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Aims The aims of the Critical Care Cardiology Trials Network (CCCTN) are to develop a registry to investigate the epidemiology of cardiac critical illness and to establish a multicentre research network to conduct randomised clinical trials (RCTs) in patients with cardiac critical illness. Methods and results The CCCTN was founded in 2017 with 16 centres and has grown to a research network of over 40 academic and clinical centres in the United States and Canada. Each centre enters data for consecutive cardiac intensive care unit (CICU) admissions for at least 2 months of each calendar year. More than 20 000 unique CICU admissions are now included in the CCCTN Registry. To date, scientific observations from the CCCTN Registry include description of variations in care, the epidemiology and outcomes of all CICU patients, as well as subsets of patients with specific disease states, such as shock, heart failure, renal dysfunction, and respiratory failure. The CCCTN has also characterised utilization patterns, including use of mechanical circulatory support in response to changes in the heart transplantation allocation system, and the use and impact of multidisciplinary shock teams. Over years of multicentre collaboration, the CCCTN has established a robust research network to facilitate multicentre registry-based randomised trials in patients with cardiac critical illness. Conclusion The CCCTN is a large, prospective registry dedicated to describing processes-of-care and expanding clinical knowledge in cardiac critical illness. The CCCTN will serve as an investigational platform from which to conduct randomised controlled trials in this important patient population.

Although multidimensional frailty scales have been proven to predict mortality and morbidity in cardiac surgery, there is a need for rapid tools that could be easily administered at the point of care. Handgrip strength (HGS) is an attractive option that can be measured in acutely ill and bed-bound patients, although it has yet to be validated in a large cardiac surgery cohort.This is a post hoc analysis of a multicentre prospective study in older patients undergoing coronary artery bypass grafting and/or valve surgery from 2011 to 2019. HGS was measured before surgery and classified by sex-stratified cutoffs. The primary outcome was 1-year mortality and secondary outcomes were 30-day mortality, discharge disposition, and prolonged length of stay.There were 1245 patients included in the analysis (mean age 74.0 ± 6.6 years; 30% female). Weak HGS was associated with advanced age, heart failure, kidney disease, malnutrition, and various frailty scales. In those with weak vs normal HGS, respectively, 1-year mortality was 17% vs 6%, 30-day mortality was 10% vs 3%, prolonged length of stay was 34% vs 19%, and discharge to a health care facility was 45% vs 26% (all P0.001). After adjustment, HGS was predictive of 1-year and 30-day mortalities, with odds ratios of 2.44 (95% confidence interval [CI] 1.39-4.29) and 2.83 (1.38-5.81), respectively. HGS cutoffs of26 kg in men and16 kg in women had the highest predictive performance.HGS is a simple and effective tool to identify patients at higher risk of mortality and protracted recovery after cardiac surgery.

Aim To assess the beliefs, attitudes and knowledge of nurses, physicians and physiotherapists in a cardiovascular intensive care unit (CICU) on patient mobilization. Design Survey of CV healthcare providers in the CICU at two academic tertiary care hospitals. Methods The validated Patient Mobilization Attitudes and Beliefs Survey was distributed to CV providers. The survey is a 26‐item self‐administered questionnaire that assesses providers' perceived barriers in three domains: attitude, behaviour and knowledge. Results Participants (N = 142) completed the survey (nurses, N = 67, physicians, N = 59 and physiotherapists, N = 16; 155 eligible participants, 91.6% overall completion rate). Nurses had lower overall knowledge, attitude and behaviour barriers to mobilization than physicians, but higher than physiotherapists (all p

This paper describes a knee prosthesis that provides primarily-passive behavior akin to a state-of-the-art modulated passive microprocessor-controlled knee prosthesis (MPK), but also offers powered stance and swing assistance, which are layered on top of the passive functionality. The combination of both passive and powered behaviors is enabled by a unique electronically-selectable two-speed transmission, which enables the combination of very low output impedance and high resistive torques necessary for passive functionality, while also enabling the generative torque-speed characteristics suitable for stance and swing phase assistance. A control system is described that consolidates behaviors appropriate for a wide range of activities of daily living (ADLs) into six states, with each state providing adaptive torque behaviors appropriate for different phases of gait, whether powered or passive. Experimental results on an individual with transfemoral amputation suggest that the prosthesis and controller provide similar or improved passive behaviors relative to a commercially-available MPK, in addition to providing powered functionality commensurate with a powered prosthesis.

Patient and family engagement in research may improve the design, conduct, and dissemination of clinical research, but little is known about whether these stakeholder groups are involved in the design and conduct of randomized clinical trials.To characterize the involvement and role of patient and family representatives in the design and conduct of randomized clinical trials by reviewing randomized clinical trials from 3 peer-reviewed medical and surgical journals with high impact factors.In this systematic review, the first 50 consecutive randomized clinical trials published on or after January 1, 2021, until September 30, 2021, from each of 3 medical and surgical journals with high impact factors were reviewed for patient or family involvement in trial design and/or conduct. The manuscript, supplemental data, and trial registry records were searched for trial design and governance structures. Two independent, blinded reviewers screened citations and extracted data. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.Only 7 of 150 randomized clinical trials (5%) reported patient or family representation in their study design or conduct. Most studies with patient or family representation (n = 5) were from a single journal. Stakeholder involvement was mainly in the execution phase (n = 7), although in 2 studies stakeholders were also involved in the translation phase.The findings of this systematic review suggest that patient or family involvement in the design and conduct of randomized clinical trials in the publications with high impact factors is lacking. We found that when patient or family groups are involved in research, the focus was mainly on the execution phase of research design. There is a need to increase stakeholder involvement in the research design, conduct, and translation of randomized clinical trials.

