Analgesia and Sedation Use During Noninvasive Ventilation for Acute Respiratory Failure.

OBJECTIVES: To describe U.S. practice regarding administration of sedation and analgesia to patients on noninvasive ventilation (NIV) for acute respiratory failure (ARF) and to determine the association of this practice with odds of intubation or death. DESIGN: A retrospective multicenter cohort study. SETTING: A total of 1017 hospitals contributed data between January 2010 and September 2020 to the Premier Healthcare Database, a nationally representative healthcare database in the United States. PATIENTS: Adult (≥ 18 yr) patients admitted to U.S. hospitals requiring NIV for ARF. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 433,357 patients on NIV of whom (26.7% [95% CI] 26.3%-27.0%) received sedation or analgesia. A total of 50,589 patients (11.7%) received opioids only, 40,646 (9.4%) received benzodiazepines only, 20,146 (4.6%) received opioids and benzodiazepines, 1.573 (0.4%) received dexmedetomidine only, and 2,639 (0.6%) received dexmedetomidine in addition to opioid and/or benzodiazepine. Of 433,357 patients receiving NIV, 50,413 (11.6%; 95% CI, 11.5-11.7%) patients underwent invasive mechanical ventilation on hospital days 2-5 or died on hospital days 2-30. Intubation was used in 32,301 patients (7.4%; 95% CI, 7.3-7.6%). Further, death occurred in 24,140 (5.6%; 95% CI, 5.5-5.7%). In multivariable analysis adjusting for relevant covariates, receipt of any medication studied was associated with increased odds of intubation or death. In inverse probability weighting, receipt of any study medication was also associated with increased odds of intubation or death (average treatment effect odds ratio 1.38; 95% CI, 1.35-1.40). CONCLUSIONS: The use of sedation and analgesia during NIV is common. Medication exposure was associated with increased odds of intubation or death. Further investigation is needed to confirm this finding and determine whether any subpopulations are especially harmed by this practice.

Routine Emergency Department Screening to Decrease Subsequent Physical Abuse.

STUDY OBJECTIVE: Emergency department (ED) screening for child physical abuse has been widely implemented, with uncertain effects on child abuse identification. Our goal was to determine the effect of screening on referrals to child protective services (CPS) identifying abuse. METHODS: We performed a retrospective cohort study of children younger than 6 years old with an ED encounter at 1 of 2 large health care systems, one of which implemented routine child abuse screening. The main outcome was initial (<2 days) or subsequent (3 to 180 days) referral to CPS identifying child abuse using linked records. We compared outcomes for the 2-year period after screening was implemented to the preperiod and nonscreening EDs using generalized estimating equations to adjust for sex, age, race/ethnicity, payor and prior ED encounters and clustered by center. RESULTS: Of the 331,120 ED encounters, 41,589 (12.6%) occurred at screening EDs during the screening period. Screening was completed in 34,272 (82%) and was positive in 188 (0.45%). Overall, 7,623 encounters (2.3%) had a subsequent referral, of which 589 (0.2%) identified moderate or severe abuse. ED screening did not change initial (adjusted odds ratio [aOR]=1.01, 95% confidence interval [CI] 0.89 to 1.15) or subsequent referral to CPS when compared to the prescreening period (aOR=1.05, 95% CI 0.9 to 1.18) or to the nonscreening EDs (aOR=1.06, 95% CI 0.92 to 1.21). CONCLUSION: Routine screening did not affect initial or subsequent referrals to CPS.

Streaming Success: Harnessing Social Media for Dynamic Radiology Education.

Social media are increasingly used as tools in radiologists education. This article describes features that aid with the selection of SM platforms, and how to emulate educator roles in the digital world. In addition, we summarize best practices regarding curating and delivering stellar content, building a SM brand, and rules of professionalism when using SM in radiology education.

A Verbal De-escalation Standardized Patient Workshop for Third- and Fourth-Year Medical Students.

