The business community has developed strategies to ensure the quality of the goods or services they produce and to improve the management of multidisciplinary work teams. With modification, many of these techniques can be imported into intensive care units (ICUs) to improve clinical operations and patient safety. In Part I of a three-part ATS Seminar series, we argue for adopting business management strategies in ICUs and set forth strategies for targeting selected quality improvement initiatives. These tools are relevant to health care today as focus is placed on limiting low-value care and measuring, reporting, and improving quality. In the ICU, the complexity of illness and the need to standardize processes make these tools even more appealing. Herein, we highlight four techniques to help prioritize initiatives. First, the "80/20 rule" mandates focus on the few (20%) interventions likely to drive the majority (80%) of improvement. Second, benchmarking--a process of comparison with peer units or institutions--is essential to identifying areas of strength and weakness. Third, root cause analyses, in which structured retrospective reviews of negative events are performed, can be used to identify and fix systems errors. Finally, failure mode and effects analysis--a process aimed at prospectively identifying potential sources of error--allows for systems fixes to be instituted in advance to prevent negative outcomes. These techniques originated in fields other than health care, yet adoption has and can help ICU managers prioritize issues for quality improvement.

ÖZ The ongoing COVID-19 outbreak has unprecedented effects worldwide and the extent of infection, illness, and fatalities have forced governments to take more stringent measures. This study aims to identify the risk factors to stop the spread of the virus, develop preliminary plans, and determine applicable measures in workplaces, in summary, to determine new normals in workplaces in the context of the Corona virus challange, utilizing lessons learned from the past pandemics. The United States (US) Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Administration (OSHA) sources, and Google Scholar, PubMed, Scopus and Web of Science databases were reviewed comprehensively to identify transmission methods, protection methods and risk factors. “Anticipate, Recognize, Evaluate, Control, Confirm (ARECC)”, an industrial hygiene decision making method, was used to manage the risk of pathogens in workplaces and hierarchy of hazard control method by the US National Institute for Occupational Safety and Health (NIOSH) was implemented to determine measures. This study identifies hazards, assesses risks, and suggests control measures in changing pandemic conditions with a systematic approach, and presents the suitable ways minimizing the risk to prevent new waves for the pandemics. Devam eden COVID-19 salgınının, dünya çapında benzeri görülmemiş sonuçları olmuş ve enfeksiyon, hastalık ve ölümlerin boyutu hükümetleri daha katı önlemler almaya zorlamıştır. Bu çalışma, normalleşme sürecine girilen bu günlerde geçmiş pandemilerden edinilen tecrübelerden yararlanarak işyerlerinde virüsün yayılmasını durdurmak için risk faktörlerinin tanımlanması, hazırlık planlarının geliştirilmesi, uygulanabilir önlemlerin tespit edilmesi, özetle Corona virüsü mücadelesinde işyerlerinde yeni normalleri belirlemeyi amaçlamaktadır. Birleşik Devletler Hastalık Kontrol ve Korunma Merkezi (CDC), Mesleki Güvenlik ve Sağlık İdaresi (OSHA) kaynakları ile Google Scholar, PubMed, Scopus ve Web of Science veri tabanları bulaşma yöntemleri, koruma yöntemleri ve riski faktörlerini belirlemek için kapsamlı bir şekilde gözden geçirilmiştir. İşyerinde patojenler kaynaklı risklerin yönetilmesi için endüstriyel hijyen karar verme yöntemi olan "Öngör, Tanı, Değerlendir, Kontrol Et, Onayla" (ARECC) yöntemi, önlemlerin olarak belirlenmesi için de Birleşik Devletler Ulusal İş Sağlığı ve Güvenliği Enstitüsü (NIOSH) tarafından hazırlanan tehlike kontrolü hiyerarşisi yöntemi uygulanmıştır. Bu çalışma sistematik bir yaklaşımla değişen pandemi koşullarında tehlikeleri tanımlar, riskleri değerlendirir, kontrol önlemleri önerir ve mevcut ve gelecekteki pandemiler için risk yönetimi kararlarını kolaylaştırma nihai hedefi ile yeni dalgaları önlemek için riski en aza indirmenin en uygun yollarını sunar. Anahtar Sözcükler: ARECC, COVID-19 pandemic, normalization process in pandemic, occupational health and safety in pandemic conditions, risk assessment