Early mobilization (EM) is recommended in critical care units. However, there is little known about EM in people with acute cardiovascular disease.Consecutive admissions to a tertiary-care cardiovascular intensive care unit (CICU) before and after implementation of an EM program were reviewed. The Level of Function (LOF) Mobility Scale, which ranges from 0 (bed immobile) to 5 (able to walk20 m), was used to measure and guide mobility. The primary outcome was discharge home.There were 1489 patients included in the analysis (preintervention, N = 637; intervention, N = 852). There were no differences in age, sex, or admission for ischemic heart disease (age 68.1 ± 16.1 years; 39.3% female). In the intervention cohort, one-quarter (N = 222; 26.1%) had at least mildly impaired prehospital functional status. The LOF was 4.6 ± 0.7 prehospital, 3.2 ± 1.4 on admission, and 4.2 ± 0.9 on CICU discharge. Half of patients (51.6%) increased their LOF by ≥1 during CICU admission. Nearly all mobility opportunities had a mobility activity (97.0%). The adverse event rate was 0.3% with no life-threatening events, falls, line dislodgements, or health care personnel injuries. The intervention group, compared with the preintervention group, was more likely to be discharged home (83.9% vs 78.3%, P0.007) and had a lower rate of in-hospital death (4.2% vs 6.8%; P = 0.04). When adjusted for age, sex, and comorbid illness, admission LOF was a predictor of discharge to health care facility (odds ratio = 0.72; P0.001).EM is safe and feasible in the CICU and effective at increasing discharge home.

This paper describes a semi-powered ankle prosthesis and corresponding unified controller that provides biomimetic behavior for level and sloped walking without requiring identification of ground slope or modulation of control parameters. The controller is based on the observation that healthy individuals maintain an invariant external quasi-stiffness (spring like behavior between the shank and ground) when walking on level and sloped terrain. Emulating an invariant external quasi-stiffness requires an ankle that can vary the set-point (i.e., equilibrium angle) of the ankle stiffness. A semi-powered ankle prosthesis that incorporates a novel constant-volume power-asymmetric actuator was developed to provide this behavior, and the unified controller was implemented on it. The device and unified controller were assessed on three subjects with transtibial amputations while walking on inclines, level ground, and declines. Experimental results suggest that the prosthesis and accompanying controller can provide a consistent external quasi-stiffness similar to healthy subjects across all tested ground slopes.

Background: Limited data exists regarding sex differences in outcome and predictive accuracy of intensive care unit-based scoring systems when applied to cardiac intensive care unit patients. Methods: We reviewed medical records of patients admitted to cardiac intensive care unit from 1 January 2011–31 December 2016. Sex differences in mortality rates and the performance of intensive care unit-based scoring systems in predicting in-hospital mortality were analyzed. Calibration was assessed by the Hosmer-Lemeshow test and locally weighted scatterplot smoothing curves. Discrimination was assessed using the c statistic and receiver-operating characteristic curve. Results: Among 6963 patients, 2713 (39%) were women. Overall in-hospital and cardiac intensive care unit mortality rates were similar in women and men (9.1% vs 9.4%, p=0.67 and 5.9% vs 6%, p=0.88, respectively) and in age and major diagnosis subgroups. Of the scoring systems, Acute Physiology and Chronic Health Evaluation III and Sequential Organ Failure Assessment had poor calibration (Hosmer-Lemeshow p value 0.8). In the subgroups of acute myocardial infarction and heart failure patients, all scores had good calibration (Hosmer-Lemeshow p>0.001) and discrimination (C statistic >0.8) while in diagnosis subgroups with highest mortality, the calibration varied among scores and by sex, and discrimination was poor. Conclusions: No sex differences in mortality were seen in cardiac intensive care unit patients. The mortality predictive value of intensive care unit-based scores is limited in both sexes and variable among different subgroups of diagnoses.

Background Early mobilization (EM) is beneficial in critical care units and in older hospitalized patients, but little is known about EM in older adults with acute cardiovascular disease. Methods Consecutive admissions of adults ≥80 years old to a Cardiac Intensive Care Unit (CICU) prior to and following implementation of a nurse-driven EM program were reviewed. Mobility was measured using the Level of Function (LOF) Mobility Scale, which ranges from 0 (bed immobile) to 5 (able to walk >20 meters). The primary outcome was discharge home. Results There were 412 patients included (N = 234, intervention; N = 178, preintervention). There was no difference in age between groups (overall 86.3 ± 4.8 years old) or sex (overall female N = 215, 52.2%). In the intervention group, functional impairment was present in 89 patients (38.0%) prehospitalization and in 209 patients (89.3%) on admission. Nearly half of patients (N = 107; 45.7%) improved their LOF by ≥1 during admission. Mobilization occurred during nearly all opportunities (838/850; 98.6%), and most mobility activities were completed (2,207/2,553; 86.4%). Adverse events were rare (5/2,207 activities [0.2% adverse event rate]) and transient. Patients in the intervention group were more likely than patients in the preintervention group to be discharged home (74.4 vs. 65.7%, P = 0.047, respectively) and had a lower rate of in-hospital death (6.4 vs. 14.6%, P = 0.006, respectively). There was no difference in mean length of hospital stay, 30-day emergency department visit or hospital re-admission. Conclusion EM is safe in older adults in the CICU and is associated with reduced discharge to healthcare facility and in-hospital mortality.

People with severe mental illness, consisting of schizophrenia, bipolar disorder, and major depression, have a high burden of modifiable cardiovascular risk behaviors and conditions and have a cardiovascular mortality rate twice that of the general population. People with acute and chronic cardiovascular disease are at a higher risk of developing mental health symptoms and disease. There is emerging evidence for shared etiological factors between severe mental illness and cardiovascular disease that includes biological, genetic, and behavioral mechanisms. This state-of-the art review will describe the relationship between severe mental illness and cardiovascular disease, explore the factors that lead to poor cardiovascular outcomes in people with severe mental illness, propose strategies to improve the cardiovascular health of people with severe mental illness, and present areas for future research focus.

