Noninvasive Ventilation in the Cardiac Intensive Care Unit.

Over the last several decades, the cardiac intensive care unit (CICU) has seen an increase in the complexity of the patient population and etiologies requiring CICU admission. Currently, respiratory failure is the most common reason for admission to the contemporary CICU. As a result, noninvasive ventilation (NIV), including noninvasive positive-pressure ventilation and high-flow nasal cannula, has been increasingly utilized in the management of patients admitted to the CICU. In this review, we detail the different NIV modalities and summarize the evidence supporting their use in conditions frequently encountered in the CICU. We describe the unique pathophysiologic interactions between positive pressure ventilation and left and/or right ventricular dysfunction. Additionally, we discuss the evidence and strategies for utilization of NIV as a method to reduce extubation failure in patients who required invasive mechanical ventilation. Lastly, we examine unique considerations for managing respiratory failure in certain, high-risk patient populations such as those with right ventricular failure, severe valvular disease, and adult congenital heart disease. Overall, it is critical for clinicians who practice in the CICU to be experts with the application, risks, benefits, and modalities of NIV in cardiac patients with respiratory failure.

Propofol vs etomidate for induction prior to invasive mechanical ventilation in patients with acute myocardial infarction.

BACKGROUND: Patients with acute myocardial infarction (AMI) requiring invasive mechanical ventilation (IMV) have a high mortality. However, little is known regarding the impact of induction agents, used prior to IMV, on clinical outcomes in this population. We assessed for the association between induction agent and mortality in patients with AMI requiring IMV. METHODS: We compared clinical outcomes between those receiving propofol compared to etomidate for induction among adults with AMI between October 2015 and December 2019 using the Vizient® Clinical Data Base, a multicenter, US national database. We used inverse probability treatment weighting (IPTW) to assess for the association between induction agent and in-hospital mortality. RESULTS: We identified 5,147 patients, 1,386 (26.9%) of received propofol and 3,761 (73.1%) received etomidate for IMV induction. The mean (SD) age was 66.1 (12.4) years, 33.0% were women, and 51.6% and 39.8% presented with STEMI and cardiogenic shock, respectively. Patients in the propofol group were more likely to require preintubation vasoactive medication and mechanical circulatory support (both, P < .05). Utilization of propofol was associated with lower mortality compared to etomidate (32.3% vs 36.1%, P = .01). After propensity weighting, propofol use remained associated with lower mortality (weighted mean difference -4.7%; 95% confidence interval: -7.6% to -1.8%, P = .002). Total cost, ventilator days, and length of stay were higher in the propofol group (all, P < .001). CONCLUSIONS: Induction with propofol, compared with etomidate, was associated with lower mortality for patients with AMI requiring IMV. Randomized trials are needed to determine the optimal induction agent for this critically ill patient population.

A pilot clinical trial of the Screening and Tool for Awareness and Relief of Trauma for survivors of gun violence.

BACKGROUND: Survivors of gun violence have significant sequelae including reinjury with a firearm and mental health disorders that often go undiagnosed and untreated. The Screening and Tool for Awareness and Relief of Trauma (START) is a targeted behavioral mental health intervention developed for patients who come from communities of color with sustained and persistent trauma. METHODS: In this pilot study, we evaluate the feasibility of completing a randomized controlled trial to test the START intervention. Using a mixed methods study design, we used both quantitative and qualitative data collection to assess the START intervention and the feasibility of completing a randomized controlled trial. The purpose of this study was to estimate important study parameters that would enable a future randomized controlled trial. RESULTS: We were able to make conclusions about several crucial domains of a behavioral intervention trial: (1) recruitment and retention-we had a high follow-up rate, but our recruitment was low (34% of eligible participants); (2) acceptability of the intervention-the addition of audiovisual resources would make the tools more accessible; (3) feasibility of the control-more appropriate for a stepped wedge cluster randomized controlled trial design; (4) intervention fidelity-there was an 81% concordance rate between the fidelity survey results and the audio recordings; (5) approximate effect size-there was a 0.4-point decrease in the PTSD Checklist-Civilian Version in the control compared with a 10.7-point decrease in the treatment group for the first month. CONCLUSION: While it was feasible to conduct a randomized controlled trial, our findings suggest that a stepped wedge cluster randomized controlled trial design may be the most successful trial design for the START intervention. In addition, the inclusion of a "credible messenger" to recruit participants into the study and the development of audiovisual resources for START would improve recruitment and effectiveness. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Implementation of an emerging hospital-based violence intervention program: a multimethod study.

