Respiratory drive heterogeneity associated with systemic inflammation and vascular permeability in acute respiratory distress syndrome.

Background: In acute respiratory distress syndrome (ARDS), respiratory drive often differs among patients with similar clinical characteristics. Readily observable factors like acid-base state, oxygenation, mechanics, and sedation depth do not fully explain drive heterogeneity. This study evaluated the relationship of systemic inflammation and vascular permeability markers with respiratory drive and clinical outcomes in ARDS.

Promoting maternal-child health by increasing breastfeeding rates: a National Canadian Baby-Friendly Initiative Quality Improvement Collaborative Project.

While breastfeeding has long been an important, globally recognized aspect of population health, disparities exist across Canada. The Baby-Friendly Initiative (BFI) is a WHO/UNICEF best-practice program that helps ensure families receive evidence-based perinatal care and is associated with improved breastfeeding rates. However, <10% of hospitals in Canada are designated as 'Baby-Friendly'.

Development of Interventions to Support Provincial Implementation of the Baby-Friendly Initiative: A Study Protocol.

Breastfeeding is internationally recognized as the optimal form of infant nutrition. The Baby-Friendly Initiative (BFI) is an evidence-informed program that leads to improved breastfeeding outcomes. Despite the benefits of breastfeeding, Nova Scotia has one of the lowest breastfeeding rates in Canada.

Effect of Esophageal Pressure-guided Positive End-Expiratory Pressure on Survival from Acute Respiratory Distress Syndrome: A Risk-based and Mechanistic Reanalysis of the EPVent-2 Trial.

In acute respiratory distress syndrome (ARDS), the effect of positive end-expiratory pressure (PEEP) may depend on the extent to which multiorgan dysfunction contributes to risk of death, and the precision with which PEEP is titrated to attenuate atelectrauma without exacerbating overdistension. To evaluate whether multiorgan dysfunction and lung mechanics modified treatment effect in the EPVent-2 (Esophageal Pressure-guided Ventilation 2) trial, a multicenter trial of esophageal pressure (Pes)-guided PEEP versus empirical high PEEP in moderate to severe ARDS. This reanalysis of the EPVent-2 trial evaluated for heterogeneity of treatment effect on mortality by baseline multiorgan dysfunction, determined via Acute Physiology and Chronic Health Evaluation II (APACHE-II).

Reverse Trigger Phenotypes in Acute Respiratory Distress Syndrome.

Reverse triggering is an underexplored form of dyssynchrony with important clinical implications in patients with acute respiratory distress syndrome. This retrospective study identified reverse trigger phenotypes and characterized their impacts on Vt and transpulmonary pressure. Fifty-five patients with acute respiratory distress syndrome on pressure-regulated ventilator modes were included.

Effect of dimethyl fumarate on lymphocyte subsets in patients with relapsing multiple sclerosis.

Background: In patients treated with dimethyl fumarate, absolute lymphocyte count decline typically occurs during the first year and then plateaus; early drops have been associated with the development of severe prolonged lymphopenia.

Objective: We investigated the effect of dimethyl fumarate on absolute lymphocyte counts and CD4+/CD8+ T cells in patients with relapsing-remitting multiple sclerosis treated with dimethyl fumarate in routine practice.

Methods: Lymphocyte data were collected via medical chart abstraction.

Relative effectiveness and cost-effectiveness of the midwifery-led care in Nova Scotia, Canada: A retrospective, cohort study.

Objectives: To compare neonatal and maternal outcomes, and the relative risk of interventions between mothers attended to by midwives, general practitioners, and obstetricians, and to assess the cost-effectiveness of the employee-model of midwifery-led care in Nova Scotia, Canada, when compared with general practitioners.

Design, Setting, And Participants: The study was a retrospective cohort study involving routinely collected clinical and administrative data from all low-risk births from January 1, 2013 to December 31, 2017. There were 24,662 observations.

Systematic Review and Meta-analysis of Psychosocial Uncertainty Management Interventions.

Background: Psychosocial uncertainty management interventions (UMIs) targeting patients and their family members might help to alleviate the negative influences of illness-related uncertainty, such as diminished quality of life and poor adjustment.

Objectives: The aims of this study were to evaluate the key characteristics of psychosocial UMIs and assess intervention effects on patients' and their family members' short-term and long-term illness-related uncertainty.

Methods: We conducted a systematic review and meta-analysis of psychosocial UMIs published through 2017.

Effect of Titrating Positive End-Expiratory Pressure (PEEP) With an Esophageal Pressure-Guided Strategy vs an Empirical High PEEP-Fio2 Strategy on Death and Days Free From Mechanical Ventilation Among Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

Importance: Adjusting positive end-expiratory pressure (PEEP) to offset pleural pressure might attenuate lung injury and improve patient outcomes in acute respiratory distress syndrome (ARDS).