Robotics is a forward-looking discipline. Attention is focused on identifying the next grand challenges. In an applied field such as medical robotics, however, it is important to plan the future based on a clear understanding of what the research community has recently accomplished and where this work stands with respect to clinical needs and commercialization. This Review article identifies and analyzes the eight key research themes in medical robotics over the past decade. These thematic areas were identified using search criteria that identified the most highly cited papers of the decade. Our goal for this Review article is to provide an accessible way for readers to quickly appreciate some of the most exciting accomplishments in medical robotics over the past decade; for this reason, we have focused only on a small number of seminal papers in each thematic area. We hope that this article serves to foster an entrepreneurial spirit in researchers to reduce the widening gap between research and translation. ISSN:2470-9476

Older adults undergoing major surgery have increased protein requirements in the postoperative period, but there are limited data describing actual protein intake following cardiac surgery.We performed a prospective sub-study within a registry of older adults ≥60 years of age undergoing cardiac surgery at a tertiary care centre. A dietician administered a food frequency questionnaire before surgery and 1-4 months after surgery. In-hospital food intake was recorded by direct observation for 3 days in the early postoperative period. Food intake was analyzed to calculate the protein intake per kilogram of body weight per day (g/kg/d) during the three phases of care, compared to the dietary reference intake. Frailty was measured by a questionnaire and physical performance tests before surgery. There were 22 patients (8 females, 14 males; 59% frail) enrolled in the study with a mean age of 72.0 ± 7.8 years. The mean protein intake was 1.3 ± 0.5 g/kg/d, 0.7 ± 0.3 g/kg/d, and 1.3 ± 0.6 g/kg/d in the preoperative, early postoperative, and postdischarge periods, respectively (P 0.0001 for early postoperative compared to other periods). Compared to the targeted dietary reference intake of 1.5 g/kg/d, there was a mean protein deficit of 0.8 g/kg/d in the early postoperative period. Only one patient (5%) met the protein dietary reference intake in the early postoperative period.In older adults undergoing cardiac surgery, dietary protein intake was substantially lower than the recommended target in the early postoperative period. Strategies to improve protein intake, particularly in frail older patients, may be considered as a therapeutic target.

Background The experimental study of stumble recovery is essential to better understanding the reflexive mechanisms that help prevent falls as well as the deficiencies in fall-prone populations. This study would benefit from a system that can introduce perturbations that: 1) are realistic (e.g., obstacle disrupting the foot in swing phase), 2) are unanticipated by subjects, 3) are controllable in their timing, and 4) allow for kinematic and kinetic evaluation. Methods A stumble perturbation system was designed that consists of an obstacle delivery apparatus that releases an obstacle onto a force-instrumented treadmill and a predictive targeting algorithm which controls the timing of the perturbation to the foot during swing phase. Seven healthy subjects were recruited to take part in an experimental protocol for system validation, which consisted of two sub-experiments. First, a perception experiment determined whether subjects could perceive the obstacle as it slid onto the treadmill belt. Second, a perturbation experiment assessed the timing accuracy of perturbations relative to a target percent swing input by the experimenter. Data from this experiment were then used to demonstrate that joint kinematics and kinetics could be computed before and after the perturbation. Results Out of 168 perception trials (24 per subject), not a single obstacle was perceived entering the treadmill by the subjects. Out of 196 perturbation trials, 190 trials successfully induced a stumble event, with a mean targeting accuracy, relative to the desired percent swing, of 25 ms (6.2% of swing phase). Joint kinematic and kinetic results were then computed for three common stumble recovery strategies and shown to be qualitatively consistent with results from prior stumble studies conducted overground. Conclusions The stumble perturbation system successfully introduced realistic obstacle perturbations that were unanticipated by subjects. The targeting accuracy substantially reduced mistrials (i.e., trials that did not elicit a stumble) compared to previous studies. This accuracy enables stumble recovery to be studied more systematically as a function of when the perturbation occurs during swing phase. Lastly, joint kinematic and kinetic estimates allow for a comprehensive analysis of stumble recovery biomechanics. Electronic supplementary material The online version of this article (10.1186/s12984-019-0527-7) contains supplementary material, which is available to authorized users.

This paper describes stair ambulation control and functionality of a semi-powered knee prosthesis that supplements nominally passive prosthesis behavior with swing-phase assistance. A set of stair ascent and descent controllers are described. The controllers were implemented in a semi-powered prosthesis prototype, and the prospective benefits of swing assist in stair ambulation were assessed on a group of three participants with unilateral, transfemoral amputation, relative to their respective daily-use prostheses. Results indicate that ambulation with the semi-powered knee resulted in improved stair ascent gait symmetry when compared to the participants’ passive daily-use devices, and increased similitude to healthy stair ascent movement.

Background Transfemoral prosthesis users’ high fall rate is related to increased injury risk, medical costs, and fear of falling. Better understanding how stumble conditions (e.g., participant age, prosthesis type, side tripped, and swing phase of perturbation) affect transfemoral prosthesis users could provide insight into response deficiencies and inform fall prevention interventions. Methods Six unilateral transfemoral prosthesis users experienced obstacle perturbations to their sound limb in early, mid, and late swing phase. Fall outcome, recovery strategy, and kinematics of each response were recorded to characterize (1) recoveries versus falls for transfemoral prosthesis users and (2) prosthesis user recoveries versus healthy adult recoveries. Results Out of 26 stumbles, 15 resulted in falls with five of six transfemoral prosthesis users falling at least once. By contrast, in a previously published study of seven healthy adults comprising 214 stumbles using the same experimental apparatus, no participants fell. The two oldest prosthesis users fell after every stumble, stumbles in mid swing resulted in the most falls, and prosthesis type was not related to strategy/fall outcomes. Prosthesis users who recovered used the elevating strategy in early swing, lowering strategy in late swing, and elevating or lowering/delayed lowering with hopping in mid swing, but exhibited increased contralateral (prosthetic-side) thigh abduction and trunk flexion relative to healthy controls. Falls occurred if the tripped (sound) limb did not reach ample thigh/knee flexion to sufficiently clear the obstacle in the elevating step, or if the prosthetic limb did not facilitate a successful step response after the initial sound-side elevating or lowering step. Such responses generally led to smaller step lengths, less anterior foot positioning, and more forward trunk flexion/flexion velocity in the resulting foot-strikes. Conclusions Introducing training (e.g., muscle strength or task-specific motor skill) and/or modifying assistive devices (e.g., lower-limb prostheses or exoskeletons) may improve responses for transfemoral prosthesis users. Specifically, training or exoskeleton assistance could help facilitate sufficient thigh/knee flexion for elevating; training or prosthesis assistance could provide support-limb counteracting torques to aid in elevating; and training or prosthesis assistance could help initiate and safely complete prosthetic swing.

