Recommendations For Use Research Articles

Cross-classified multilevel models (CCMM) in health research: A systematic review of published empirical studies and recommendations for best practices.

Recognizing that health outcomes are influenced by and occur within multiple social and physical contexts, researchers have used multilevel modeling techniques for decades to analyze hierarchical or nested data. Cross-Classified Multilevel Models (CCMM) are a statistical technique proposed in the 1990s that extend standard multilevel modeling and enable the simultaneous analysis of non-nested multilevel data. Though use of CCMM in empirical health studies has become increasingly popular, there has not yet been a review summarizing how CCMM are used in the health literature. To address this gap, we performed a scoping review of empirical health studies using CCMM to: (a) evaluate the extent to which this statistical approach has been adopted; (b) assess the rationale and procedures for using CCMM; and (c) provide concrete recommendations for the future use of CCMM. We identified 118 CCMM papers published in English-language literature between 1994 and 2018. Our results reveal a steady growth in empirical health studies using CCMM to address a wide variety of health outcomes in clustered non-hierarchical data. Health researchers use CCMM primarily for five reasons: (1) to statistically account for non-independence in clustered data structures; out of substantive interest in the variance explained by (2) concurrent contexts, (3) contexts over time, and (4) age-period-cohort effects; and (5) to apply CCMM alongside other techniques within a joint model. We conclude by proposing a set of recommendations for use of CCMM with the aim of improved clarity and standardization of reporting in future research using this statistical approach.

Assessment of Employability Skills: A Systematic Review of the Availability and Usage of Professional Behavior Assessment Instruments

Background/Purpose. Professionalism is highly valued by health care practitioners, resulting in an increased focus by education programs on explicit instruction and development of student professional behaviors (PB), skills and abilities. However, a comprehensive review of valid and reliable PB assessment instruments (PBAIs) for use in educational programs is lacking. The purpose of this systematic review is twofold 1) to identify and evaluate PBAIs available for use within professional physical therapy (PT) programs and 2) to present a PB advising model to guide student development. Methods. CINHAL, PubMed, ERIC, and ProQuest were searched from 1999 to present using key words, along with hand and grey literature searches for studies that assessed PB in PT, occupational therapy (OT), and/or speech language pathology students. Extracted data included study type, design, purpose, study characteristics and PBAI components, including descriptions of processes followed implementing the tool. The McMaster Critical Appraisal tool was used to evaluate methodological quality of studies. Results. Fourteen different PBAIs were identified for PB assessment. Five PBAIs were student self-assessment tools, 7 for use by academic or clinical faculty and 2 were both self and faculty assessment tools. Ten parameters for PB advising plans were extracted after synthesizing recommendations for use of each instrument. Discussion and Conclusion. Professional behavior assessment instruments are available for use in PT and OT disciplines. A new conceptual PB advising framework is offered. The identified PBAIs can be utilized to assess student performance and should be integrated into student advising process. Future research should focus on further validation of the PBAIs.

Proposing a Community-Based Wildlife Conservation Well-Being Instrument

In this perspective article, we propose a well-being survey instrument based on Bhutan’s Gross National Happiness (GNH) framework for use in community-based wildlife conservation projects. Allgood, Hofberg, Musikanski, Michelini and Moser (2019) found that while there is a need, there is not a well-being survey instrument that includes indicators to measure the impacts on community and wildlife for communality-based wildlife conservation projects. The instrument proposed in this paper is designed to meet the unmet need. It is developed based existing instruments as well as indicators adapted by the authors based on the authors’ experience. The proposal concludes with recommendations for use of the instrument.

Prescription of Sulphonylureas among Patients with Type 2 Diabetes Mellitus in Italy: Results from the Retrospective, Observational Multicentre Cross-Sectional SUSCIPE (Sulphonyl_UreaS_Correct_Internal_Prescription_Evaluation) Study.

