Care for critically-ill patients with shock could be improved, it is hoped, after the first successful testing at the John Radcliffe Hospital of a new machine to record oxygen consumption in real time. The new technology has arisen through a collaboration between Professor Peter Robbins in the University of Oxford’s Department of Physiology, Anatomy and Genetics and Professors Grant Ritchie and Gus Hancock in the Department of Chemistry. It combines laser spectroscopy and precise flow measurement of breath in a single medical device which fits into a standard ventilation tube. The work has received public funding from the NIHR Oxford Biomedical Research Centre, a collaboration between the University of Oxford and Oxford University Hospitals NHS Foundation Trust, and the Medical Research Council. Professor Peter Robbins, who is directing the research, said: “This is the culmination of many years of development and it has finally come to fruition. “It is exciting for us to be able to offer something to doctors that has the potential to improve significantly the care of very sick patients.” Patients in shock suffer a lack of oxygen throughout the body, causing many of their organs to deteriorate and eventually even stop working altogether. The possible underlying causes of shock include heart attack, hemorrhage and sepsis. Common treatments include drugs, oxygen and blood transfusions. Doctors do not at present have any direct way of measuring how much oxygen is being used by the body, making it difficult for them to judge which treatments are likely to be most beneficial. Tests in healthy volunteers and in patients having anesthetics at Oxford’s John Radcliffe Hospital indicate the precision of the device is better than anything previously achieved. Stuart McKechnie, Consultant in Intensive Care at the John Radcliffe Hospital, said “Though we already monitor critically-ill patients very closely, this device promises to provide highly useful additional information that may help us to care better for patients with sepsis and shock in the future.”
John Radcliffe Hospital http://tinyurl.com/ze8oh7f
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Rising rates of opioid prescriptions have been linked to the opioid epidemic, and a significant number of opioid deaths have been linked to prescriptions written by surgeons. However, new study results suggest that a more vigilant prescribing guideline for surgeons could reduce by as much as 40 percent the number of opioid pills prescribed after operations, and still meet patients’ pain management needs. Lead study author Richard J. Barth Jr., MD, and colleagues at Dartmouth Hitchcock Medical Center in Lebanon, NH, have suggested the guideline. “We specifically looked at the number of opioid pills that surgical inpatients took the day before discharge from the hospital, and we found that this number was the strongest predictor of how many opioid pills the patients would use after discharge,” Dr. Barth said. The recommendation does not mean patients won’t get enough pills to manage their pain after they leave the hospital. “The guideline was based on satisfying at least 85 percent of patients’ home opioid requirement,” Dr. Barth said. The study included 333 hospital inpatients discharged to home after six different types of general surgery operations: bariatric procedures; operations on the stomach, liver, and pancreas; ventral hernia repair; and colon operations. The researchers followed up with the patients after discharge by using questionnaires and phone surveys; 90 percent of the discharged patients completed the follow-up process. The study group did not include any chronic opioid users. This study represents the first time that specific guidelines have been proposed for prescribing opioids upon discharge after general surgery operations that require inpatient admission. Although some states have adopted laws to curb opioid prescriptions, they are ambiguous. Dr. Barth noted that several New England states limit doctors to prescribing a seven-day supply of opioids, but they include no limits on dosing. “So a seven-day supply could be 84 pills or 21 pills,” he said. The researchers found that patients typically took only a fraction of the opioids prescribed at discharge once they went home. While 85 percent of patients were prescribed an opioid after they went home, only 38 percent of prescribed opioid pills were taken. The study also looked at why a small fraction of patients took more opioids than the new guidelines called for. “Over half of them were taking opioids for non-pain-related reasons, such as to sleep better, or because they felt they should take all the pills the physician prescribed and other various and sundry reasons,” Dr. Barth said. Patients who undergo operations have a higher risk of becoming chronic opioid users than non-surgical patients do, according to previously published research Dr. Barth and his colleagues cited.1–4 Also, unused opioid pills laying around the home contribute to chronic opioid use; 71 percent of chronic opioid users receive their pills through diversionary methods like a relative’s unused prescription.4,5 The guideline Dr. Barth and colleagues developed recommends the following schedule for post-discharge prescription based on the number of opioid pills taken the day before discharge: no pills for patients who took no opioids the day before they left the hospital; 15 pills for those who took one to three pills the day before; and 30 pills for those who took four or more pills on their last day in the hospital. “This guideline was true for multiple different