The ongoing coronavirus disease 2019 (COVID-19) pandemic has placed pressure on healthcare systems and intensive care unit capacity worldwide. Respiratory insufficiency is the most common reason for hospital admission in patients with COVID-19. The most severe form of respiratory failure is acute respiratory distress syndrome (ARDS), which is associated with significant morbidity and mortality. Patients with ARDS are often treated with invasive mechanical ventilation according to established evidence-based and guideline recommended management strategies. With growing strain on critical care capacity, clinicians from diverse backgrounds, including cardiovascular specialists, may be required to help care for the growing number of patients with severe respiratory failure and ARDS. The aim of this article is to outline the fundamentals of ARDS diagnosis and management, including mechanical ventilation (MV), for the non-intensivist. In the absence of MV trials specifically in COVID-19 associated ARDS, the information presented is based on general ARDS trials., Brief Summary The acute respiratory distress syndrome (ARDS) is a serious condition with significant morbidity and mortality. During the current COVID-19 pandemic, non-intensivists, including cardiovascular specialists, may be called upon to help manage critically ill patients with ARDS. This article aims to provide a concise and pragmatic review of the diagnosis and management of ARDS, with a focus on the basic principles of safe mechanical ventilation which can be applied to patients with respiratory failure including those with COVID-19.

Risk-adjusted mortality has been proposed as a quality of care indicator to gauge cardiovascular intensive care Unit (CICU) performance. Mortality is easily measured, readily understandable, and a meaningful outcome for the patient, provider, administrative agencies, and other key stakeholders. Disease-specific risk-adjusted mortality is commonly used in cardiovascular medicine as an indicator of care quality, for external accreditation, and to determine payer reimbursement. However, the evidence base for overall risk-adjusted mortality in the CICU is limited, with most available data coming from the general critical care literature. In addition, existing risk-adjusted mortality models vary considerably in terms of approach and composition, and there is no nationally recognized standard. Thus, the objective of this study was to review the use of risk-adjusted mortality as a measure of overall unit performance and quality of care in the CICU. We found a considerable variability in the risk-adjustment methodology for cardiovascular disease. Although predictive models for disease-specific risk-adjusted mortality in cardiovascular disease have been developed, there are limited published data on overall risk-adjusted mortality for the CICU. Without standardization of risk-adjustment methodology, researchers are often required to use existing risk-adjustment models developed in noncardiac patient populations. Further studies are needed to establish whether risk-adjusted overall CICU mortality is a valid performance measure and whether it reflects care quality.

This paper presents a control system for a powered transtibial prosthesis that provides stair ascent and descent capability, as well as ability for user-controlled transitions between walking, standing, stair ascent, and stair descent. The control system was implemented on a powered prosthesis and evaluated on a single unilateral transtibial amputee subject. The ability of the prosthesis to provide appropriate functionality during stair ascent and descent was assessed by comparing gait kinematics and kinetics of the prosthesis to those of a passive dynamic elastic response prosthesis and those of a set of non-amputee subjects. Data from the assessment indicates that the powered prosthesis is able to provide some desirable stair ascent and stair descent characteristics, relative to the passive prosthesis.

This paper describes the development of a controller for a powered ankle prosthesis that is intended to provide appropriate biomechanical behavior for walking on both even and uneven terrain without having to explicitly detect local slope to do so. In order to inform development of the controller, the authors conducted a small study of five healthy subjects walking on even and uneven terrain. Data from the healthy subject study were used to formulate behavioral models for the healthy ankle, which were then implemented as controller behaviors in the powered prosthesis prototype and comparatively assessed on an amputee subject.

Noncardiovascular comorbidities and critical illness are increasing in cardiovascular intensive care units (CICUs). There are limited data comparing critical care delivery, resource utilization, and costs between contemporary CICUs and medical intensive care units (MICUs).All CICU (n = 6967; 22 748 patient-days) and MICU (n = 10 892; 39 211 patient-days) admissions to Cedars-Sinai Medical Center, a tertiary care academic medical center, between January 2011 and December 2016 were reviewed. Both the CICU and MICU admitted patients for primary cardiovascular or medical conditions during the study period, but not for postoperative surgical care.Patients admitted to the CICU were more frequently older, male, and had more preexisting cardiac disease ( P.0001). More than one-fifth (21.4%) of CICU patients had a noncardiovascular primary admission diagnosis, compared to 89.2% of MICU patients. Cardiovascular intensive care unit patients had lower Acute Physiology and Chronic Health Evaluation III scores (51.1 [19.9] vs 61.1 [24.9], P.0001) and shorter median hospital length of stay ( P.001), but not in-unit stay, as compared to MICU patients. Mechanical ventilation, vasopressors, inotropes, renal replacement therapy, and/or blood transfusion were required in 35.0% of CICU patients compared with 62.2% of MICU patients ( P.0001). The unit mortality rate was lower for CICU than MICU patients (4.8% vs 13.0%, P.0001), as was the hospital mortality rate (9.3% vs 21.6%, P.0001). The standardized mortality ratio was 0.73 for the CICU and 0.86 for the MICU. There was no difference in the mean direct cost of care per patient-day between the CICU and MICU ($4011 USD [376] vs $3990 USD [214], P = .77).The burden of noncardiovascular diseases and the requirement for critical care therapies are high in contemporary CICU patients but remain lower compared to the MICU population. Our findings support the growing complexity of care in tertiary CICUs. Further studies are required to explore the association between critical care delivery and outcomes in this evolving population.