Background: Individuals who experience assaultive firearm injury are at elevated risk for violent reinjury and multiple negative physical and psychological health outcomes. Hospital-based violence intervention programs (HVIPs) may improve patient outcomes through intensive, community-based case management. Methods: We conducted a multimethod evaluation of an emerging HVIP at a large trauma center using the RE-AIM framework. We assessed recruitment, violent reinjury outcomes, and service provision from 2020 to 2022. Semistructured, qualitative interviews were performed with HVIP participants and program administrators to elicit experiences with HVIP services. Directed content analysis was used to generate and organize codes from the data. We also conducted clinician surveys to assess awareness and referral patterns. Results: Of the 319 HVIP-eligible individuals who presented with non-fatal assaultive firearm injury, 39 individuals (12%) were enrolled in the HVIP. Inpatient admission was independently associated with HVIP enrollment (OR 2.6, 95% CI 1.3 to 5.2; p=0.01). Facilitators of Reach included engaging with credible messengers, personal relationships with HVIP program administrators, and encouragement from family to enroll. Fear of disclosure to police was cited as a key barrier to enrollment. For the Effectiveness domain, enrollment was not associated with reinjury (OR 0.70, 95% CI 0.16 to 3.1). Participants identified key areas of focus where needs were not met including housing and mental health. Limited awareness of HVIP services was a barrier to Adoption. Participants described strengths of Implementation, highlighting the deep relationships built between clients and administrators. For the long-term Maintenance of the program, both clinicians and HVIP clients reported that there is a need for HVIP services for individuals who experience violent injury. Conclusions: Credible messengers facilitate engagement with potential participants, whereas concerns around police involvement is an important barrier. Inpatient admission provides an opportunity to engage patients and may facilitate recruitment. HVIPs may benefit from increased program intensity. Level of evidence: IV.

Community distress and risk of adverse outcomes after peripheral vascular intervention.

INTRODUCTION: Community distress is associated with adverse outcomes in patients with cardiovascular disease; however, its impact on clinical outcomes after peripheral vascular intervention (PVI) is uncertain. The Distressed Communities Index (DCI) is a composite measure of community distress measured at the zip code level. We evaluated the association between community distress, as measured by the DCI, and 24-month mortality and major amputation after PVI. METHODS: We used the Vascular Quality Initiative database, linked with Medicare claims data, to identify patients who underwent initial femoropopliteal PVI between 2017 and 2018. DCI scores were assigned using patient-level zip code data. The primary outcomes were 24-month mortality and major amputation. We used time-dependent receiver operating characteristic curve analysis to determine an optimal DCI value to stratify patients into risk categories for 24-month mortality and major amputation. Mixed Cox regression models were constructed to estimate the association of DCI with 24-month mortality and major amputation. RESULTS: The final cohort consisted of 16,864 patients, of whom 4734 (28.1%) were classified as having high community distress (DCI ≥70). At 24 months, mortality was elevated in patients with high community distress (30.7% vs 29.5%, P = .02), as was major amputation (17.2% vs 13.1%, P <.001). After adjusting for demographic and clinical characteristics, a 10-point higher DCI score was associated with increased risk of mortality (hazard ratio: 1.01; 95% confidence interval: 1.00-1.03) and major amputation (hazard ratio: 1.02; 95% confidence interval: 1.00-1.04). CONCLUSIONS: High community distress is associated with increased risk of mortality and major amputation after PVI.

Parental attitudes, beliefs, and practices related to firearm storage: a qualitative study.