operations,” Dr. Barth said. “It didn’t matter whether someone had a colon operation, liver procedure or hernia repair; no matter what type of general surgery operation they had, this association held throughout all procedures studied. So the beauty of this finding is that one guideline would apply for multiple different surgical procedures.” A second factor that influenced patient opioid use after surgery was age. “Patients who were older ended up taking fewer opioids than younger patients,” he said. Patients younger than age 60 averaged about 13 pills after discharge while those 60 and older averaged four pills. The increased use of e-prescribing—in which a physician can send an electronic prescription directly to a pharmacy—is another factor that should encourage physicians to write prescriptions for fewer pills after surgery. “With e-prescribing, patients don’t have to come back to the clinic if they need more pills,” Dr. Barth said. The guideline has already been adopted at Dr. Barth’s institution and can easily be applied at other centers, he said. American College of Surgeons www.facs.org/media/press-releases/2017/opioids113017
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In 2004, pneumonia killed more than 2 million children worldwide, according to the World Health Organization. By 2015, the number was less than 1 million. Better access to antibiotics and improved nutrition account for part of the decline. But scientists say it’s mostly due to vaccines introduced in the early 2000s that target up to 23 of the most deadly forms of the bacterium that causes pneumonia, Streptococcus pneumoniae. Now, a new vaccine under development could deal another blow to the disease, lowering the number of deaths even further by targeting dozens of additional strains of S. pneumoniae, and anticipating future versions of the bacteria responsible for the disease. The vaccine provoked an immune response to 72 forms of S. pneumoniae — including the 23 mentioned above — in lab tests on animals. The study represents the “most comprehensive” coverage of pneumococcal disease to date, researchers say. “We’ve made tremendous progress fighting the spread of pneumonia, especially among children. But if we’re ever going to rid ourselves of the disease, we need to create smarter and more cost-effective vaccines,” says Blaine Pfeifer, PhD, associate professor of chemical and biological engineering at the University at Buffalo’s School of Engineering and Applied Sciences, and the study’s co-lead author. Each strain of S. pneumoniae contains unique polysaccharides. Vaccines such as Prevnar 13 and Synflorix connect these sugars — by the sharing of an electron — to a protein called CRM197. The process, known as a covalent bond, creates a potent vaccine that prompts the body to find and destroy bacteria before it colonizes the body. While effective, creating covalent bonds for each strain of S. pneumoniae is time-consuming and expensive. Plus, this type of immunization, known as a conjugate vaccine, prompts the body to eliminate each of the targeted bacteria types — regardless of whether the bacteria is idyll or attacking the body. Another vaccine, Pneumovax 23, contains sugars of 23 of the most common types S. pneumoniae. However, the immune response it provokes is not as strong as Prevnar because the sugars are not covalently linked. “Traditional vaccines completely remove bacteria from the body. But we now know that bacteria — and in a larger sense, the microbiome — are beneficial to maintaining good health, says Charles H. Jones, the study’s other co-lead author. “What’s really exciting is that we now have the ability — with the vaccine we’re developing — to watch over bacteria and attack it only if it breaks away from the colony to cause an illness. That’s important because if we leave the harmless bacteria in place, it prevents other harmful bacteria from filling that space.” Varieties of S. pneumoniae not covered by current immunizations are responsible for a small portion — for example, 7 to 10 percent among U.S. children, according to the Centers for Disease Control and Prevention — of pneumonia, meningitis and other cases of pneumococcal disease. But officials worry that will change, as these less common forms — and, potentially, yet-to-be discovered antimicrobial resistant strains — replace the 23 more common types targeted by current immunizations. The new vaccine provokes a strong immune response (comparable to Prevnar) and is engineered in a way that makes it easy to add sugars (like Pneumovax) for a broad immune response. Key to the technology is a liposome — a tiny liquid-filled bubble made of fat — that acts as a storage tank for the sugars. Because the sugars are not covalently bonded, it’s possible that the liposome could host all of the sugars that identify individual strains of S. pneumoniae. The research team added proteins at the surface of the liposome (also non-covalently) which, together with the sugars, provoke strong immunotherapy. According to tests performed on mice and rabbits, the new vaccine stimulated an immune response to 72 of the more than 90 known strains of S. pneumoniae. In many cases, it outperformed Prevnar and Pneumovax. “The advantage of our approach is that we don’t have to apply the more complex covalent chemistry that is required for Prevnar,” Pfeifer says. “As a result, we can extend beyond the 13 types of sugars, potentially providing universal coverage against bacteria that causes pneumonia, meningitis, sepsis and other types of pneumococcal disease. “It holds the promise of saving hundreds of thousands of lives each year.”