IntroductionRecent guidelines for the treatment of type 2 diabetes mellitus (T2DM) provide evidence supporting limited use of sulphonylureas (SUs), especially in specific risk patient categories, yet data from national registries still suggest their widespread use. The aim of this study was to investigate characteristics of patients with diabetes treated with SUs and quantify the proportion of patients that met the recommendations for use of SUs by recent guidelines and of those presenting characteristics representing an inappropriate prescription risk (IPR).MethodsA multicenter, retrospective, cross-sectional, observational study in patients with T2DM receiving treatment with SUs (as monotherapy or in combination with another diabetes therapy) was conducted between 2017 and 2018 in 22 outpatient diabetes clinics across Italy. Exclusion criteria were type 1 diabetes, diabetes mellitus secondary to other conditions, and presence of severe/life-threatening diseases.ResultsA total of 510 patients with T2DM (306 men, 204 women; mean age ± standard deviation 69.8 ± 9.3 years) who were receiving treatment with a SU (as monotherapy or in combination therapy) were assessed in the study. Overall, 70.6% [n = 360; 95% confidence interval (CI) 66.4%, 74.5%] were assessed to have an IPR. Of these, approximately half presented one factor for risk of inappropriate prescription, and 27 and 10.6% presented two and three factors, respectively. In terms of factors contributing to the total burden of risk of inappropriate treatment with SUs, 37.5% (95% CI 33.2%, 41.8%) of all patients were obese; 33.3% (95% CI 29.3%, 37.6%)] were aged ≥ 75 years; 18.6% (95% CI 15.3%, 22.3%) had a history of cardiovascular disease; 14.1% (95% CI 11.2%, 17.4%) had chronic renal insufficiency; 1.8% (95% CI 0.8%, 3.3%) had a history of severe hypoglycemia; 1.8% (95% CI 0.8%; 3.3%) had cognitive impairment; and 2.4% (95% CI 1.2%, 4.1%) had a risky occupation.ConclusionsThe results of this study provide evidence of a high rate of inappropriate SU prescription risk among patients with T2DM, especially among those with overweight/obesity, older age, history of cardiovascular disease, and hypoglycemia.Electronic supplementary materialThe online version of this article (10.1007/s13300-020-00871-5) contains supplementary material, which is available to authorized users.

Selected Fuel Properties of Alcohol and Rapeseed Oil Blends

The alcohols ethanol and 1-butanol are interesting options as blending components for renewable fuels. We studied whether it is possible to mix these alcohols with a little refined material, rapeseed oil, to obtain stable fuel samples. At room temperature, the stable samples consisted of rapeseed oil blended with butanol at 5 vol-%, 10 vol-%, 20 vol-%, 30 vol-% and one sample of rapeseed oil with 5 vol-% of ethanol. The samples’ fuel properties analysed were kinematic viscosity (at 40 °C), density (at 15 °C) and surface tension. Cold filter plugging point was measured for rapeseed oil with 20 vol-% and 30 vol-% of butanol. Stability of butanol or ethanol and rapeseed oil blends can be achieved at the studied volumes. The density of neat rapeseed oil and all the alcohol–rapeseed oil blends met the requirements set for residual marine fuels. The 30 vol-% butanol–rapeseed oil blend met the requirements for distillate marine oil for density, and almost for kinematic viscosity. The blends appeared most suitable for power plants and marine engines. More detailed analyses of their properties are needed before recommendations for use can be given.

Open-source institutional guideline recommendations during the COVID-19 pandemic.

PurposeThe global coronavirus disease 2019 (COVID-19) pandemic and the search for ways in which to provide the best available care have created unprecedented times in terms of rapidly evolving reports of available treatment options. The primary objective of our analysis was to categorize online, open-source guidance to determine how US institutions approached their recommendations for management of patients with COVID-19 in the early weeks of the pandemic.MethodsA search for open-source, online institutional guidelines for the treatment of COVID-19 was conducted using predefined criteria. The search was limited to the United States and conducted from April 12 through 14, 2020, and again on April 22, 2020. Searches were conducted at 2 points in time in order to identify changes in treatment recommendations due to evolving literature or institutional experience. Treatment recommendations, including guidance on antiviral therapy, corticosteroid and interleukin-6 inhibitor use, and nutritional supplementation were compared.ResultsOf the 105 institutions that met initial screening criteria, 14 institutions (13.3%) had online COVID-19 guidance available. Supportive care and clinical trial enrollment were the primary recommendations in all evaluated guidance. Recommendations to consider antimicrobial and adjunctive therapy varied. Eighty-six percent of guidelines contained recommendations for use, or consideration of use, of hydroxychloroquine. Guidance from 2 institutions mentioned use of hydroxychloroquine and azithromycin in combination. Of the 13 institutions listing hydroxychloroquine dosing recommendations, 62% recommended maintenance dosing of 200 mg twice daily. Infectious diseases or other specialty consultation was required by 89% of institutions using interleukin-6 inhibitors for COVID-19 management.ConclusionOverall, the analysis revealed variability in treatment or supplemental pharmacologic therapy for the management of COVID-19.