Despite data associating exposure to traffic-related polycyclic aromatic hydrocarbons (PAH) in asthma, mechanistic support has been limited. We hypothesized that both prenatal and early postnatal exposure to PAH would increase airway hyperreactivity (AHR) and that the resulting AHR may be insensitive to treatment with a β 2AR agonist drug, procaterol. Further, we hypothesized that these exposures would be associated with altered β 2AR gene expression and DNA methylation in mouse lungs. Mice were exposed prenatally or postnatally to a nebulized PAH mixture versus negative control aerosol 5 days a week. Double knockout β 2AR mice were exposed postnatally only. Prenatal exposure to PAH was associated with reduced β 2AR gene expression among nonsensitized mice offspring, but not increases in DNA methylation or AHR. Postnatal exposure to PAH was borderline associated with increased AHR among sensitized wildtype, but not knockout mice. In the first study that delivers PAH aerosols to mice in a relatively physiological manner, small effects on AHR and β 2AR gene expression, but not β 2AR agonist drug activity, were observed. If confirmed, the results may suggest that exposure to PAH, common ambient urban pollutants, affects β 2AR function, although the impact on the efficacy of β 2AR agonist drugs used in treating asthma remains uncertain.

A 35-year-old woman was brought to the ED by family members with a 3-day history of behavioral changes. The patient exhibited confusion, confabulation, and occasional combativeness. Her family denied any recent flu-like symptoms, sick contacts, or recent travels. Her medical history was significant for mild intermittent asthma. The patient had no history of psychiatric illness. Her medications included occasional albuterol use for well-controlled asthma. She worked as a registered nurse and was married with three children. She smoked one-half a pack of cigarettes a day and drank alcohol occasionally. According to her husband, the patient had a remote history of inhalational cocaine use and recent tattoos but no history of IV drug use.

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Article on page 17 Apocynin Attenuates Ischemia-reperfusion Lung Injury in an Isolated and Perfused Rat Lung Model Chiang C-H, Chuang C-H, Liu S-L Ischemia-reperfusion (I/R)-related pulmonary injury is a clinical problem responsible for some cases of acute allograft failure after lung transplantation and is important after spontaneous and surgical resolution of pulmonary emboli, for lung reexpansion after pneumothorax, and during the return of spontaneous circulation after cardiac arrest. Much mechanistic data link reactive oxygen species (ROS) such as H2O2, O2-, and peroxynitrites to the pathophysiology of I/R injury in lung, heart, intestine, liver, and kidney allografts; other data show that interruption of ROS generation or scavenging attenuates injury in these organs. For this reason, most allografts are preserved with a cold solution containing, among other things, antioxidants such as allopurinol and glutathione. Although a role for ROS in I/R is clear, it is not certain whether I/R derived ROS are a result of hypoxia followed by reoxygenation or whether they stem from proinflammatory pathways activated at some point during or after I/R. Article on page 17 Apocynin Attenuates Ischemia-reperfusion Lung Injury in an Isolated and Perfused Rat Lung Model Chiang C-H, Chuang C-H, Liu S-L

BACKGROUND:Architectural design of health-care facilities can influence patient safety; however, it is unknown whether patient outcomes are significantly affected by ICU design.METHODS:Six hundred sixty-four patients admitted to the medical ICU (MICU) of Columbia University Medical Center during 2008 were included in this retrospective study. Patient outcome measures, which included hospital mortality, ICU mortality, ICU length of stay (LOS), and ventilator-free days, were compared based on random room assignment. Rooms that were not visible from the MICU central nursing station were designated as low-visible rooms (LVRs), whereas the remaining rooms were designated as high-visible rooms (HVRs).RESULTS:Overall hospital mortality did not differ among patients assigned to LVRs vs HVRs; however, severely ill patients (those with Acute Physiology and Chronic Health Evaluation II scores > 30) had significantly higher hospital mortality when admitted to an LVR than did similarly ill patients admitted to an HVR (82.1% and 64.0%, n = 39 and 75, respectively; P = .046). ICU mortality showed a similar pattern. ICU LOS and ventilator-free days did not differ significantly between groups.CONCLUSIONS:Severely ill patients may experience higher mortality rates when assigned to ICU rooms that are poorly visualized by nursing staff and physicians.

