAL LEADERS substudy.

Cessation of one component of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) has been associated with increased risk of ischemic events but it is uncertain whether discontinuation of aspirin is preferable to discontinuation of the oral P2Y12 inhibitor. The GLOBAL LEADERS study compared two antiplatelet strategies following PCI, cessation of aspirin at 1 month with continued ticagrelor monotherapy for 23 months versus standard DAPT for 12 months followed by aspirin monotherapy for a further 12 months. We assessed recovery of platelet reactivity after withdrawal of either aspirin or ticagrelor at 1 month and 12 months, respectively, in this study. Platelet aggregation (PA) was assessed before cessation of DAPT ('baseline') and after 2, 7, and 14 days post-cessation using Multiplate whole-blood aggregometry with collagen, thrombin-receptor-activating peptide (TRAP), adenosine diphosphate (ADP) and arachidonic acid (AA) as agonists. Following cessation of aspirin at 1 month, there was marked recovery of PA induced by AA (baseline [mean ± SD]: 11.1 ± 7.4 U vs. 14 days: 64.9 ± 19.6 U, p < .0001) and collagen (37.4 ± 22.9 U vs. 79.8 ± 13.8 U, p < .0001), whereas PA induced by ADP (18.6 ± 6.6 vs. 69.1 ± 20.5, p < .0001) and collagen (34.4 ± 18.7 U vs. 43.0 ± 21.0, p = .0018) recovered following cessation of ticagrelor at 12 months. There were no significant changes in TRAP-induced PA in either group. In conclusion, cessation of either component of DAPT leads to substantial increase in platelet reactivity with differential effects on different pathways of platelet activation when aspirin or the P2Y12 inhibitor is stopped. Further work is required to determine which patients receive net benefit from long-term continuation of DAPT.

A cross-sectional examination of US gun ownership and support for gun control measures: Sociodemographic, geographic, and political associations explored.

Public opinion regarding gun ownership and control coincide with deep political and sociodemographic divisions in the US population. The study objective was to analyze the prevalence and predictors of gun ownership and support for gun control policy using a national representative sample of US adults. Nationally representative data from the General Social Survey (2010 to 2016) were used to examine sociodemographic, geographic, and attitudinal differences in gun ownership and views towards laws requiring police permits before gun purchases (N = 6184). Prevalence ratios and 95% CIs were calculated using logistic regression models. Among US adults, 22.1% reported owning a gun (n = 1358) and 72.5% favored presale gun permit laws (n = 4445). Adults who were aged 65+, male, non-Hispanic white, and politically conservative; earned $35,000+ annually; and did not reside in the Northeast region of the US were significantly more likely to own guns (p < 0.05). Adults who were aged 65+, female, non-Hispanic blacks/other or Hispanics, college graduates, politically liberal, and resided in the Northeast were significantly more likely to favor presale gun permit laws than their counterparts (p < 0.05). Gun safety and prevention efforts must address political and sociodemographic divisions that have stymied the passage of meaningful legislation.

Interoperator and intraoperator variability of whole blood coagulation assays: a comparison of thromboelastography and rotational thromboelastometry.

OBJECTIVES: Near-patient viscoelastic tests have proved useful in decreasing blood and blood product use in cardiac surgery. Two different analyzers are available, TEG and ROTEM. Many different individuals operate these devices, which raises concern that this factor may significantly affect results. The present study sought to objectively assess variability in results between operators. DESIGN: Prospective study. SETTING: Regional cardiac center. PARTICIPANTS: Adult patients undergoing elective cardiac surgery. INTERVENTIONS: Thirty-six mL of blood were taken from each of 21 patients. TEG kaolin and functional fibrinogen (FF) analyses and the equivalent ROTEM INTEM S and FIBTEM S analyses were performed. Six operators performed one of each test per patient to assess interoperator variability. One further operator performed 6 of each test per patient to assess intraoperator variability. MEASUREMENTS AND MAIN RESULTS: All routine measurement parameters were noted and the coefficient of variation (CV) calculated, analyzing comparable parameters. All inter-operator CVs were significantly lower for ROTEM analyses compared with TEG. CV for INTEM S CT/ kaolin r time was 4.7 versus 16.3 and MCF/MA was 2.6 versus 4.3 (p < 0.01). Similarly, FIBTEM S MCF/ FF MA was 8.3 versus 12.2. All intraoperator CVs were significantly lower for ROTEM analyses compared with TEG (p<0.01). CV for INTEM S CT/kaolin r time was 3.1 versus 9.8 and MCF/ MA was 1.6 versus 4. Similarly, FIBTEM S MCF/ MA was 6.9 versus 12.1. CONCLUSIONS: This series of results suggested ROTEM analyses are more reproducible than TEG and, consequently, that ROTEM may be better suited for use in a multiuser environment.

Care planning for children with lower limb amputation.