Objective: To determine whether PEEP titration guided by esophageal pressure (PES), an estimate of pleural pressure, was more effective than empirical high PEEP-fraction of inspired oxygen (Fio2) in moderate to severe ARDS.

Design, Setting, And Participants: Phase 2 randomized clinical trial conducted at 14 hospitals in North America.

Revisiting atelectasis in lung units with low ventilation/perfusion ratios.

Patients on high inspired O concentrations are at risk of atelectasis, a problem that has been quantitatively assessed using analysis of ratio of ventilation to perfusion (V̇a/Q̇) equations. This approach ignores the potential of the elastic properties of the lung to support gas exchange through "apneic" oxygenation in units with no tidal ventilation, and is based on an error in the conservation of mass equations. To fill this gap, we correct the error and compare the pressure drops associated with apneic gas exchange with the pressure differences that can be supported by lung recoil.

Should we titrate peep based on end-expiratory transpulmonary pressure?-yes.

Ventilator management of patients with acute respiratory distress syndrome (ARDS) has been characterized by implementation of basic physiology principles by minimizing harmful distending pressures and preventing lung derecruitment. Such strategies have led to significant improvements in outcomes. Positive end expiratory pressure (PEEP) is an important part of a lung protective strategy but there is no standardized method to set PEEP level.

Pressure-decay testing of pleural air leaks in intact murine lungs: evidence for peripheral airway regulation.

The critical care management of pleural air leaks can be challenging in all patients, but particularly in patients on mechanical ventilation. To investigate the effect of central airway pressure and pleural pressure on pulmonary air leaks, we studied orotracheally intubated mice with pleural injuries. We used clinically relevant variables - namely, airway pressure and pleural pressure - to investigate flow through peripheral air leaks.

Effects of Prone Positioning on Transpulmonary Pressures and End-expiratory Volumes in Patients without Lung Disease.

Background: The effects of prone positioning on esophageal pressures have not been investigated in mechanically ventilated patients. Our objective was to characterize effects of prone positioning on esophageal pressures, transpulmonary pressure, and lung volume, thereby assessing the potential utility of esophageal pressure measurements in setting positive end-expiratory pressure (PEEP) in prone patients.

Methods: We studied 16 patients undergoing spine surgery during general anesthesia and neuromuscular blockade.

Quantifying the Arousal Threshold Using Polysomnography in Obstructive Sleep Apnea.

Study Objectives: Precision medicine for obstructive sleep apnea (OSA) requires noninvasive estimates of each patient's pathophysiological "traits." Here, we provide the first automated technique to quantify the respiratory arousal threshold-defined as the level of ventilatory drive triggering arousal from sleep-using diagnostic polysomnographic signals in patients with OSA.

Methods: Ventilatory drive preceding clinically scored arousals was estimated from polysomnographic studies by fitting a respiratory control model (Terrill et al.

Esophageal pressure: research or clinical tool?

Esophageal manometry has traditionally been utilized for respiratory physiology research, but clinicians have recently found numerous applications within the intensive care unit. Esophageal pressure (P) is a surrogate for pleural pressures (P), and the difference between airway pressure (P) and P provides a good estimate for the pressure across the lung also known as the transpulmonary pressure (P). Differentiating the effects of mechanical ventilation and spontaneous breathing on the respiratory system, chest wall, and across the lung allows for improved personalization in clinical decision making.

Stable Breathing in Patients With Obstructive Sleep Apnea Is Associated With Increased Effort but Not Lowered Metabolic Rate.

Study Objectives: In principle, if metabolic rate were to fall during sleep in a patient with obstructive sleep apnea (OSA), ventilatory requirements could be met without increased respiratory effort thereby favoring stable breathing. Indeed, most patients achieve periods of stable flow-limited breathing without respiratory events for periods during the night for reasons that are unclear. Thus, we tested the hypothesis that in patients with OSA, periods of stable breathing occur when metabolic rate (VO2) declines.

Use of Art-Making Intervention for Pain and Quality of Life Among Cancer Patients: A Systematic Review.

Background: Although pain is one of the most prevalent symptoms among cancer patients, medications do not always result in sufficient pain relief. Furthermore, these medications only address the physical component of pain. Art making, a holistic approach, may distract the user's attention from pain and allow expression of the nonphysical (e.

Macrophage migration inhibitory factor (MIF) modulates trophic signaling through interaction with serine protease HTRA1.

Macrophage migration inhibitory factor (MIF), a small conserved protein, is abundant in the immune- and central nervous system (CNS). MIF has several receptors and binding partners that can modulate its action on a cellular level. It is upregulated in neurodegenerative diseases and cancer although its function is far from clear.