Introduction: Verbal de-escalation is an essential skill for physicians across specialties and is the first-line intervention for patients who present with agitation. Training in verbal de-escalation for medical students is less robust compared to other health care disciplines. We describe the creation and evaluation of a novel verbal de-escalation curriculum for third- and fourth-year medical students on their psychiatry clerkship rotation. Method: We developed a simulation using standardized patient (SP) methodology and a dedicated reflection session, implementing it in the third-year psychiatry clerkship. Participants in the scenario received targeted feedback from their peers and SPs. The sessions were video recorded, and a random sample was selected and reviewed to identify key observations and themes from student performance. Results: A total of 139 students participated in the encounter. One hundred twenty-two of 125 students (82%) stated the activity met the learning objectives, with 108 (86%) assigning the letter grade A to the activity. Written feedback indicated that the majority of students believed the activity to be realistic, instructive, and helpful but felt the SPs de-escalated too quickly. Video review of the encounters found that while the students effectively used the skills, many jumped to a quick fix, and some offered inappropriate choices to end the encounter. Discussion: This SP activity was effective in allowing students to practice skills in a safe setting and was valued by students. In the future, adding another workshop in the fourth year could facilitate higher retention and practice of skills.

Health at Home: Investigating Low-Income Housing Quality on Colfax Avenue.

Addressing housing insecurity contributes to health care programs as stable housing has positive health benefits. Home environmental hazards may reduce these potential health benefits and could increase morbidity for conditions such as asthma. This study examined housing and indoor air quality among urban low-income households in Colorado to inform housing-insecurity interventions. We conducted a community-engaged study among residents of motels, mobile homes, apartments, and single-family homes that included a survey on the home environment, health, and sociodemographic factors, spirometry, and indoor air quality measurement. We enrolled 60 households: 50% single-family homes, 37% apartments, and 13% residential motels. Perceived stress and depression were higher among motel residents compared with other housing types. We did not find differences in lung function by housing type. Indoor fine particulate matter (PM2.5) and black carbon concentrations were higher in motels than in other housing types. The differential health impacts of housing type support housing programs that jointly address security and quality.

Training the New Radiologists: Approaches for Education.

The field of Radiology is continually changing, requiring corresponding evolution in both medical student and resident training to adequately prepare the next generation of radiologists. With advancements in adult education theory and a deeper understanding of perception in imaging interpretation, expert educators are reshaping the training landscape by introducing innovative teaching methods to align with increased workload demands and emerging technologies. These include the use of peer and interdisciplinary teaching, gamification, case repositories, flipped-classroom models, social media, and drawing and comics. This publication aims to investigate these novel approaches and offer persuasive evidence supporting their incorporation into the updated Radiology curriculum.

Prevalence of Alcohol Use Characterized by Phosphatidylethanol in Patients With Respiratory Failure Before and During the COVID-19 Pandemic.

BACKGROUND: Alcohol misuse is overlooked frequently in hospitalized patients, but is common among patients with pneumonia and acute hypoxic respiratory failure. Investigations in hospitalized patients rely heavily on self-report surveys or chart abstraction, which lack sensitivity. Therefore, our understanding of the prevalence of alcohol misuse before and during the COVID-19 pandemic is limited. RESEARCH QUESTION: In critically ill patients with respiratory failure, did the proportion of patients with alcohol misuse, defined by the direct biomarker phosphatidylethanol, vary over a period including the COVID-19 pandemic? STUDY DESIGN AND METHODS: Patients with acute hypoxic respiratory failure receiving mechanical ventilation were enrolled prospectively from 2015 through 2019 (before the pandemic) and from 2020 through 2022 (during the pandemic). Alcohol use data, including Alcohol Use Disorders Identification Test (AUDIT)-C scores, were collected from electronic health records, and phosphatidylethanol presence was assessed at ICU admission. The relationship between clinical variables and phosphatidylethanol values was examined using multivariable ordinal regression. Dichotomized phosphatidylethanol values (≥ 25 ng/mL) defining alcohol misuse were compared with AUDIT-C scores signifying misuse before and during the pandemic, and correlations between log-transformed phosphatidylethanol levels and AUDIT-C scores were evaluated and compared by era. Multiple imputation by chained equations was used to handle missing phosphatidylethanol data. RESULTS: Compared with patients enrolled before the pandemic (n = 144), patients in the pandemic cohort (n = 92) included a substantially higher proportion with phosphatidylethanol-defined alcohol misuse (38% vs 90%; P < .001). In adjusted models, absence of diabetes, positive results for COVID-19, and enrollment during the pandemic each were associated with higher phosphatidylethanol values. The correlation between health care worker-recorded AUDIT-C score and phosphatidylethanol level was significantly lower during the pandemic. INTERPRETATION: The higher prevalence of phosphatidylethanol-defined alcohol misuse during the pandemic suggests that alcohol consumption increased during this period, identifying alcohol misuse as a potential risk factor for severe COVID-19-associated respiratory failure. Results also suggest that AUDIT-C score may be less useful in characterizing alcohol consumption during high clinical capacity.

