Chest
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Randomized Controlled Trial
Acute Effect of an Inhaled Glucocorticosteroid on Albuterol-induced Bronchodilation in Patients with Moderately Severe Asthma.
We have previously shown that in patients with asthma a single dose of an inhaled glucocorticosteroid (ICS) acutely potentiates inhaled albuterol-induced airway vascular smooth muscle relaxation through a nongenomic action. An effect on airway smooth muscle was not seen, presumably because the patients had normal lung function. The purpose of the present study was to conduct a similar study in patients with asthma with airflow obstruction to determine if an ICS could acutely also potentiate albuterol-induced airway smooth muscle relaxation in them. ⋯ This pilot study showed that in adult patients with asthma with airflow obstruction, a single standard dose of an ICS can acutely increase the FEV1 response to a standard dose of inhaled albuterol administered simultaneously. The associated potentiation of albuterol-induced vasodilation in the airway was of greater magnitude and retained when the ICS was administered 30 min before albuterol. The clinical significance of this observation will have to be established by a study involving a larger patient cohort.
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Insomnia disorder is characterized by chronic dissatisfaction with sleep quantity or quality that is associated with difficulty falling asleep, frequent nighttime awakenings with difficulty returning to sleep, and/or awakening earlier in the morning than desired. Although progress has been made in our understanding of the nature, etiology, and pathophysiology of insomnia, there is still no universally accepted model. Greater understanding of the pathophysiology of insomnia may provide important information regarding how, and under what conditions, the disorder develops and is maintained as well as potential targets for prevention and treatment. ⋯ Working within several models of insomnia, evidence for the pathophysiology of the disorder is presented across levels of analysis, from genetic to molecular and cellular mechanisms, neural circuitry, physiologic mechanisms, sleep behavior, and self-report. We discuss the role of hyperarousal as an overarching theme that guides our conceptualization of insomnia. Finally, we propose a model of the pathophysiology of insomnia that integrates the various types of evidence presented.
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Multicenter Study
SURROGATE RECEPTIVITY TO PARTICIPATION IN CRITICAL ILLNESS GENETIC RESEARCH: Aligning Research Oversight and Stakeholder Concerns.
Collection of genetic biospecimens as part of critical illness investigations is increasingly commonplace. Oversight bodies vary in restrictions imposed on genetic research, introducing inconsistencies in study design, potential for sampling bias, and the possibility of being overly prohibitive of this type of research altogether. We undertook this study to better understand whether restrictions on genetic data collection beyond those governing research on cognitively intact subjects reflect the concerns of surrogates for critically ill patients. ⋯ Expressing trust in health-care providers and viewing genetic research favorably were associated with increased willingness for study enrollment, while concern regarding breach of confidentiality and black race had the opposite effect. Study setting had no bearing on willingness to participate.
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Multicenter Study
Trends in Mechanical Ventilation among Patients Hospitalized with Acute Exacerbation of COPD in the United States, 2001 to 2011.
The use of noninvasive ventilation (NIV) in acute exacerbation of COPD has increased over time. However, little is known about patient factors influencing its use in routine clinical practice. ⋯ The use of NIV for COPD exacerbations has increased steadily, whereas IMV use has declined. Several patient factors, including age, race, and comorbidities, influenced the receipt of NIV. Further research is needed to identify the factors driving these patterns.
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Improving value within critical care remains a priority because it represents a significant portion of health-care spending, faces high rates of adverse events, and inconsistently delivers evidence-based practices. ICU directors are increasingly required to understand all aspects of the value provided by their units to inform local improvement efforts and relate effectively to external parties. A clear understanding of the overall process of measuring quality and value as well as the strengths, limitations, and potential application of individual metrics is critical to supporting this charge. ⋯ We then describe how ICU leaders can develop their own value measurement process by identifying target areas, selecting appropriate measures, acquiring the necessary data, analyzing the data, and disseminating the findings. Within this measurement process, we summarize common metrics that can be used to characterize ICU value. As health care, in general, and critical care, in particular, changes and data become more available, it is increasingly important for ICU leaders to understand how to effectively acquire, evaluate, and apply data to improve the value of care provided to patients.