Buffalo University www.buffalo.edu/news/releases/2017/10/039.html
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A new study questions the efficacy of treatments for depression based on stimulating brain areas with low-intensity electric current. The technique, known as transcranial direct-current stimulation (tDCS), was considered a promising alternative to treatment with antidepressant drugs. In the new study, researchers at the University of São Paulo’s teaching hospital (HU-USP) and the Psychiatry Institute of Hospital das Clínicas (HC-FMUSP-IP), the largest general hospital in Brazil, describe a trial in which they found tDCS to be less effective than escitalopram, an anti-depressant. The team of researchers led by André Brunoni, a professor in the Psychiatry Department of the University of São Paulo’s Medical School (FMUSP) and director of HC-FMUSP-IP’s Interdisciplinary Neuromodulation Service, randomly divided 245 patients with depression into three groups. One group was treated with tDCS plus oral placebo, the second received sham tDCS treatment plus the anti-depressant, and the third received sham tDCS treatment plus oral placebo. The tDCS treatment was administered in 30-minute sessions for 15 consecutive weekdays, followed by seven once-weekly sessions. Escitalopram was administered at a dose of 10 mg per day for three weeks and 20 mg per day for another seven weeks. "We defined non-inferiority of stimulation compared with medication as at least 50%, meaning that tDCS would have to be at least 50% as effective as the anti-depressant, but this wasn’t the case," Brunoni said. "We found that treatment with tDCS was not half as effective as treatment with escitalopram and concluded that transcranial stimulation cannot be recommended as first-line therapy. The anti-depressant is easier to administer and much more effective. On the other hand, tDCS performed better than placebo in our previous studies." About 12%-14% of the world’s population is estimated to suffer from depression, and it is relatively easy to find self-help websites with videos showing how to administer tDCS at home. Brunoni stressed the importance of not confusing tDCS with other methods such as electroconvulsive therapy (ECT), which involves a far stronger current – typically 800 milliamperes, or 800 times the current used in tDCS – and is designed to produce a controlled seizure. Other differences include the fact that ECT delivers a brief pulse rather than a steady current.
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Researchers from LSTM’s Research Centre for Drugs and Diagnostics (RCDD) have found a way of significantly reducing the treatment required for lymphatic filariasis and onchocerciasis from several weeks to seven days. By targeting Wolbachia, a bacterial symbiont that the filarial parasites need to live, the team has discovered a drug synergy that enables effective treatment over a shorter time. Lymphatic filariasis (LF), which can cause elephantiasis or hydrocele, swelling of the limbs or scrotum and onchocerciasis, also known as river blindness, affect millions of people in some of the world’s poorest communities. Both are caused by filarial parasites for which the bacterial symbiont Wolbachia is essential for development. Filarial Neglected Tropical Diseases are prioritised for elimination, in line with fulfilment of the 2030 United Nations Sustainable Development Goals. A consensus of expert opinion, including the WHO, and major donors, USAID and UK DFID, considers that successful implementation of a macrofilaricidal (curative) or permanent sterilising drug would greatly accelerate the end game elimination of lymphatic filariasis and onchocerciasis. Traditional treatment for these conditions require repetitive, long-term mass drug administrations, and although targeting the symbiont with doxycycline has proved clinically effective, it is programmatically challenging due to the long treatment time and exclusion of pregnant women and children. In a new paper researchers provide proof-of-concept of a radical improvement to the targeting of Wolbachia via a drug synergy between the anthelmintic drug albendazole and antibiotics. LSTM’s Professor Mark Taylor is senior author on the paper. He said: “As part of the A·WOL programme, we have screened all registered drugs for anti-Wolbachia activity, which has allowed us to look at repurposing existing and registered drugs against these debilitating conditions. The combination of an antibiotic and the anti-worm drug albendazole provided the greatest surprise when they acted synergistically to reduce the treatment time from weeks to days, opening up the opportunity to scale-up this approach at the community level.” The team believe that their work is of immediate public health importance because the drugs that have been used, rifampicin and albendazole, are already registered. “These