Ellen L. Burnham

Objectives: To evaluate whether race and ethnicity are associated with increased odds of physical impairment among post-ICU survivors and to assess how impairment influences healthcare utilization after hospital discharge. Design: This was a retrospective cohort study. Setting: The study was conducted at an academic medical center. Patients: We included 4370 adult ICU survivors who experienced shock, respiratory failure, or received extracorporeal membrane oxygenation. Interventions: None. Measurements and Main Results: The primary exposure was self-reported race and ethnicity. The primary outcome was impairment at hospital discharge, defined using the International Classification of Diseases , 10th Revision codes and/or a Johns Hopkins Highest Level of Mobility score of less than or equal to 5. Multivariable logistic regression was used to assess associations with impairment, and Fine-Gray models evaluated post-discharge healthcare utilization. Impairment was identified in 31% of ICU survivors. Non-Hispanic Black race was associated with increased odds of any impairment (adjusted odds ratio [aOR], 1.34; 95% CI, 1.04–1.72), and Hispanic ethnicity was associated with increased odds of new impairment (aOR, 1.42; 95% CI, 1.05–1.91), compared with non-Hispanic White-identifying survivors. Among those with impairment, both non-Hispanic Black and Hispanic individuals had increased risk of healthcare utilization within 1 year. Conclusions: Non-Hispanic Black race and Hispanic ethnicity are associated with increased odds of post-ICU physical impairment and subsequent healthcare utilization. These findings highlight the need to understand root causes better and explore targeted interventions to reduce disparities among ICU survivors.

Background: Tobacco and cannabis are among the most widely used substances globally, and rates of co-use are on the rise. Understanding the impact of inhaled tobacco-cannabis co-use on health outcomes and tobacco cessation is critical for guiding patients and clinicians. Objectives: To summarize the existing evidence, identify knowledge gaps, and prioritize research questions related to effects of inhaled tobacco-cannabis co-use on tobacco cessation and lung health. Methods: A multidisciplinary committee was convened to review the evidence, identify knowledge gaps, and develop research questions in four priority research areas: 1) common data elements and terminology, 2) patterns and prevalence of co-use, 3) impact of co-use on tobacco cessation, and 4) effects of co-use on lung health. A modified Delphi process was conducted in three rounds to reach consensus on prioritizing research questions. Results: The evidence reviewed by the expert panel in four priority research areas yielded the following gaps in the literature with high priority to address with future research: 1) lack of consensus on terminology and recommended co-use data elements, 2) limited research on co-use and tobacco-related disparities, 3) insufficient evidence on how cannabis use affects tobacco cessation, and 4) alarming yet inconsistent findings on the effects of co-use on lung health. Conclusions: This statement outlines and guides a research agenda on the effects of inhaled tobacco-cannabis co-use on tobacco cessation and lung health. Consensus-driven recommendations include adopting harmonized terms and minimum data elements, studying the prevalence of co-use among populations experiencing tobacco-related disparities, evaluating the impact of co-use on tobacco cessation pharmacotherapies, and assessing the effects of co-use on the development and progression of lung diseases.

Background: Excessive alcohol use is a leading cause of preventable death in the United States, with the emergency department (ED) serving as a critical touchpoint for individuals with alcohol use disorder (AUD). Despite clinical guidelines recommending initiation of medication for AUD (MAUD), such as naltrexone, ED prescribing remains rare. The objective of this study is to characterize clinician naltrexone prescribing practices for ED patients with hazardous drinking or AUD and identify patient‐ and encounter‐level predictors of naltrexone prescribing within a large, integrated health system.Methods: We conducted a retrospective cohort study of adult ED encounters across 12 hospitals from 2022 to 2024. Eligible encounters included patients with a positive Alcohol Use Disorders Identification Test‐Consumption (AUDIT‐C) screen, indicating hazardous alcohol use or an active AUD, who had no exclusion criteria contraindicating naltrexone and were discharged from the ED. The primary outcome was provision of a naltrexone prescription at ED discharge, and the secondary outcome was prescription fill. We used a multivariable logistic regression model with generalized estimating equation (GEE) to identify predictors of prescribing.Results: Of 52,701 treatment‐eligible ED encounters, only 0.5% resulted in a naltrexone prescription. Prescriptions were more likely in encounters involving younger, male patients with higher AUDIT‐C scores, alcohol‐related complaints, and those occurring at an academic ED. In the logistic GEE model, academic setting, alcohol withdrawal diagnosis, and greater alcohol misuse severity were independently associated with increased prescribing. Nearly half (45%) of ED naltrexone prescriptions were filled.Conclusions: Naltrexone prescribing among treatment‐eligible patients is rare. Encouragingly, nearly half of patients receiving a prescription proceeded to fill it, highlighting a promising opportunity for ED‐based prescribing of naltrexone to initiate AUD treatment. To improve AUD care, systematic ED‐based strategies are urgently needed that go beyond universal screening to address barriers to MAUD initiation.