On the use of PCA for Diagnostics via Novelty Detection: interpretation, practical application notes and recommendation for use

The Principal Component Analysis (PCA) is the simplest eigenvector-based multivariate data analysis tool and dates back to 1901 when Karl Pearson proposed it as a way for finding the best fitting d-1 hyperplane of a system of points in a d-dimensional (Euclidean) space.
 Over the time, the PCA evolved in different fields with several different names and with different scopes, but, in its essence, it is always an orthogonal transformation to convert a set of observations of possibly correlated variables into a set of values of linearly uncorrelated variables called principal components.
 Generalizing Pearson’s purpose, the knowledge derived by such an analysis is mostly used to find a subspace which effectively and efficiently summarizes the original system of points by losing a minimum amount of information.
 In the field of Diagnostics, the fundamental task of detecting damage is basically a binary classification problem which is in many cases tackled via Novelty Detection: an observation is classified as novel if it differs significantly from other observations. Novelty can, in principle, be assessed directly in the original space, but the effectiveness of the estimated novelty can be improved by taking advantage of the PCA.
 In this work, the traditional PCA will be compared to a robust modification that is commonly used in the field of diagnostics to face the issue of confounding influences which could affect the novelty-damage correspondence. Comparisons will be made to shed light on the main misleading aspects of PCA, and finally, define a unique, theoretically justified procedure for Diagnostics via Novelty Detection.

Rhinitis 2020: A practice parameter update

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tabletallergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

Factors Associated with Cloth Face Covering Use Among Adults During the COVID-19 Pandemic - United States, April and May 2020.

On April 3, 2020, the White House Coronavirus Task Force and CDC announced a new behavioral recommendation to help slow the spread of coronavirus disease 2019 (COVID-19) by encouraging the use of a cloth face covering when out in public (1). Widespread use of cloth face coverings has not been studied among the U.S. population, and therefore, little is known about encouraging the public to adopt this behavior. Immediately following the recommendation, an Internet survey sampled 503 adults during April 7-9 to assess their use of cloth face coverings and the behavioral and sociodemographic factors that might influence adherence to this recommendation. The same survey was administered 1 month later, during May 11-13, to another sample of 502 adults to assess changes in the prevalence estimates of use of cloth face coverings from April to May. Within days of the release of the first national recommendation for use of cloth face coverings, a majority of persons who reported leaving their home in the previous week reported using a cloth face covering (61.9%). Prevalence of use increased to 76.4% 1 month later, primarily associated with increases in use among non-Hispanic white persons (54.3% to 75.1%), persons aged ≥65 years (36.6% to 79.2%), and persons residing in the Midwest (43.7% to 73.8%). High rates were observed in April and by May, increased further among non-Hispanic black persons (74.4% to 82.3%), Hispanic or Latino persons (77.3% to 76.2%), non-Hispanic persons of other race (70.8% to 77.3%), persons aged 18-29 years (70.1% to 74.9%) and 30-39 years (73.9% to 84.4%), and persons residing in the Northeast (76.9% to 87.0%). The use of a cloth face covering was associated with theory-derived constructs that indicate a favorable attitude toward them, intention to use them, ability to use them, social support for using them, and beliefs that they offered protection for self, others, and the community. Research is needed to understand possible barriers to using cloth face coverings and ways to promote their consistent and correct use among those who have yet to adopt this behavior.

Direct estimation of the reduced scattering coefficient from experimentally measured time-resolved reflectance via Monte Carlo based lookup tables.