Background— Unrecognized obstructive sleep apnea (OSA) is highly prevalent in obesity. Both obesity and OSA are associated with vascular endothelial inflammation and increased risk for cardiovascular diseases. We investigated directly whether the endothelial alterations that are attributed commonly to obesity are in fact related to OSA. Methods and Results— Seventy-one subjects with a body mass index ranging from normal to obese underwent attended polysomnography. To assess vascular inflammation and oxidative stress directly, we quantified the expression of nuclear factor-κB and nitrotyrosine by immunofluorescence in freshly harvested venous endothelial cells. To evaluate basal endothelial nitric oxide (NO) production and activity, we quantified the expression of endothelial NO synthase (eNOS) and phosphorylated eNOS. Vascular reactivity was measured by brachial artery flow-mediated dilation. Expression of eNOS and phosphorylated eNOS and flow-mediated dilation were significantly lower, whereas expression of nitrotyrosine was significantly greater in OSA patients (n=38) than in OSA-free subjects (n=33) regardless of central adiposity. Expression of nuclear factor-κB was greater in obese OSA patients than in obese OSA-free subjects ( P =0.004). Protein expression and flow-mediated dilation were not significantly affected by increasing body mass index or central obesity in OSA patients and in OSA-free subjects. After 4 weeks of continuous positive airway pressure therapy, flow-mediated dilation and expression of eNOS and phosphorylated eNOS significantly increased whereas expression of nitrotyrosine and nuclear factor-κB significantly decreased in OSA patients who adhered to continuous positive airway pressure ≥4 hours daily. Conclusions— Untreated OSA rather than obesity is a major determinant of vascular endothelial dysfunction, inflammation, and elevated oxidative stress in obese patients.

Background Multiple studies have suggested that prenatal exposure to either allergens or air pollution may increase the risk for the development of allergic immune responses in young offspring. However, the effects of prenatal environmental exposures on adult offspring have not been well-studied. We hypothesized that combined prenatal exposure to Aspergillus fumigatus ( A. fumigatus ) allergen and diesel exhaust particles will be associated with altered IgE production, airway inflammation, airway hyperreactivity (AHR), and airway remodeling of adult offspring. Methods Following sensitization via the airway route to A. fumigatus and mating, pregnant BALB/c mice were exposed to additional A. fumigatus and/or diesel exhaust particles. At age 9-10 weeks, their offspring were sensitized and challenged with A. fumigatus . Results We found that adult offspring from mice that were exposed to A. fumigatus or diesel exhaust particles during pregnancy experienced decreases in IgE production. Adult offspring of mice that were exposed to both A. fumigatus and diesel exhaust particles during pregnancy experienced decreases in airway eosinophilia. Conclusion These results suggest that, in this model, allergen and/or diesel administration during pregnancy may be associated with protection from developing systemic and airway allergic immune responses in the adult offspring.

Zolpidem is a nonbenzodiazepine hypnotic with a favorable adverse effect profile. There are single reports of respiratory decompensation associated with zolpidem overdose. We report a case of a young woman with depression who developed deep coma with respiratory failure and a loss of brainstem reflexes as a result of zolpidem overdose. Supportive management led to a complete recovery of neurologic function. Acute zolpidem overdose should be considered in the differential diagnosis of coma with absent brainstem reflexes.

PURPOSE:To investigate the impact of obstructive sleep apnea (OSA) on endothelial repair capacity and apoptosis in the absence of potentially confounding factors including obesity. PATIENTS AND METHODS:Sixteen patients with a body mass index <30 and newly diagnosed OSA and 16 controls were studied. Circulating levels of endothelial progenitor cells, a marker of endothelial repair capacity, and endothelial microparticles, a marker of endothelial apoptosis, were quantified before and after four-week therapy with continuous positive airway pressure (CPAP). Endothelial cell apoptotic rate was also quantified in freshly harvested venous endothelial cells. Vascular reactivity was measured by flow-mediated dilation. RESULTS:Before treatment, endothelial microparticle levels were greater and endothelial progenitor cell levels were lower in patients with OSA than in controls (P < 0.001 for both). Levels of endothelial microparticles and progenitors cells were inversely related (r = -0.67, P < 0.001). Endothelial progenitor cell levels increased after effective treatment (P = 0.036). CONCLUSIONS:In the absence of any co-morbid conditions including obesity, OSA alone impairs endothelial repair capacity and promotes endothelial apoptosis. These early endothelial alterations may underlie accelerated atherosclerosis and increased cardiovascular risk in OSA.