Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients

OBJECTIVE: The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes. METHOD: Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments. RESULTS: Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30). SIGNIFICANCE OF RESULTS: Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial

What evidence exists on the links between natural climate solutions and climate change mitigation outcomes in subtropical and tropical terrestrial regions? A systematic map protocol

Background Natural climate solutions (NCS)—actions to conserve, restore, and modify natural and modified ecosystems to increase carbon storage or avoid greenhouse gas (GHG) emissions—are increasingly regarded as important pathways for climate change mitigation, while contributing to our global conservation efforts, overall planetary resilience, and sustainable development goals. Recently, projections posit that terrestrial-based NCS can potentially capture or avoid the emission of at least 11 Gt (gigatons) of carbon dioxide equivalent a year, or roughly encompassing one third of the emissions reductions needed to meet the Paris Climate Agreement goals by 2030. NCS interventions also purport to provide co-benefits such as improved productivity and livelihoods from sustainable natural resource management, protection of locally and culturally important natural areas, and downstream climate adaptation benefits. Attention on implementing NCS to address climate change across global and national agendas has grown—however, clear understanding of which types of NCS interventions have undergone substantial study versus those that require additional evidence is still lacking. This study aims to conduct a systematic map to collate and describe the current state, distribution, and methods used for evidence on the links between NCS interventions and climate change mitigation outcomes within tropical and sub-tropical terrestrial ecosystems. Results of this study can be used to inform program and policy design and highlight critical knowledge gaps where future evaluation, research, and syntheses are needed. Methods To develop this systematic map, we will search two bibliographic databases (including 11 indices) and 67 organization websites, backward citation chase from 39 existing evidence syntheses, and solicit information from key informants. All searches will be conducted in English and encompass subtropical and tropical terrestrial ecosystems (forests, grasslands, mangroves, agricultural areas). Search results will be screened at title and abstract, and full text levels, recording both the number of excluded articles and reasons for exclusion. Key meta-data from included articles will be coded and reported in a narrative review that will summarize trends in the evidence base, assess gaps in knowledge, and provide insights for policy, practice, and research. The data from this systematic map will be made open access

Does Endotracheal Tube Design Affect Cuff Seal, Safety and Subglottic Suction Performance: An in-vitro study?

Introduction: Ideally endotracheal tubes (ETT) should protect the airways without causing pressure induced tissue damage. Traditionally, the addition of a tracheal cuff was heralded as seal against aspiration. This type of ETT utilized a low volume high pressure cuff which caused tracheal damage such as stenosis and malacia. The next development in ETT design was the high volume low pressure cuffs intended to protect the airways while reducing tissue damage. Although reducing damage, the new cuff did not reliably protect the airways. Microaspiration still remains a serious complication of intubation. A taper shaped cuff design was recently introduced to prevent microaspiration without causing tracheal damage. Concerns were raised regarding the contact area and the resultant pressure against the tracheal wall of the taper shaped cuff. Another innovation introduced to prevent microaspiration is subglottic suction present in the tube design. Therefore, the aim of this paper is to evaluate cuff seal performance, cuff safety and intrinsic suction efficiency of current commercially available ETT. Methods: Three separate studies evaluated these areas of interest. Cuff seal performance was evaluated using an approved in vitro test fixture mimicking the human trachea. We investigated the cuff seal performance of 7 endotracheal tubes with different cuff designs and identical tracheal tube size using water as the medium. Three different size tubes from 3 different manufacturers were tested to determine subglottic suction efficiency and cuff sealing performance using the same in vitro test fixture. In a similar fixture a pressure sensitive array was mounted to compare the surface pressure of a standard barrel shaped cuff to the taper shaped cuff. The array design allowed for the pressure profile of the cuff to be mapped where it contacted the cylinder wall. In all tests the cuff pressures were maintained at 25 cm H2 O according to manufacturer’s recommendations. Results: The sealing performance varied between the tube manufacturers with TaperGuard (TG) showing the lowest leak at .6 g/5minutes and Kimberly Clark Micro cuff (KCmc) with the highest 59.2 g/5 minutes. In terms of suction efficiency Teleflex ISIS (ISIS) had the best suction performance (.2-5.3ml/sec) at all viscosities and Portex (SACETT) (.3-2.9 ml/min) was the lowest. When comparing surface force the taper shaped cuff was less compared to the barrel shaped cuff. Conclusions: Performance in all areas tested ETTs varied considerably in terms of sealing and suction efficiency. However, the taper shaped cuff demonstrated the least surface pressure and best sealin