This article explores the pathways of care for children who undergo lower limb amputation, from pre-surgery to rehabilitation. The consequences of surgery are manifold, including that children and their families must cope with life with a disability, effects on mobility, greater demands on metabolic reserve, disfigurement, pain and discomfort. Care can be divided into multidisciplinary pre-operative, post-operative, mid-term rehabilitation, including prosthetic limb casting and fitting, and long-term rehabilitation over many weeks and years. The involvement of the multidisciplinary team as the child progresses is described. It is recommended that care should be co-ordinated by a nominated lead professional. Effective discharge planning is crucial to a successful transition home and continuing rehabilitation.

Effects of dynavision training as a preparatory intervention status postcerebrovascular accident: a case report.

ABSTRACT Objective. This is a case study of a 67-year-old woman, status post right hemispheric ischemic lesion cerebrovascular accident (CVA), and her use of Dynavision training as a preparatory intervention to determine its influence on her performance skills and perceived occupational performance. Method. The participant engaged in 6 weeks of Dynavision intervention, 3 days per week. The participant was evaluated using a broad battery of assessments at pretest and posttest. Outcome measures included the Action Research Arm Test (ARAT), Canadian Occupational Performance Measure (COPM), and goniometric active range of motion (AROM) measurements for the upper extremity. Standing activity tolerance during engagement in occupations also was assessed. A qualitative interview was employed to ascertain the participant's perceptions of how Dynavision training influenced her performance in activities of daily living (ADL) and instrumental activities of daily living (IADL). Results. Improvements in performance skills, perceived occupational performance, and perceived satisfaction with engagement in occupation were noted. The participant demonstrated improved AROM, functional activity tolerance, and greater awareness of the neglected side. Qualitative interviews revealed that the participant's satisfaction and confidence with ADL and IADL tasks improved at the time of posttest. Conclusion. Data suggest positive effects of Dynavision intervention when used with an individual status post-CVA.

Blood conservation in cardiac surgery.

Cardiac surgery is one of the largest users of blood and blood products--currently estimated at 15% of U.K. blood stocks. While the blood supply could be considered to be the safest it has ever been, there are well recognised risks associated with the transfusion of red cells and blood products. It is appropriate that attempts should be made to decrease and optimise the transfusion of blood and blood products.

Respiratory function in rats restrained for extended periods: assessment of the effects of bethanecol.

INTRODUCTION: The ICH guideline S7A recommends that the effects of drugs on the respiratory system are evaluated in laboratory mammals prior to administration in man. Previously, animals have been placed in plethysmography chambers for short durations. This study investigates the possibility of restraining animals in chambers for a longer duration to assess respiratory function over extended periods. METHODS: Respiratory function in conscious rats was assessed using plethysmography chambers where the rat body was enclosed in a sealed chamber while the head was free. Thoracic movements were measured by pressure transducers linked to a Buxco amplifier system and respiratory parameters were captured and analyzed by the Notocord HEM data acquisition system. Each animal was subjected to 5 acclimatization sessions of escalating duration (1, 2, 4, 5, and 6 hours (h)) over 5 days prior to testing, with a baseline recording session conducted the day prior to dosing. Animals (8 males/group) were dosed subcutaneously with saline or bethanecol (3, 10, or 30 mg/kg) and placed in the chambers for 6 h of continuous recording. Additionally, a recording session was conducted at 24 h post-dose. RESULTS: Subcutaneous administration of 30 mg/kg bethanecol decreased respiration rate by up to 33% during the first 1.5 h post-dose and increased tidal volume by up to 46% from 0.25 to 1.25 h post-dose when compared to vehicle group data. A decrease in minute volume of up to 33% was observed 0.25 h following administration of the 10 and 30 mg/kg doses. DISCUSSION: These data show a respiratory depression caused by the cholinergic agonist bethanecol, an effect partially compensated for by an increase in tidal volume. This also demonstrates the ability to continuously restrain and record respiratory parameters in conscious rats for up to 6 h without any negative impact on the quality of the data.

The effect of regional cooling on toxicity associated with intravenous infusion of pegylated liposomal doxorubicin in recurrent ovarian carcinoma.

OBJECTIVE: The purpose of this study is to determine if regional cooling reduces palmar-plantar erythrodysesthesia (PPE) associated with intravenous infusion of pegylated liposomal doxorubicin (PLD). METHODS: A retrospective review over 3 years identified 20 women who were treated with single-agent intravenous PLD for recurrent ovarian carcinoma. During PLD infusion, patients kept ice packs around their wrists and ankles, and consumed iced liquids. These steps were continued for 24 h after completion of chemotherapy. All patients were instructed not to ingest hot food or liquids, to avoid contact with hot water, and to minimize friction on the hands and feet for 72 h posttreatment. RESULTS: Seventeen of the twenty patients (85%) followed the regional cooling protocol, and three of twenty (15%) did not. In the group who underwent regional cooling, 16/17 (94%) had none to mild PPE (grades 0-2), and 1/17 (6%) had moderate to severe PPE (grades 3-4). Of the three patients without regional cooling, 1/3 (33%) had grades 0-2 PPE and 2/3 (67%) had grades 3-4 PPE (P = 0.047). CONCLUSIONS: Regional cooling may reduce the frequency and severity of PPE associated with intravenous PLD infusion for recurrent ovarian carcinoma. Prospective, randomized evaluation is needed to confirm this observation.