drugs can be tested in infected people as soon as possible,” continued Professor Taylor. The first author on the paper, LSTM’s Dr Joe Turner, added, “the discovery of drug synergy between a common anthelmintic and different classes of antibiotics is also exciting because even more potent synergism may be evident when we combine with our next generation, ‘designer’ anti-Wolbachia drugs currently in development as part of the A·WOL programme. Potentially, we may be in a position to reduce curative treatment time frames down to five days or less for filariasis, with better acceptability and reduced costs for patients and local health systems” Liverpool School of Tropical Medicine www.lstmed.ac.uk/news-events/news/new-combination-therapy-of-registered-re-purposed-drugs-dramatically-shortens-anti
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An experimental device that employs a pair of magnets offers surgeons a new safe and simple alternative to standard methods for creating an anastomosis for the first time in nearly 50 years. An anastomosis is a surgical connection between tubular anatomic structures, such as blood vessels, urinary tract, or bowel. In its first proof-of-concept clinical trial in humans, the device was easy for surgeons to use, even with patients who required complicated surgical reconstruction. It also was safe; none of the patients had any complications related to the use of the device or the anastomosis it fashioned. An anastomosis is common in many kinds of operations performed by general surgeons. It currently is done in one of two ways. The first approach involves suturing two pieces of tissue together with a needle and thread. This option is inexpensive and can be done in any surgical setting. However, suturing requires either an open operation so surgeons have enough room to manoeuver instruments, or highly specialized technical skills in minimally invasive procedures, and it takes time to place multiple layers of sutures during a procedure, said Claire Graves, MD, lead author and research fellow at the University of California San Francisco when the study was conducted. When surgical staplers were introduced in the 1970s, stapling often became the preferred method for performing an anastomosis. Stapling is faster than suturing, and it produces a more consistent result. Staples are, however, expensive, and the devices can sometimes fail or misfire, added Dr. Graves, a current resident in general surgery at Columbia University Medical Center, New York City. Magnetic compression anastomosis applies the force of magnetic attraction to form an anastomosis without sutures or staples. The technique utilizes a Magnamosis device, which houses two rare earth magnets in a specially engineered medical grade polycarbonate shell. The magnetic implants have different polarities so they are drawn to one another. The magnets also have different shapes–one is convex and one is concave–so they fit smoothly together. In the formation of an anastomosis, a magnet is placed in each side of the tube that is being surgically connected, and then the magnets are drawn together, compressing the tissue between them and blocking blood flow. “The tissue between the magnets dies off, a hole forms from the necrotic tissue, and the surrounding area heals. Once the connection is fully formed, the magnets fall through the hole, pass into the bowel, and are excreted in the stool, leaving nothing behind,” Dr. Graves explained. In animal studies, the Magnamosis device consistently created anastomoses that were comparable or better than hand-sewn or stapled alternatives as demonstrated in tissue samples and tests of the strength of the connection.
American College of Surgeons http://tinyurl.com/ya7k8k4a
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Clinicians today have an arsenal of more than 200 drugs at their disposal for treating a range of cancers — 68 drugs were approved between 2011 and 2016 alone. But many chemotherapeutic agents pose stubborn challenges: they cause serious side effects because they kill healthy cells in addition to cancer cells; some forms of cancer develop resistance to drugs; and many such chemotherapies, being poorly water-soluble, demonstrate low bio-availability resulting in sub-optimal drug delivery to cancer cells. A potential solution lies in the synergistic combination of a chemotherapeutic drug with engineered genetic material designed to neutralize the malevolent genes conferring resistance to that drug, among other functions. While there are numerous examples of synthetic dual gene and drug delivery vehicles, new hybrid materials developed in the lab at the NYU Tandon School of Engineering use easily modifiable proteins to deliver a chemical one-two punch: they combine a lipid “container” for transfection — the transportation of cargo past a cell membrane — and an easy-to-make protein capsule that