A heuristic method for estimating the reduced scattering coefficient (µs') of turbid media using time-resolved reflectance is presented. The technique requires measurements of the distributions of times-of-flight (DTOF) of photons arriving at two identical detection channels placed at unique distances relative to a source. Measured temporal shifts in DTOF peak intensities at the two channels were used to estimate µs' of the medium using Monte Carlo (MC) simulation-based lookup tables. MC simulations were used to compute temporal shifts in modeled reflectance at experimentally employed source-detector separations (SDS) for media spanning a wide range of optical properties to construct look up tables. Experiments in Intralipid (IL) phantoms demonstrated that we could retrieve µs' with errors ranging between 6-25% of expected (literature) values, using reflectance measured across 650-800 nm and SDS of 5-15 mm. Advantages of the technique include direct processing of measured data without requiring iterative non-linear curve fitting. We also discuss applicability of this approach for media with low scattering coefficients where the commonly employed diffusion theory analysis could be inaccurate, with practical recommendations for use.

Best Practice Use Of Wearable Accelerometers In Gait Biomechanics

Advances in wearable technology provide opportunities to collect biomechanical data in real time and non-lab settings. However, there are currently no standards for best practice use of wearable sensors for gait applications. PURPOSE: Provide best practice recommendations for use of wearable accelerometers (WA) in gait biomechanics. METHODS: Literature was reviewed to determine appropriate WA range for gait biomechanics and establish procedures for calibrating and processing WA data for gait applications. Drop tests of three, simultaneously initialized, commercially available WAs were performed to determine signal time synchronization and 1 g acceleration accuracy. WAs were secured to different lower limb locations (pelvis, knee, ankle) and walking and running trials performed. Peak acceleration magnitude and timing were compared within and among WAs by location and gait type. Vertical ground reaction force (GRFvert) was estimated using a regression model, developed based on pelvis acceleration data, to determine the sensitivity of the GRFvert estimates to WA placement. RESULTS: Peak lower limb accelerations can exceed 25 g during running. WAs initialized at the same time had significant temporal differences (up to 1.06 s). Accelerations during freefall were within 17 % of 1 g. After synchronizing WA signals based on the drop test results, there were no significant differences in WA magnitude and timing among three WAs located around the right iliac crest, but there were significant acceleration differences among WAs located at the right iliac crest, knee, and ankle. Walking and running peak GRFvert estimates based on accelerations of the iliac crest differed from estimates based on accelerations of the knee (-5 ± 28 N and -142 ± 80 N, respectively) and ankle (261 ± 28 N and -274 ± 66 N, respectively). CONCLUSIONS: WAs should be: (1) selected to measure a range greater than 25 g, (2) calibrated to ensure accuracy, (3) manually time synched if using multiple sensors, (4) placed carefully though exact placement is not critical to anatomical site acceleration estimates near the hip, and (5) located at the same anatomical site that was used to develop an acceleration-dependent model if the goal is to use that model to estimate a particular quantity (i.e. GRFvert).

Improving Hair Transplant Surgery Safety in the United Kingdom

The World Health Organization (WHO) released a Surgical Safety Checklist in 2008 that was created in association with the Harvard School of Public Health. The recommendation for use was part of the WHO “Safe Surgery” campaign.[1][1] The current version of the checklist (shown below) was

The effect of superabsorbent polymers on the mitigation of plastic shrinkage cracking of conventional concrete, results of an inter-laboratory test by RILEM TC 260-RSC

This article presents the results of an inter-laboratory study performed by six international research groups in the framework of RILEM Technical Committee 260 RSC “Recommendations for use of superabsorbent polymers in concrete construction”. Two commercially available superabsorbent polymer (SAP) samples with different chemical compositions were tested in terms of their ability to mitigate plastic shrinkage cracking of concrete. The SAP mixtures showed a clear reduction of plastic shrinkage cracking in conventional concrete. On the contrary, if only additional water is added and no SAP, the area of plastic shrinkage cracks increases. This suggest the ability of SAP to mitigate plastic shrinkage cracking. Upon addition of the predetermined amount of SAP and additional water, the compressive strength decreased on average by 3% for the mixtures with 0.15% SAP (by mass of cement) and by 10% for the mixtures with 0.30% SAP.

