Reducing failed extubations in the intensive care unit

BACKGROUND: Failed extubation is associated with substantially increased morbidity, mortality, and costs for patients receiving mechanical ventilation. A study was designed in 1998 to identify risk factors for failed extubation and use a quality improvement model to reduce failed extubation rates in a surgical intensive care unit (SICU) in an academic hospital. METHODS: Study design involved a prospective cohort SICU with a concurrent control SICU. The primary outcome was rate of failed extubations per 1,000 ventilator days. Information on risk factors for failed extubations was also collected. Performance improvement staff identified failed extubation patients, and respiratory therapy provided information on ventilator days. The quality improvement model implemented three phases between October 1998 and June 2000: (1) identifying factors associated with failed extubation, (2) developing a guideline to reduce failed extubation, and (3) implementing the guideline. RESULTS: Significant factors associated with failed extubation included suctioning more frequently than every 4 hours versus the current model of "every 4 hours or greater" (odds ratio [OR] 11.3; 95% confidence interval [CI] 1.5-88.3), being agitated or sedated versus being alert (OR 4.5, CI: 1.2-14.7), and oxygen saturation < or = 95% versus > or = 95% (OR 4.0; CI: 1.2-13). Failed extubation rate in the SICU decreased from 8/1,000 in October 1998 to 1.5/1,000 in June 2000, and control SICU rates remained unchanged (8/1,000). DISCUSSION: The intervention significantly reduced the rate of failed extubation in the SICU. By employing a quality improvement model and identifying risk factors for failed extubation, providers should be able to decrease risk of failed extubation for SICU patients.     

Cerebro-protective effects of ENA713, a novel acetylcholinesterase inhibitor, in closed head injury in the rat

Focal ischemic brain damage and diffuse brain swelling occur in severe cases of traumatic head injury. Ischemia decreases brain acetylcholine (ACh) levels and head trauma upregulates acetylcholinesterase (AChE) in experimental animal models. The present study determined whether a brain-selective AChE inhibitor, ENA713, given once, up to 2 h after closed head injury (CHI) could reduce the vasogenic edema and accelerate recovery from neurological deficits induced by the injury in rats. ENA713 1-5 mg/kg produced a dose-related inhibition of AChE ranging from 40-85% in the cortex and hippocampus. Doses of 1, 2 and 5 mg/kg, significantly reduced the motor and neurological deficits and speeded recovery, as indicated by measurements made 7 and 14 days after injury. The two larger doses were still effective when injected 1 or 2 h after CHI. The acceleration by ENA713 of recovery of motor function was independent of its reduction in body temperature and was prevented by the simultaneous injection of mecamylamine (2.5 mg/kg), but not by scopolamine (0.2 or 1 mg/kg). Edema in the contused hemisphere (24 h after injury) and disruption of the blood brain barrier (4 h after injury) were significantly reduced (about 50%) by doses of 2 and 5 mg/kg, but not by 1 mg/kg. The data support the hypothesis that ENA713 exerts a neuroprotective effect in brain injury by preventing the decrease in cholinergic activity in cerebral vessels and in neurones.     

Relation of low-severity violence to women's health

OBJECTIVE: To determine if women who experience low-severity violence differ in numbers of physical symptoms, psychological distress, or substance abuse from women who have never been abused and from women who experience high-severity violence. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Four community-based, primary care, internal medicine practices. PATIENTS: Survey respondents were 1,931 women aged 18 years or older. SURVEY DESIGN: Survey included questions on violence; a checklist of 22 physical symptoms; the Symptom Checklist-22 (SCL-22) to measure depression, anxiety, somatization, and self-esteem; CAGE questions for alcohol use; and questions about past medical history. Low-severity violence patients had been "pushed or grabbed" or had someone "threaten to hurt them or someone they love" in the year prior to presentation. High-severity violence patients had been hit, slapped, kicked, burned, choked, or threatened or hurt with a weapon. MAIN RESULTS: Of the 1,931 women, 47 met criteria for current low-severity violence without prior abuse, and 79 met criteria for current high-severity violence without prior abuse, and 1,257 had never experienced violence. The remaining patients reported either childhood violence or past adult abuse. When adjusted for socioeconomic characteristics, the number of physical symptoms increased with increasing severity of violence (4.3 for no violence, 5.3 for low-severity violence, 6.4 for high-severity violence, p < .0001). Psychological distress also increased with increasing severity of violence (mean total SCL22 scores 32.6 for no violence, 35.7 for low-severity violence, 39.5 for high-severity violence, p < .0001). Women with any current violence were more likely to have a history of substance abuse (prevalence ratio [PR] 1.8 for low-severity, 1.9 for high-severity violence) and to have a substance-abusing partner (PR 2.4 for both violence groups). CONCLUSIONS: In this study, even low-severity violence was associated with physical and psychological health problems in women. The data suggest a dose-response relation between the severity of violence and the degree of physical and psychological distress.     

Childhood family antecedents of dependency and self-criticism: Implications for depression.

Presents an etiologic model of how relationships with parents in childhood influence differential vulnerability to distinctive depressive experiences associated with issues of dependency or self-criticism. 86 female undergraduates were administered a battery of measures, including the Depressive Experiences Questionnaire, to measure Ss' current experiences of dependency and self-criticism. These were correlated with their retrospective reports of parental behavior in childhood. It was predicted that Ss high on dependency would report the mother as being the more dominant parent and as emphasizing strict control, expressing inconsistent affection, and expecting conformity to authority rather than achievement. Individuals high on self-criticism, in contrast, would report the father as more dominant and both parents as emphasizing strict control, expressing inconsistent affection, and expecting achievement and success rather than passive conformity. Results generally support these predictions and complement the findings of other recent studies of depressed individuals' memories of their parents' childrearing practices. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)