Rationale: Neuromuscular blockade (NMB) is frequently used during acute respiratory distress syndrome (ARDS) to improve ventilator synchrony. Which sedating medications are used concomitantly during NMB and whether sedation choice influences patient outcomes are unclear. Objectives: To determine national sedation practice patterns during NMB in patients with and at risk for ARDS and to establish whether the use of propofol and opioids compared with benzodiazepines and opioids is associated with improved outcomes. Methods: Using a U.S. national database from 2010 to 2021, intubated and mechanically ventilated patients receiving NMB for a diagnosis of ARDS or an ARDS risk factor over at least two hospital days after admission were included. Charges for sedation and analgesia during the first two hospital days were recorded for each patient. The relationships between propofol and opioids and between benzodiazepines and opioids, with a primary outcome of ventilator-free days, as well as secondary outcomes of 28-day survival and discharge home were examined in multivariable analyses. Results: We determined that the use of propofol has increased compared with that of benzodiazepines as the primary sedative used during NMB for ARDS. Compared with benzodiazepine and opioid use, propofol and opioid use during NMB for ARDS was associated with increased ventilator-free days (adjusted odds ratio, 1.38 [95% confidence interval, 1.24–1.54]), greater odds for survival at 28 days (adjusted odds ratio, 1.15 [95% confidence interval, 1.01–1.31]), and greater odds for discharge home (adjusted odds ratio, 1.26 [95% confidence interval, 1.09–1.46]), adjusting for patient-level and hospital-level characteristics. Conclusions: From 2010 to 2021, sedation practice during NMB for ARDS shifted from predominately benzodiazepine use to predominately propofol use. The use of propofol and opioids is associated with an increase in ventilator-free days compared with the use of benzodiazepines and opioids. These results suggest that sedation choice during NMB for ARDS may affect clinical outcomes; further investigation is needed to validate these findings.

The purpose of this work is to evaluate the feasibility of lung imaging using 3D electrical impedance tomography (EIT) during spontaneous breathing trials (SBTs) in patients with acute hypoxic respiratory failure. EIT is a noninvasive, nonionizing, real-time functional imaging technique, suitable for bedside monitoring in critically ill patients. EIT data were collected in 24 mechanically ventilated patients immediately preceding and during a SBT on two rows of 16 electrodes using a simultaneous multicurrent source EIT system for 3D imaging. Dynamic 3D EIT images of conductivity were computed, as well as the EIT-derived rapid shallow breathing index, regional ventilation delay, global inhomogeneity index, and time traces of tidal volumes. 3D reconstructions and derived measures demonstrated inhomogeneity in ventilation distribution within patients. We conclude that 3D EIT images can provide information regarding ventilatory heterogeneity across the lung and may be useful in guiding ventilator management.

We investigate the use of electrical impedance tomography, a non-invasive, non-ionizing imaging modality that provides real-time images of the ventilation distribution throughout the lung at the bedside, to image patients with acute hypoxic respiratory failure at the bedside and as data to inform an algorithm to determine the airway resistance throughout the bronchial tree. In this work, 3-D Electrical Impedance Tomography (EIT) difference image reconstructions and ventilator data are used in a multi-compartment lung model to solve an inverse problem to estimate the airway resistance along the bronchial tree. The method is demonstrated on five hospitalized patients who received mechanical ventilation as part of their hospital care. Comparisons of the EIT and airway resistance reconstructions are shown to be in good agreement with computed tomography (CT) scans and/or chest x-rays taken as part of the patients' care, and the results are consistent with their clinical condition. Patients with acute hypoxic respiratory failure often have heterogeneous distribution of ventilation, which makes the optimization of ventilator settings more difficult and increases the risk of ventilator-induced lung injury. Knowledge of the airway distribution along the bronchial tree could aid in determining personalized ventilator settings in such patients.

Background: Clinical trials in patients with COVID‐19 have exclusively used self‐ or proxy‐reporting to characterize alcohol consumption. The aim of this study was to measure an objective biomarker of recent alcohol use in patients hospitalized with severe COVID‐19‐associated respiratory failure who were enrolled in an investigational clinical trial to determine the prevalence of alcohol misuse, and to explore the relationship of alcohol use with outcomes.Methods: We conducted a substudy of patients enrolled in the multicenter, phase 2, adaptive platform design, Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging And molecular Analysis in COVID‐19 trial (ClinicalTrials.gov: NCT04488081), conducted at 20 hospital systems across the United States. Three hundred and fifty‐five patients with available red blood cell (RBC) samples and 60‐day follow‐up assessments were included. RBCs were utilized to measure phosphatidylethanol (PEth). Prespecified thresholds of PEth were utilized to stratify patients into groups: low/no alcohol use (PEth < 20 ng/mL), significant alcohol use (PEth 20–200 ng/mL), and heavy alcohol use (PEth ≥ 200 ng/mL).Results: In this cohort, 17% of patients met criteria for significant alcohol use, while 4% met criteria for heavy alcohol use. Alcohol misuse was associated with diminished odds for home discharge, though this finding did not achieve statistical significance.Conclusions: In a cohort of patients with severe COVID‐19 enrolled in a clinical trial, alcohol consumption of two or more standard drinks per day was present among 21%, approximating the proportion of patients with diabetes, and raising the possibility that alcohol consumption alters risk for severe viral pneumonia. Undetected alcohol misuse among clinical trial participants has the potential to influence study outcomes or contribute to adverse events.