“You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome.”—Hunter Patch Adams [(1)][1] Years of training had thoroughly ingrained in my mind that all medical care, by definition, was focused on the patient. Thus, when I first heard

This paper describes the implementation of a movement control method for lower limb exoskeletons with single-joint actuation. In such applications, the single-joint must coordinate movement with other non-controlled joints. The authors have previously proposed a multi-joint control method called a flow controller, which provides several desirable characteristics for such assistance. In this paper, the authors adapt the fundamentally multi-joint flow control approach to a system with a single actuated joint, but with multiple movement degrees of freedom. The single degree of actuation flow control method was implemented on a representative system, specifically a knee exoskeleton that coordinates assistance with ipsilateral thigh movement during walking. The ability of the controller and knee exoskeleton to appropriately influence knee movement was evaluated in level walking experiments on three subjects with unilateral lower-limb impairment. Results show the device and controller provide improvements in knee movement in all subjects. Subjective feedback from the subjects indicates a high level of comfort with the controller.

Background: Emerging evidence suggests that coronary intensive care units are evolving into intensive care environments with an increasing burden of non-cardiovascular illness, but previous studies have been limited to older populations or single center experiences. Methods: Canadian national health-care data was used to identify all patients ≥18 years admitted to dedicated coronary intensive care units (2005–2015) and admissions were categorized as primary cardiac or non-cardiac. The outcomes of interest included longitudinal trends in admission diagnoses, critical care therapies, and all-cause in-hospital mortality. Results: Among the 373,992 patients admitted to a coronary intensive care unit, minimal changes in the proportion of patients admitted with a primary cardiac (88.2% to 86.9%; p Conclusion: In a national dataset we observed a changing case-mix among patients admitted to a coronary intensive care unit, though the proportion of patients with a primary cardiac diagnosis remained stable. There was an increase in clinical acuity highlighted by critical care therapies, but in-hospital mortality rates for both primary cardiac and non-cardiac conditions declined across all hospitals. Our findings confirm the changing coronary intensive care unit case-mix and have implications for future coronary intensive care unit training and staffing.

BACKGROUND There are currently no validated tools that are reliable and easy to use for nurses to assess mobility in people with acute cardiovascular disease in the Cardiovascular Intensive Care Unit (CICU). METHODS A multidisciplinary team at an academic tertiary care centre developed the Level of Function (LOF) Mobility Scale for use in a nurse-driven early progressive mobilisation in the CICU. To determine inter-rater reliability, the prehospital and admission LOF were assessed independently by two CICU nurses. Pairwise comparisons between raters were evaluated using Cohen's kappa statistic. To determine convergence validity, the LOF and Activity Measure for Post-Acute Care 6-Clicks score upon admission were compared with Spearman's correlation. To determine feasibility, a 9-item mobility scale questionnaire was distributed to CICU nurses with and without experience using the LOF Mobility Scale. The STROBE reporting guidelines were used. RESULTS The LOF Mobility Scale had good inter-rater reliability for assessment of LOF prior to hospitalisation (N = 131, kappa = 0.66, p

The cardiac intensive care unit (CICU) has changed considerably over time and now serves a unique patient population with a high burden of cardiovascular and noncardiovascular critical illness. Patient complexity and technological evolutions in the CICU have catalyzed the development of critical care cardiology, a fledgling discipline that combines specialization in cardiovascular diseases with knowledge and experience in critical care medicine. Numerous uncertainties and challenges threaten to stymie the growth of this field. A multidisciplinary dialogue focused on the best care design for the CICU patient is needed as we consider alternative approaches to clinical training, staffing, and investigation in this rapidly evolving arena.

Bedrest and immobilization following a myocardial infarction (MI) can lead to functional impairment that can persist following hospitalization. Early mobilization (EM) is associated with good functional and clinical outcomes in critical care, medical and surgical settings. However, the impact and current role of EM in post-MI care has not been well-defined. Our objective was to assess the evidence for post-MI mobilization, define current post-MI mobilization practice, and understand perspectives of cardiovascular professionals toward mobilization. A scoping review related to "early mobilization" and "myocardial infarction" was performed using the Joanna Briggs Institute Methodology. Pubmed, Embase, Google Scholar, Cochrane Library and CINAHL databases were included. Results were categorized into six topic areas. There were 59 references included in the analysis. There was evidence for the effectiveness and safety of earlier mobilization in experimental studies of the pre-revascularization era, but there was a lack of strong evidence for EM in contemporary post-MI care. Mobilization appears to be safe following arterial catheterization and is associated with minimal hemodynamic and respiratory compromise. Most people are delayed in mobilizing post-MI and spend the majority of the initial hospitalization period lying in bed. Only 1 of 7 current major cardiovascular professional societies guidelines recommend EM post-MI. There were no studies exploring the perspectives of cardiovascular professionals toward mobilization. EM may be beneficial in the post-MI care. However, there is an evidence gap for the impact of EM post-MI in the contemporary literature. More robust evidence from randomized clinical trials is required to inform clinicians and influence practice.

This paper presents the design and control of a lightweight swing assist (SA) knee prosthesis. The SA knee relies on passive stability to provide support during the stance phase of walking and incorporates a small motor and battery to actively assist the knee motion during the swing phase. A prototype SA knee was constructed and experimentally evaluated on a single transfemoral amputee. The experiments consisted of treadmill walking at three speeds, first on a dailyuse passive prosthesis and subsequently on the SA prosthesis prototype, while recording motion capture and ground reaction force data from which prosthesis knee kinematics and affectedside hip torque were computed. A comparison of the passive daily-use prosthesis and the SA prosthesis indicates that the SA prosthesis provides more consistent and repeatable knee motion and reduces pre-swing peak hip torque across all walking speeds.

This paper describes a controller for guiding and assisting leg movement during walking with a lower limb exoskeleton with actuated hip and knee joints. The primary novel aspect of the controller is that it employs a virtual flow field to influence movement during swing, rather than a more typical potential-energy-based field. The controller was tested on a single stroke subject. The stroke subject's leg kinematics demonstrate that the controller is capable of appropriately influencing leg kinematics during overground walking.