Extraneous Load, Patient Census, and Patient Acuity Correlate With Cognitive Load During ICU Rounds.

BACKGROUND: Cognitive load theory asserts that learning and performance degrade when cognitive load exceeds working memory capacity. This is particularly relevant in the learning environment of ICU rounds, when multidisciplinary providers integrate complex decision-making and teaching in a noisy, high-stress environment prone to cognitive distractions. RESEARCH QUESTION: What features of ICU rounds correlate with high provider cognitive load? STUDY DESIGN AND METHODS: This was an observational, multisite study of multidisciplinary providers during ICU rounds. Investigators recorded rounding characteristics and hourly extraneous cognitive load events during rounds (defined as distractions, episodes of split-attention or repetition, and deviations from standard communication format). After rounds, investigators measured each provider's cognitive load using the provider task load (PTL), an instrument derived from the National Aeronautics and Space Administration Task Load Index survey that assesses perceived workload associated with complex tasks. Relationships between rounding characteristics, extraneous load, and PTL score were evaluated using mixed-effects modeling. RESULTS: A total of 76 providers were observed during 32 rounds from December 2020 to May 2021. The mean rounding census ± SD was 12.5 ± 2.9 patients. The mean rounding time ± SD was 2 h 17 min ± 49 min. The mean extraneous load ± SD was 20.5 ± 4.5 events per hour, or one event every 2 min 51 s. This included 8.6 ± 3.4 distractions, 8.2 ± 4.2 communication deviations, 1.9 ± 1.4 repetitions, and 1.8 ± 1.3 episodes of split-attention per hour. Controlling for covariates, the hourly extraneous load events, number of new patients, and number of higher acuity patients were each associated with increased PTL score (slope, 2.40; 95% CI, 0.76-4.04; slope, 5.23; 95% CI, 2.02-8.43; slope, 3.35; 95% CI, 1.34-5.35, respectively). INTERPRETATION: Increased extraneous load, new patients, and patient acuity were associated with higher cognitive load during ICU rounds. These results can help direct how the ICU rounding structure may be modified to reduce workload and optimize provider learning and performance.

The effects of oxygenation on acute vasodilator challenge in pulmonary arterial hypertension.

Identification of long-term calcium channel blocker (CCB) responders with acute vasodilator challenge is critical in the evaluation of patients with pulmonary arterial hypertension. Currently there is no standardized approach for use of supplemental oxygen during acute vasodilator challenge. In this retrospective analysis of patients identified as acute vasoresponders, treated with CCBs, all patients had hemodynamic measurements in three steps: (1) at baseline; (2) with 100% fractional inspired oxygen; and (3) with 100% fractional inspired oxygen plus inhaled nitric oxide (iNO). Those meeting the definition of acute vasoresponsiveness only after first normalizing for the effects of oxygen in step 2 were labeled "iNO Responders." Those who met the definition of acute vasoresponsiveness from a combination of the effects of 100% FiO2 and iNO were labeled "oxygen responders." Survival, hospitalization for decompensated right heart failure, duration of CCB monotherapy, and functional data were collected. iNO responders, when compared to oxygen responders, had superior survival (100% vs. 50.1% 5-year survival, respectively), fewer hospitalizations for acute decompensated right heart failure (0% vs. 30.4% at 1 year, respectively), longer duration of CCB monotherapy (80% vs. 52% at 1 year, respectively), and superior 6-min walk distance. Current guidelines for acute vasodilator testing do not standardize oxygen coadministration with iNO. This study demonstrates that adjusting for the effects of supplemental oxygen before assessing for acute vasoresponsiveness identifies a cohort with superior functional status, tolerance of CCB monotherapy, and survival while on long-term CCB therapy.