Reliability Centered Maintenance Management in the laboratory area of a Higher Education Institution

Maintaining that waits for failure to intervene to occur resulting in production losses, high costs and decreased life cycle of the asset. In the Head of Department of Laboratories and Audiovisual Resources institution of higher education, it requires teams with opportunity for improvement in terms of reliability, maintainability and availability are identified. The objective was: proposal for implementation of maintenance through the methodology of Reliability Centered Maintenance to manage equipment availability; which consists of seven steps: 1) define the system and determine the criticality of equipment, 2) identify and define their functions; 3) determine failures; 4) establish failure modes; 5) determine the effects of failures; 6) assess consequences; 7) and develop a plan for equipment maintenance. As a result seven critical to equipment failure analysis were obtained; technical specifications; recommendations for use; Application forms and work orders; schedule of activities, maintenance strategies and indicators for the area. It is concluded that the objective to make a proposal for implementation of maintenance measures that support generating increasing the availability previously compliance with reliability and maintainability fulfilled.

Values Education and its Implications on Guidance and Counselling

This paper looks at Values Education and its implications on Guidance and Counseling, as well as its recommendation for use in the Colleges of Education in Ghana. It considers the classification, methods, theoretical framework, advantages, and disadvantages of values education. The Psychoanalytic and behavioural theories were used to explain the link and effects of people’s past experiences and those of the present experiences. It further examines the values counsellors and counsellees are expected to develop and exhibit, and its implications on Guidance and Counseling services. Published books, articles, and personal observation during teaching and counseling services provided the main sources of information. The study brings to the fore the fact that values education serves as a preparatory ground for effective Guidance and Counseling Services to take place in educational institutions. It is therefore recommended that educators be exposed to values education and be encouraged to teach values that are associated with their courses. This is vital to lay a good foundation for counsellors and counsellees for effective counseling services to go on in the Colleges of Education in Ghana.

The Military Academic Motivation Scale (MAMS)

Abstract. The purpose of the present paper is to introduce the Military Academic Motivation Scale (MAMS), a short and reliable instrument for assessing the different types of motivation among military cadets. Three representative samples of military cadets completed the MAMS. In Study 1 ( N = 452), the hypothesized five-factor structure of the MAMS was empirically tested and supported. In Study 2 ( N = 1,372), the factorial invariance across both gender and cohorts of the MAMS was explored and confirmed. Study 3 ( N = 520) provided evidence of the external validity of the five MAMS factors with respect to important organizational outcomes (work engagement, organizational commitment, job performance, extra-role behaviors, burnout, and intention to quit). The potential applications of the MAMS were extensively discussed, and recommendations for use in the military academy setting were given.

Metacontrol: A Python based application for self-optimizing control using metamodels

In this contribution, a detailed description of a Python based application tool that enables fast implementation of the Self-Optimizing Control (SOC) technology with the help of surrogate models is presented. The paper also outlines the potential uses of the Metacontrol (from Metamodel-based self-optimizing control) software through case studies of representative test-bed industrial processes. As a result, an in-depth analysis of Metacontrol from a plantwide control perspective is discussed, together with recommendations for use. The data, examples, and the Metacontrol source code are available for download at https://github.com/feslima/metacontrol.

Evaluation of Probiotics for Warfighter Health and Performance.

The probiotic industry continues to grow in both usage and the diversity of products available. Scientific evidence supports clinical use of some probiotic strains for certain gastrointestinal indications. Although much less is known about the impact of probiotics in healthy populations, there is increasing consumer and scientific interest in using probiotics to promote physical and psychological health and performance. Military men and women are a unique healthy population that must maintain physical and psychological health in order to ensure mission success. In this narrative review, we examine the evidence regarding probiotics and candidate probiotics for physical and/or cognitive benefits in healthy adults within the context of potential applications for military personnel. The reviewed evidence suggests potential for certain strains to induce biophysiological changes that may offer physical and/or cognitive health and performance benefits in military populations. However, many knowledge gaps exist, effects on health and performance are generally not widespread among the strains examined, and beneficial findings are generally limited to single studies with small sample sizes. Multiple studies with the same strains and using similar endpoints are needed before definitive recommendations for use can be made. We conclude that, at present, there is not compelling scientific evidence to support the use of any particular probiotic(s) to promote physical or psychological performance in healthy military personnel. However, plausibility for physical and psychological health and performance benefits remains, and additional research is warranted. In particular, research in military cohorts would aid in assessing the value of probiotics for supporting physical and psychological health and performance under the unique demands required of these populations.