Older adults account for an increasing number of cardiac intensive care unit (CICU) admissions. This study sought to determine the predictive value of illness severity scores for mortality in CICU patients ≥70 years of age. Adult patients admitted to the CICU from 2007 to 2015 at one tertiary care hospital were reviewed. Severity of illness scores were calculated on the first CICU day. Area under the receiver-operator characteristic curve (AUROC) values were used to assess discrimination for hospital mortality in patients ≥70 versus

Little is known about the effects of early mobilization in older adults in the Cardiovascular Intensive Care Unit (CICU).We reviewed consecutive patients ≥60 years of age admitted to the CICU at an academic tertiary care center from 2016 to 2017. The level of function (LOF) was assessed prehospital, at CICU admission, and at CICU transfer using a graded scale ranging from LOF 1 (bedbound) to 4 (walk 50 ft). The prehospital frailty status was assessed using Rockwood's Clinical Frailty Scale. We sought to determine whether the mean change of LOF during CICU admission differed based on frailty status.There were 264 patients in the cohort (77.1 ± 9.3 years old; 40% female; 34% frail). Frail patients were more likely to have lower prehospital, CICU admission, day of transfer LOFs (all P 0.001). The mean LOF improvement during CICU stay was 0.5 ± 0.8 and did not differ based on frailty status. Frailty was not predictive of EM responsiveness in the adjusted analysis.EM is feasible in older adults admitted to the CICU. Functional status improved in both frail and non-frail older adults during CICU admission. Prospective studies are needed to determine whether frail older adults may benefit from EM.

This paper presents a control approach for a lower-limb exoskeleton intended to facilitate recovery of walking in individuals with lower-extremity hemiparesis after stroke. The authors hypothesize that such recovery is facilitated by allowing the patient rather than the exoskeleton to provide movement coordination. As such, an assistive controller that provides walking assistance without dictating the spatiotemporal nature of joint movement is described here. Following a description of the control laws and finite state structure of the controller, the authors present the results of an experimental implementation and preliminary validation of the control approach, in which the control architecture was implemented on a lower limb exoskeleton, and the exoskeleton implemented in an experimental protocol on three subjects with hemiparesis following stroke. In a series of sessions in which each patient used the exoskeleton, all patients showed substantial single-session improvements in all measured gait outcomes, presumably as a result of using the assistive controller and exoskeleton.

This paper presents a running control architecture for a powered knee and ankle prosthesis that enables a transfemoral amputee to run with a biomechanically appropriate running gait and to intentionally transition between a walking and running gait. The control architecture consists firstly of a coordination level controller, which provides gait biomechanics representative of healthy running, and secondly of a gait selection controller that enables the user to intentionally transition between a running and walking gait. The running control architecture was implemented on a transfemoral prosthesis with powered knee and ankle joints, and the efficacy of the controller was assessed in a series of running trials with a transfemoral amputee subject. Specifically, treadmill trials were conducted to assess the extent to which the coordination controller provided a biomechanically appropriate running gait. Separate trials were conducted to assess the ability of the user to consistently and reliably transition between walking and running gaits.

Background Relatives of people with coronary artery disease are at high risk of cardiovascular (CV) disease, but the effect of focused screening and treatment of this population is uncertain. Methods We searched the Cochrane Library, Medline, and Embase from inception until June 30, 2014 for articles that described screening strategies and primary prevention interventions targeting family members of patients with coronary artery disease to reduce CV risk. Results were pooled using a random-effects meta-analysis. Results We identified 18 studies that reported screening strategies and 15 reporting interventions to reduce CV risk. Proband willingness to refer relatives for screening was high (n = 6 studies, pooled rate = 87%; 95% confidence interval [CI], 80%-95%). Studies using a screening strategy in which the relative was contacted by health care professionals reported a pooled participation rate of 88% (95% CI, 78%-99%). The quality of interventional studies was highly variable. Random-effects meta-analysis of the highest quality randomized studies (n = 6) consisting of a specialized risk factor intervention compared with usual care was consistent with modest improvements in low-density lipoprotein cholesterol control (−0.18 mmol/L low-density lipoprotein cholesterol, 95% CI, −0.35 to −0.001; P = 0.048). Improvements in diet, smoking rates, exercise, and blood pressure were also observed with active intervention; however, reported outcomes were heterogeneous precluding a formal meta-analysis. Conclusions Screening strategies that target family members, particularly when led by a health care professional, achieve a high participation rate. Although the available evidence is of variable quality, interventions that target individuals with a family history of coronary artery disease appear to be feasible and might be effective in improving certain risk factors or health behaviours but their long-term CV benefits remain uncertain.

This paper presents a control approach for a myoelectric transhumeral prostheses that supplements a typical two-site electromyograms (EMG) input with the inertial measurement of arm motion. The inertial measurement is employed to: 1) provide synergistic movement between the prosthetic elbow joint and intact upper arm and 2) to switch control between the myoelectric elbow and hand. In order to assess the prospective efficacy of the control method, experiments were conducted on six healthy subjects who performed a series of pick-and-place tasks within a virtual environment. The assessments compared the time required to complete the pick-and-place tasks using the proposed coordinated control approach, with the time required using a sequential control approach (i.e., the conventional approach used in commercial devices). Subjects on average completed the pick-and-place tasks 34% faster with the coordinated control approach, relative to the conventional sequential EMG method, with no difference in compensatory torso motion.

Acquired von Willebrand syndrome (VWS) due to loss of high-molecular-weight multimers (HMWMs) has been reported with longer term mechanical devices and is associated with mucosal bleeding, a primary hemostasis type of bleeding. However, little is known whether a similar defect occurs in patients with short-term mechanical circulatory support (STMCS) devices. We reviewed von Willebrand factor (VWF) profiles in patients with STMCS devices who underwent VWS workup from December 2015 to March 2017 at an academic quaternary care hospital. There were a total of 18 patients (57.0 ± 12.7 years old; 83.3% male) including nine with mucosal bleeding and nine with decreasing hemoglobin. The STMCS devices included Impella (n = 11), Impella and right ventricular assist device (n = 2), and an extracorporeal membrane oxygenator (n = 5). The mean HMWM by quantitative VWF multimer analysis was 3.6% ± 1.3% (normal cutoff: 18–34%). In all 10 cases in which VWF activity, fibrinogen, factor VIII, or VWF antigen level were obtained, they were either normal or elevated. All cases demonstrated high normal or elevated levels of low molecular weight multimers (LMWMs). These findings are consistent with type 2 VWS (qualitative defect). This is the first study that quantitatively describes STMCS device–associated HMWM loss, which may contribute to mucosal bleeding. This finding may have implications for intraoperative management during implantation of longer term devices or heart transplantation or other surgery while on STMCS.