can bind both small chemotherapeutic molecules and nucleic acids. Developed by a team led by NYU Tandon Associate Professor of Chemical and Biomolecular Engineering Jin Kim Montclare — who also serves as an Affiliate Professor of Chemistry at NYU’s College of Arts and Sciences, and an Affiliate Professor of Biomaterials at NYU College of Dentistry, as well as being affiliated with SUNY Downstate as a Professor of Biochemistry — the hybrid lipid-protein material, called a lipoproteoplex, comprises both a coiled supercharged protein macromolecule and a commercially available transfection agent called Lipofectamine 2000. Lipoproteoplex allows researchers to swap out a supercharged protein or lipid component and any number of siRNA to address a specific cell line and type of drug. Because the researchers engineered the protein macromolecule with extensive positive charges on the surface and a hydrophobic core, it can be easily festooned with negatively charged short interfering RNA (siRNA) — a powerful tool for suppressing genes that invoke drug resistance and propagate disease states —while also serving as an efficient, and toxicity reducing, carryall for the hydrophobic chemotherapeutic agent doxorubicin. In research published, the team details how the lipoproteoplex exposed to samples of the MCF-7 breast cancer cell line delivered more doxorubicin to target cells than did Lipofectamine 2000 alone, resulting in a substantial decrease in MCF-7 cell viability. They also demonstrated that the hybrid macromolecule was highly successful at siRNA transfection, silencing the gene by 60 percent. Montclare said a key benefit of the new lipoproteoplex is ease of modification, an asset to researchers studying cells whose genetically invoked behaviour changes over time and differs by cell line and patient. Rather like a system of mix-and-match components, the lipoproteoplex allows researchers to swap out a supercharged protein or lipid component and any number of siRNA to address a specific cell line and type of drug. “Unlike other pursuits at producing dual gene and drug delivery systems, this approach doesn’t require tedious chemical synthesis procedures; rather we can biosynthesize any variant of the supercharged protein,” she said. “This allows for substituting different siRNA molecules and chemotherapeutic drugs to suit lab needs.”
New York University Tandon School of Engineering engineering.nyu.edu/press-releases/2017/08/09/researchers-nyu-tandon-create-new-biomaterial-delivers-drug-gene-silencer
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Results of a University of Nebraska Medical Center study found if the standard supplementation of 400 IUs of vitamin D is increased to 800 IUs daily there are reductions in the number of premature and preterm babies with extremely low bone density. Physicians have been prescribing vitamin D in premature and preterm infants in neonatal intensive care units (NICU) to prevent rickets, a disease that causes soft, weak bones in children and is often associated with vitamin D deficiency. In spite of this, a sizeable number of infants still develop rickets, said Ann Anderson Berry, M.D., associate professor in the division of newborn medicine and medical director of the NICU at Nebraska Medicine, UNMC’s clinical partner. She said current recommendations of vitamin D supplementation for preterm infants span a wide range of doses, even among major medical groups such as the American Academy of Pediatrics, the Institute of Medicine, and the Endocrine Society. And response to vitamin D supplementation and impact on outcomes in preterm infants is not well understood, she said. The study provided more evidence in regards to bone health and ideal supplementation. The objective was to evaluate changes in vitamin D in the blood over four weeks in two groups of premature infants born between 24 to 32 weeks gestation. Researchers studied 32 infants at doses of 400 or 800 IU/day of vitamin D. Researchers saw an improvement in bone density and vitamin D levels in the blood at four weeks. They also saw improvement in growth that significantly decreased the risk of infants having very low bone density. “We are hopeful that neonatologists will consider giving pre-term infants 800 IUs,” Dr. Anderson Berry said. “We know that even with standard vitamin D dosing, we were still seeing a fair number of pre-term infants who suffered from impaired bone health. This is another form of NICU therapy that can help decrease that risk.” She said the study is one of the first to look at higher dosing of vitamin D in premature infants. Information will be incorporated as a recommended practice for health professionals. Dr. Anderson Berry is first author of the paper, senior author is Corrine Hanson, Ph.D., UNMC College of Allied Health Professions, and contributing author is Elizabeth Lyden of the UNMC College of Public Health.