BACKGROUND: Firearm injury is a leading cause of death among children. Safer firearm storage practices are associated with a reduced risk of childhood suicide and unintentional firearm death. However, these practices are underutilized. The objective of this study was to characterize parental attitudes and beliefs related to firearm storage and identify facilitators and barriers to safer storage practices. METHODS: Semi-structured, qualitative interviews were conducted to identify motivations for using different storage methods among parents who kept firearms in southern Connecticut. The constant comparative method was used to code interview transcripts and derive themes directly from the data. RESULTS: Twenty participants completed the study. 60% were male, 90% were white, and all were between 32 and 53 years old. 85% of participants stored firearms locked, 60% unloaded, 65% kept ammunition locked or did not keep ammunition in their home, and 45% stored ammunition separate from firearms. The following themes were identified: (1) firearm storage must be compatible with a specific context of use; (2) some parents engage in higher-risk storage because they believe it is adequate to reduce the risk of injury; (3) firearm practices are influenced by one's social network and lived experience; (4) parents who own firearms may be amenable to changing storage practices; and (5) parents' conceptualization of firearm injury prevention is multimodal, involving storage, education, and legislation. CONCLUSIONS: Parents who keep firearms value convenience and utility, which may be at odds with safer storage practices; however, some may be amenable to adopting safer practices. Family and peer relationships, education, and legislation represent important facilitators of storage practices. Understanding parental attitudes and beliefs on firearm storage may inform future interventions to improve storage practices.

"I can't do it": A qualitative study exploring case and contact experiences with COVID-19 contact tracing.

BACKGROUND: Low engagement in contact tracing for COVID-19 dramatically reduces its impact, but little is known about how experiences, environments and characteristics of cases and contacts influence engagement. METHODS: We recruited a convenience sample of COVID-19 cases and contacts from the New Haven Health Department's contact tracing program for interviews about their contact tracing experiences. We analyzed transcripts thematically, organized themes using the Capability, Opportunity, Motivation, Behavior (COM-B) model, and identified candidate interventions using the linked Behavior Change Wheel Framework. RESULTS: We interviewed 21 cases and 12 contacts. Many felt physically or psychologically incapable of contact tracing participation due to symptoms or uncertainty about protocols. Environmental factors and social contacts also influenced engagement. Finally, physical symptoms, emotions and low trust in and expectations of public health authorities influenced motivation to participate. CONCLUSION: To improve contact tracing uptake, programs should respond to clients' physical and emotional needs; increase clarity of public communications; address structural and social factors that shape behaviors and opportunities; and establish and maintain trust. We identify multiple potential interventions that may help achieve these goals.

Lessons Learned From COVID-19 Contact Tracing During a Public Health Emergency: A Prospective Implementation Study.

Background: Contact tracing is a core element of the public health response to emerging infectious diseases including COVID-19. Better understanding the implementation context of contact tracing for pandemics, including individual- and systems-level predictors of success, is critical to preparing for future epidemics. Methods: We carried out a prospective implementation study of an emergency volunteer contact tracing program established in New Haven, Connecticut between April 4 and May 19, 2020. We assessed the yield and timeliness of case and contact outreach in reference to CDC benchmarks, and identified individual and programmatic predictors of successful implementation using multivariable regression models. We synthesized our findings using the RE-AIM implementation framework. Results: Case investigators interviewed only 826 (48%) of 1,705 cases and were unable to reach 545 (32%) because of incomplete information and 334 (20%) who missed or declined repeated outreach calls. Contact notifiers reached just 687 (28%) of 2,437 reported contacts, and were unable to reach 1,597 (66%) with incomplete information and 153 (6%) who missed or declined repeated outreach calls. The median time-to-case-interview was 5 days and time-to-contact-notification 8 days. However, among notified contacts with complete time data, 457 (71%) were reached within 6 days of exposure. The least likely groups to be interviewed were elderly (adjusted relative risk, aRR 0.74, 95% CI 0.61-0.89, p = 0.012, vs. young adult) and Black/African-American cases (aRR 0.88, 95% CI 0.80-0.97, pairwise p = 0.01, vs. Hispanic/Latinx). However, ties between cases and their contacts strongly influenced contact notification success (Intraclass Correlation Coefficient (ICC) 0.60). Surging caseloads and high volunteer turnover (case investigator n = 144, median time from sign-up to retirement from program was 4 weeks) required the program to supplement the volunteer workforce with paid public health nurses. Conclusions: An emergency volunteer-run contact tracing program fell short of CDC benchmarks for time and yield, largely due to difficulty collecting the information required for outreach to cases and contacts. To improve uptake, contact tracing programs must professionalize the workforce; better integrate testing and tracing services; capitalize on positive social influences between cases and contacts; and address racial and age-related disparities through enhanced community engagement.

Penetrating deep pelvic injury due to "less-lethal" beanbag munitions: a case report and policy implications.