Background Quality indicators (QIs) are increasingly used in cardiovascular care as measures of performance but there is currently no consensus on indicators for the cardiovascular intensive care unit (CICU). Methods We searched Medline, CINAHL, EMBASE, and COCHRANE databases from inception until October 2016 and websites for organizations involved in quality measurement for QIs relevant to cardiovascular disease in an intensive or critical care setting. We surveyed 14 expert cardiac intensivist–administrators (7 European; 7 North American) on the importance and relevance of each indicator as a measure of CICU care quality using a scale of 1 (=lowest) to 10 (=highest). Indicators with a mean score ≥8/10 for both importance and relevance were included in the final set. Results Overall, 108 QIs (70 process, 18 structural, 18 outcome, 1 patient engagement, and 1 covering multiple domains) were identified in 30 articles representing 23 agencies, organizations, and societies. Disease-specific QIs included myocardial infarction (n = 37), heart failure (n = 31), atrial fibrillation (n = 11), and cardiac rehabilitation (n = 1); general QIs represented about one-quarter (n = 28) of all measures. Fifteen QIs were selected for the final QI set: 7 process, 2 structural, and 6 outcome measures, including 6 general and 9 disease-specific measures. Outcome measures chosen to evaluate general CICU performance included overall CICU mortality, length of stay, and readmission rate. Conclusions Numerous QIs relevant to the CICU have been recommended by a variety of organizations. The indicators chosen by the cardiac intensivist–administrators could serve as a basis for future efforts to develop a standardized set of quality measures for the CICU.

There are over 300,000 out-of-hospital cardiac arrests (OOHCA) in the United States each year, and the long-term survival rate is less than 10%. Despite improvements in postarrest management, the greatest drop-off in survival occurs during hospitalization, mostly due to myocardial dysfunction and neurological injury. Coronary artery disease is common in postcardiac arrest patients, with an incidence of approximately 60-80%. In patients with a chest pain syndrome and an ST-segment-elevation myocardial infarction pattern evident on the presenting electrocardiogram, immediate revascularization is recommended by cardiovascular societies due to established mortality benefits. However, it is less clear whether immediate or urgent coronary angiography for OOHCA survivors without ST elevation on the presenting electrocardiogram is beneficial. The current evidence base suggests that many OOHCA survivors, particularly when an acute coronary event is suspected, stand to benefit from early coronary angiography, although prospective trial data are lacking. Further studies are needed to identify whether all or even a subset of OOHCA survivors without ST elevation should undergo routine early coronary angiography.

Objective: This paper describes a gait classification method that utilizes measured motion of the thigh segment provided by an inertial measurement unit. Methods: The classification method employs a phase-variable description of gait, and identifies a given activity based on the expected curvature characteristics of that activity over a gait cycle. The classification method was tested in experiments conducted with seven healthy subjects performing three different locomotor activities: level ground walking, stair descent, and stair ascent. Classification accuracy of the phase variable classification method was assessed for classifying each activity, and transitions between activities, and compared to a linear discriminant analysis (LDA) classifier as a benchmark. Results: For the subjects tested, the phase variable classification method outperformed LDA when using nonsubject-specific training data, while the LDA outperformed the phase variable approach when using subject-specific training. Conclusions: The proposed method may provide improved classification accuracy for gait classification applications trained with nonsubject-specific data. Significance: This paper offers a new method of gait classification based on a phase variable description. The method is shown to provide improved classification accuracy relative to an LDA pattern recognition framework when trained with nonsubject-specific data.

This paper presents the design of a hand exoskeleton intended to enable or facilitate bimanual activities of daily living (ADLs) for individuals with chronic upper extremity hemiparesis resulting from stroke. The paper describes design of the battery-powered, self-contained exoskeleton and presents the results of initial testing with a single subject with hemiparesis from stroke. Specifically, an experiment was conducted requiring the subject to repeatedly remove the lid from a water bottle both with and without the hand exoskeleton. The relative times required to remove the lid from the bottles was considerably lower when using the exoskeleton. Specifically, the average amount of time required to grasp the bottle with the paretic hand without the exoskeleton was 25.9 s, with a standard deviation of 33.5 s, while the corresponding average amount of time required to grasp the bottle with the exoskeleton was 5.1 s, with a standard deviation of 1.9 s. Thus, the task time involving the paretic hand was reduced by a factor of five, while the standard deviation was reduced by a factor of 16.

This paper presents the design and characterization of a power-asymmetric actuator for a transtibial prosthesis. The device is designed to provide the combination of: 1) joint locking, 2) high power dissipation, and 3) low power generation. This actuator functionality allows for a prosthesis to be designed with minimal mass and power consumption relative to a fully-powered robotic prosthesis while maintaining much of the functionality necessary for activities of daily living. The actuator achieves these design characteristics while maintaining a small form factor by leveraging a combination of electromechanical and hydraulic components. The design of the actuator is described herein, and results of an experimental characterization are provided that indicate that the actuator is capable of providing the functional capabilities required of an ankle prosthesis in a compact and lightweight package.

To determine whether patient- and family-centered care interventions in the ICU improve outcomes.We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016.We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs.We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes.There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.

This paper describes the design, implementation, and preliminary validation of a controller for a powered lower-limb exoskeleton that reshapes a user's leg movement during over-ground walking. The intended application of the controller is to facilitate gait training for individuals suffering from post-stroke hemiparesis. The controller mimics a kinematic constraint between the knee and hip joints during the swing phase of gait, such that movement is not dependent on time (i.e., step time is determined entirely by the user). The controller additionally incorporates real-time path planning adjustment that allows step length to be adjusted by the user. As such, the controller provides movement coordination, but still enables a user to retain the step-to-step variability required to maintain balance during walking. As a preliminary assessment of efficacy, the controller was implemented on a lower limb exoskeleton and tested on a healthy subject, who walked at varying speeds without the use of a stability aid, with and without the proposed controller. The data indicates that the exoskeleton with controller provided the intended extent of movement coordination, while still allowing the subject to maintain walking balance.