Recommendations for treating life-threatening Kaposi sarcoma during pregnancy in HIV-positive women in low income countries.

In areas of high HIV and human herpes virus 8 prevalence, life-threatening forms of Kaposi sarcoma (KS) can occur in HIV-positive women during pregnancy. Treating KS in pregnancy must balance both the well-being of the mother with the health of the fetus, yet data and recommendations on the best treatment approach for KS during pregnancy are limited. Without effective treatment, which can be difficult to obtain in low income countries (LICs), the mother and infant are at risk for poor outcomes. A successful case report is used as teaching example, followed by a detailed review of the literature that culminates in recommendations for treating KS during pregnancy among HIV-positive women in LICs. A 31-year-old HIV-positive woman presented for care in April 2016 at 28 weeks gestation with extensive KS skin lesions, KS lymphadenopathy, and a large oropharynx KS lesion causing partial airway obstruction. She had initiated antiretroviral therapy (ART) months prior and was virally suppressed, suggesting KS-immune reconstitution inflammatory syndrome. Due to the severity of KS and her third trimester status, combination chemotherapy was initiated using bleomycin, vincristine, and doxorubicin followed by maintenance therapy with paclitaxel. She showed remarkable response to the chemotherapy and had a normal vaginal delivery of a healthy baby at full term. Full clinical remission was achieved, and her baby was HIV-negative with no negative health effects of the KS or the chemotherapy. Review of the sparse existing literature demonstrates the importance, safety, and effectiveness of treating KS during pregnancy. We offer simple adaptable treatment recommendations for use in treating HIV-positive women with KS during pregnancy in LICs. Life-threatening KS can be treated using chemotherapy and ART in resource-limited settings, allowing for good outcomes in mother and infant. While monotherapy with liposomal doxorubicin or paclitaxel is preferred, these are often not available in LICs. As alternatives, bleomycin, vincristine, and doxorubicin can be safely used during the second and/or third trimesters for treating KS. Following a simple treatment approach can be an effective way to treat KS in pregnancy for pregnant women living with HIV in an LIC setting.

Nebulized Heparin for Adult Patients With Smoke Inhalation Injury: A Review of the Literature.

Objective: To review the clinical effects of nebulized heparin and N-acetylcysteine (NAC) in patients with smoke inhalation injury (IHI) and provide recommendations for use. Data Sources: A search of PubMed, MEDLINE, and Scopus databases was completed from database inception through April 15, 2020, using terms: heparin, acetylcysteine, smoke inhalation injury, and burn injury. Study Selection and Data Extraction: All studies pertaining to efficacy and safety of nebulized heparin and/or NAC for IHI in adult patients were evaluated. Reference lists were reviewed for additional publications. Nonhuman studies, non-English, and case report publications were excluded. Data Synthesis: Eight studies were included. Four demonstrated positive outcomes, 3 demonstrated no benefit or possible harm, and 1 assessed safety. Supporting trials treated patients within 48 hours of injury with 10 000 units of nebulized heparin with NAC for 7 days or until extubation. Two trials with negative findings treated patients within 72 hours, or unspecified, with 5000 units of nebulized heparin with NAC for 7 days, while the third used 25 000 units within 36 hours but was grossly underpowered for analysis. Clinical findings include reduced duration of mechanical ventilation and improved lung function with possible increase risk of pneumonia and no evidence of increased bleeding risk. Conclusions: Nebulized heparin may improve oxygenation and reduce duration of mechanical ventilation in IHI. If nebulized heparin is used, 10 000 units every 4 hours alternating with NAC and albuterol at 4-hour intervals is recommended. Sterile technique should be emphasized. Monitoring for bronchospasm or new-onset pneumonia should be considered.