"Less-lethal" munitions are designed to cause incapacitation and are often used by law enforcement officers. Although these munitions are not designed to cause severe injury, recent reports have demonstrated that they can cause severe injury, permanent disability, and death. The long-term consequences of injury due to less-lethal munitions are not well understood. We present a case of osteomyelitis and pelvic abscess secondary to a retained beanbag munition following penetrating injury in the setting of a patient with delayed presentation for care. The patient underwent surgical removal of the retained beanbag munition and irrigation and debridement of the osteomyelitis and pelvic abscess with an excellent functional outcome. We discuss the public health and policy implications of serious injury due to less-lethal munitions.

Implementation of a volunteer contact tracing program for COVID-19 in the United States: A qualitative focus group study.

BACKGROUND: Contact tracing is an important tool for suppressing COVID-19 but has been difficult to adapt to the conditions of a public health emergency. This study explored the experiences and perspectives of volunteer contact tracers in order to identify facilitators, challenges, and novel solutions for implementing COVID-19 contact tracing. METHODS: As part of a study to evaluate an emergently established volunteer contact tracing program for COVID-19 in New Haven, Connecticut, April-June 2020, we conducted focus groups with 36 volunteer contact tracers, thematically analyzed the data, and synthesized the findings using the RE-AIM implementation framework. RESULTS: To successfully reach cases and contacts, participants recommended identifying clients' outreach preferences, engaging clients authentically, and addressing sources of mistrust. Participants felt that the effectiveness of successful isolation and quarantine was contingent on minimizing delays in reaching clients and on systematically assessing and addressing their nutritional, financial, and housing needs. They felt that successful adoption of a volunteer-driven contact tracing model depended on the ability to recruit self-motivated contact tracers and provide rapid training and consistent, supportive supervision. Participants noted that implementation could be enhanced with better management tools, such as more engaging interview scripts, user-friendly data management software, and protocols for special situations and populations. They also emphasized the value of coordinating outreach efforts with other involved providers and agencies. Finally, they believed that long-term maintenance of a volunteer-driven program requires monetary or educational incentives to sustain participation. CONCLUSIONS: This is one of the first studies to qualitatively examine implementation of a volunteer-run COVID-19 contact tracing program. Participants identified facilitators, barriers, and potential solutions for improving implementation of COVID-19 contact tracing in this context. These included standardized communication skills training, supportive supervision, and peer networking to improve implementation, as well as greater cooperation with outside agencies, flexible scheduling, and volunteer incentives to promote sustainability.

Community Trace: Rapid Establishment of a Volunteer Contact Tracing Program for COVID-19.

Contact tracing was one of the core public health strategies implemented during the first months of the COVID-19 pandemic. In this essay, we describe the rapid establishment of a volunteer contact tracing program in New Haven, Connecticut. We describe successes of the program and challenges that were faced. Going forward, contact tracing efforts can best be supported by increased funding to state and local health departments for a stable workforce and use of evidence-based technological innovations.

Prevention of Firearm Injury through Policy and Law: The Social Ecological Model.

Rates of firearm injury and mortality are far higher in the United States compared to other high-income nations. Patterns of firearm injury have complex causal pathways; different social contexts may be differentially affected by firearm legislation. In the context of the diversity of social, political, and legal approaches at the state level, we suggest the application of the social ecological model as a conceptual public health framework to guide future policy interventions in the U.S.

Haptic biofeedback induces changes in ankle push-off during walking.

BACKGROUND: Ankle push-off drives forward progression during gait. Reduced peak ankle moment and peak ankle power may contribute to the increased metabolic cost of walking observed in certain clinical populations. Biofeedback is an effective gait training tool, however biofeedback targeting ankle moment has not been previously studied. RESEARCH QUESTION: Does haptic biofeedback directly targeting ankle moment enable able-bodied adults to modulate peak ankle moment during gait? METHODS: 20 able-bodied adults participated in the study. Participants completed a 90-second baseline walking trial, followed by two 2-minute trials with haptic biofeedback. Haptic biofeedback guided participants to either increase peak ankle moment (Feedback High), or decrease peak ankle moment (Feedback Low). Ten participants received haptic biofeedback alone; the other ten participants additionally received verbal suggestions of movement strategies they could adopt during the biofeedback trials. Two-way analysis of variance was used to determine the effect of walking condition and verbal instruction on key gait parameters. RESULTS: A main effect of walking condition on peak ankle moment and peak ankle power was observed (all P < 0.001). Peak ankle moment did not change from baseline during Feedback High, however peak ankle power was increased (P < 0.001). A decrease in peak ankle moment and peak ankle power was observed during Feedback Low (all P < 0.001). Verbal instruction had a significant interaction effect with walking condition in only a limited number of parameters (all P < 0.05). SIGNIFICANCE: This study demonstrates the effects of haptic biofeedback targeting peak ankle moment during gait. While this study demonstrates that able-bodied individuals have some capacity to modulate their gait pattern in response to direct biofeedback on ankle moment, further investigation is required to develop a biofeedback paradigm that can increase peak ankle moment.