Energy drink (ED) consumption has been linked to several adverse event reports, but there is limited data on related cardiovascular (CV) complications. We describe clinical characteristics, ED consumption profile, co-ingestions, and results of cardiovascular testing in a series of cardiovascular event reports temporally related to ED consumption from the literature. We searched PubMed and Embase for case reports in peer-reviewed journals from January 1, 1980, to February 1, 2013, in which an acute CV event was associated temporally with ED consumption. We identified 14 eligible articles involving 15 cases (5 atrial arrhythmias, 5 ventricular arrhythmias, 1 QT prolongation, 4 ST-segment elevations). Two additional cases of cardiac arrest from our institution are included. Of these 17 cases of ED-related acute CV events (13 male cases; 15 cases aged30 years, age range 13 to 58 years), only 1 had minor previous cardiac disease. Cardiac investigations did not reveal any predisposing cardiac abnormality in the majority of cases. Of the 11 cases related to a serious event (i.e., cardiac arrest, ventricular arrhythmia, or ST-segment elevations), 5 reported acute heavy ED consumption, 4 reported co-ingestions with alcohol or other drugs, and 2 were found to have a channelopathy. Potential mechanisms of ED-related cardiac events are reviewed. In conclusion, several adverse CV events after consuming ED have been reported in the literature. Although causality cannot be inferred from our series, physicians should routinely inquire about ED consumption in relevant cases, and vulnerable consumers such as youth should be advised that caution is warranted with heavy consumption and/or with concomitant alcohol or drug ingestion.

This paper presents a finite state-based control system for a powered transfemoral prosthesis that provides stair ascent and descent capability. The control system was implemented on a powered prosthesis and evaluated by a unilateral, transfemoral amputee subject. The ability of the powered prosthesis to provide stair ascent and descent capability was assessed by comparing the gait kinematics, as recorded by a motion capture system, with the kinematics provided by a passive prosthesis, in addition to those recorded from a set of healthy subjects. The results indicate that the powered prosthesis provides gait kinematics that are considerably more representative of healthy gait, relative to the passive prosthesis, for both stair ascent and descent.

This paper describes a control method intended to facilitate improved control of a myoelectric prosthesis containing a wrist rotator. Rather than exclusively utilizing electromyogram (EMG) for the control of all myoelectric components (e.g., a hand and a wrist), the proposed controller utilizes inertial measurement (from six-axis inertial measurement unit (IMU)) to sense upper arm abduction/adduction, and uses this input to command a wrist rotation velocity. As such, the controller essentially substitutes shoulder abduction/adduction in place of agonist/antagonist EMG to control wrist angular velocity, which preserves EMG for control of the hand (or other arm components). As a preliminary assessment of efficacy, the control method was implemented on a transradial prosthesis prototype with a powered wrist rotator and hand, and experimentally assessed on five able-bodied subjects who wore the prototype using an able-bodied adaptor and one transradial amputee subject while performing assessments representative of activities of daily living. The assessments compared the (timed) performance of the combined EMG/ IMU-based control method with a (conventional) sequential EMG control approach. Results of the assessment indicate that the able-bodied subjects were able to perform the tasks 33% faster on average with the EMG/IMU-based method, relative to a conventional sequential EMG method. The same assessment was subsequently conducted using a single transradial amputee subject, which resulted in similar performance trends, although with a somewhat lessened effect size—specifically, the amputee subject was on average 22% faster in performing tasks with the IMU-based controller.

This paper assesses the metabolic effort exerted by three transfemoral amputees, when using a powered knee and ankle prosthesis for stair ascent, relative to ascending stairs with passive knee and ankle prostheses. The paper describes a controller that provides step-over stair ascent behavior reflective of healthy stair ascent biomechanics, and describes its implementation in a powered prosthesis prototype. Stair ascent experiments were performed with three unilateral transfemoral amputee subjects, comparing the oxygen consumption required to ascend stairs using the powered prosthesis (with a step-over gait), relative to using their daily-use energetically passive prostheses (with a step-to gait). Results indicate on average a 24% reduction in oxygen consumption and a 30% reduction in stair ascent timewhen using the powered prosthesis, relative to when using the passive prostheses. All subjects expressed a strong preference for ascending stairs using the powered prosthesis.

Frailty is a risk factor for mortality, morbidity, and prolonged length of stay after cardiac surgery, all of which are major drivers of hospitalization costs. The incremental hospitalization costs incurred in frail patients have yet to be elucidated.Patients aged ≥ 60 years were evaluated for frailty before coronary artery bypass grafting or heart valve surgery at 2 academic centres between 2013 and 2015 as part of the McGill Frailty Registry. Total costs were summed from the date of the index surgery to the date of hospital discharge. Mutivariable linear regression was used to determine the association between preoperative frailty status and total costs after adjusting for conventional surgical risk factors.Among 235 patients included in the analysis, the median age was 73.0 years (interquartile range [IQR], 70.0-78.0 years) and 68 (29%) were women. The median cost was $32,742 (IQR, $23,221-$49,627) in 91 frail patients compared with $23,370 (IQR, $19,977-$29,705) in 144 nonfrail patients. Seven extreme-cost cases$100,000 were identified, and all of the patients in these cases exhibited baseline frailty. In the multivariable model, total costs were independently associated with frailty (adjusted additional cost, $21,245; 95% confidence interval [CI], $12,418-$30,073; P0.001) and valve surgery (adjusted additional cost, $20,600; 95% CI, $9,661-$31,539; P0.001).Frailty is associated with a marked increase in hospitalization costs after cardiac surgery, an effect that persists after adjusting for age, sex, surgery type, and surgical risk score. Further efforts are needed to optimize care and resource use in this vulnerable population.