University of Nebraska Medical Centerhttps://tinyurl.com/y75cfhey
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Imagine if doctors could determine, many years in advance, who is likely to develop dementia. Such prognostic capabilities would give patients and their families time to plan and manage treatment and care. Thanks to artificial intelligence research conducted at McGill University, this kind of predictive power could soon be available to clinicians everywhere. Scientists from the Douglas Mental Health University Institute’s Translational Neuroimaging Laboratory at McGill used artificial intelligence techniques and big data to develop an algorithm capable of recognizing the signatures of dementia two years before its onset, using a single amyloid PET scan of the brain of patients at risk of developing Alzheimer’s disease. Dr. Pedro Rosa-Neto, co-lead author of the study and Associate Professor in McGill’s departments of Neurology & Neurosurgery and Psychiatry, expects that this technology will change the way physicians manage patients and greatly accelerate treatment research into Alzheimer’s disease. “By using this tool, clinical trials could focus only on individuals with a higher likelihood of progressing to dementia within the time frame of the study. This will greatly reduce the cost and the time necessary to conduct these studies,” adds Dr. Serge Gauthier, co-lead author and Professor of Neurology & Neurosurgery and Psychiatry at McGill. Scientists have long known that a protein known as amyloid accumulates in the brain of patients with mild cognitive impairment (MCI), a condition that often leads to dementia. Though the accumulation of amyloid begins decades before the symptoms of dementia occur, this protein couldn’t be used reliably as a predictive biomarker because not all MCI patients develop Alzheimer’s disease. To conduct their study, the McGill researchers drew on data available through the Alzheimer’s Disease Neuroimaging Initiative (ADNI), a global research effort in which participating patients agree to complete a variety of imaging and clinical assessments. Sulantha Mathotaarachchi, a computer scientist from Rosa-Neto’s and Gauthier’s team, used hundreds of amyloid PET scans of MCI patients from the ADNI database to train the team’s algorithm to identify which patients would develop dementia, with an accuracy of 84%, before symptom onset. Research is ongoing to find other biomarkers for dementia that could be incorporated into the algorithm in order to improve the software’s prediction capabilities. “This is an example how big data and open science brings tangible benefits to patient care,” says Dr. Rosa-Neto, who is also director of the McGill University Research Centre for Studies in Aging. While new software has been made available online to scientists and students, physicians won’t be able to use this tool in clinical practice before certification by health authorities. To that end, the McGill team is currently conducting further testing to validate the algorithm in different patient cohorts, particularly those with concurrent conditions such as small strokes.
McGill Universityhttp://tinyurl.com/y8dd4zda
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Hospital chaplains provide spiritual care that helps patients facing serious illness cope with their symptoms and prognosis, yet because mechanically ventilated patients cannot speak, spiritual care of these patients has been limited. A study was undertaken to determine the feasibility and to measure the effects of chaplain-led picture-guided spiritual care for mechanically ventilated adults in the intensive care unit (ICU). Researchers conducted a quasi-experimental study at a tertiary care hospital between March 2014 and July 2015. Fifty mechanically ventilated adults in medical or surgical ICUs without delirium or dementia received spiritual care by a hospital chaplain using an illustrated communication card to assess their spiritual affiliations, emotions, and needs and were followed until hospital discharge. Feasibility was assessed as the proportion of participants able to identify spiritual affiliations, emotions, and needs using the card. Among the first 25 participants, they performed semi-structured interviews with 8 ICU survivors to identify how spiritual care helped them. For the subsequent 25 participants, they measured anxiety (on 100-mm visual analogue scales [VAS]) immediately before and after the first chaplain visit, and performed semi-structured interviews with 18 ICU survivors with added measurements of pain and stress (on ±100-mm VAS). The mean (SD) age was 59 (±16) years, median mechanical ventilation days was 19.5 (interquartile range, 7–29 d), and 15 (30%) died in hospital. Using the card, 50 (100%) identified a spiritual affiliation, 47 (94%) identified one or more emotions, 45 (90%) rated their spiritual pain, and 36 (72%) selected a chaplain intervention. Anxiety after the first visit decreased 31% (mean score change, −20; 95% confidence interval, −33 to −7). Among 28 ICU survivors, 26 (93%) remembered the intervention and underwent semi-structured interviews, of whom 81% felt more capable of dealing with their hospitalization and 0% felt worse. The 18 ICU survivors who underwent additional VAS testing during semi-structured follow-up interviews reported a 49-point reduction in stress (95% confidence interval, −72 to −24) and no significant change in physical pain that they attributed to picture-guided spiritual care. The researchers found that chaplain-led picture-guided spiritual care is feasible among mechanically ventilated adults and shows potential for reducing anxiety during and stress after an ICU admission.
American Thoracic Society http://tinyurl.com/z4phyfr
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