Effects of real-time gait biofeedback on paretic propulsion and gait biomechanics in individuals post-stroke.

Objectives Gait training interventions that target paretic propulsion induce improvements in walking speed and function in individuals post-stroke. Previously, we demonstrated that able-bodied individuals increase propulsion unilaterally when provided real-time biofeedback targeting anterior ground reaction forces (AGRF). The purpose of this study was to, for the first time, investigate short-term effects of real-time AGRF gait biofeedback training on post-stroke gait. Methods Nine individuals with post-stroke hemiparesis (6 females, age = 54 ± 12.4 years 39.2 ± 24.4 months post-stroke) completed three 6-minute training bouts on an instrumented treadmill. During training, visual and auditory biofeedback were provided to increase paretic AGRF during terminal stance. Gait biomechanics were evaluated before training, and during retention tests conducted 2, 15, and 30 minutes post-training. Primary dependent variables were paretic and non-paretic peak AGRF; secondary variables included paretic and non-paretic peak trailing limb angle, plantarflexor moment, and step length. In addition to evaluating the effects of biofeedback training on these dependent variables, we compared effects of a 6-minute biofeedback training bout to a non-biofeedback control condition. Results Compared to pre-training, significantly greater paretic peak AGRFs were generated during the 2, 15, and 30-minute retention tests conducted after the 18-minute biofeedback training session. Biofeedback training induced no significant effects on the non-paretic leg. Comparison of a 6-minute biofeedback training bout with a speed-matched control bout without biofeedback demonstrated a main effect for training type, with greater peak AGRF generation during biofeedback. Discussion Our results suggest that AGRF biofeedback may be a feasible and promising gait training strategy to target propulsive deficits in individuals post-stroke.

Effects of unilateral real-time biofeedback on propulsive forces during gait.

BACKGROUND: In individuals with post-stroke hemiparesis, reduced push-off force generation in the paretic leg negatively impacts walking function. Gait training interventions that increase paretic push-off can improve walking function in individuals with neurologic impairment. During normal locomotion, push-off forces are modulated with variations in gait speed and slope. However, it is unknown whether able-bodied individuals can selectively modulate push-off forces from one leg in response to biofeedback. Here, in a group of young, neurologically-unimpaired individuals, we determined the effects of a real-time visual and auditory biofeedback gait training paradigm aimed at unilaterally increasing anteriorly-directed ground reaction force (AGRF) in the targeted leg. METHODS: Ground reaction force data during were collected from 7 able-bodied individuals as they walked at a self-selected pace on a dual-belt treadmill instrumented with force platforms. During 11-min of gait training, study participants were provided real-time AGRF biofeedback encouraging a 20-30% increase in peak AGRF generated by their right (targeted) leg compared to their baseline (pre-training) AGRF. AGRF data were collected before, during, and after the biofeedback training period, as well as during two retention tests performed without biofeedback and after standing breaks. RESULTS: Compared to AGRFs generated during the pre-training gait trials, participants demonstrated a significantly greater AGRF in the targeted leg during and immediately after training, indicating that biofeedback training was successful at inducing increased AGRF production in the targeted leg. Additionally, participants continued to demonstrate greater AGRF production in the targeted leg after two standing breaks, showing short-term recall of the gait pattern learned during the biofeedback training. No significant effects of training were observed on the AGRF in the non-targeted limb, showing the specificity of the effects of biofeedback toward the targeted limb. CONCLUSIONS: These results demonstrate the short-term effects of using unilateral AGRF biofeedback to target propulsion in a specific leg, which may have utility as a training tool for individuals with gait deficits such as post-stroke hemiparesis. Future studies are needed to investigate the effects of real-time AGRF biofeedback as a gait training tool in neurologically-impaired individuals.