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Aim: This study was designed to investigate the association between Charlson Comorbidity Index (CCI) and in‐hospital mortality and other clinical outcomes among patients with hyperglycemic crises. Method: This retrospective cohort study was conducted using data from electric medical records. A total of 1668 diabetic patients with hyperglycemic crises from six tertiary hospitals met the inclusion criteria. CCI < 4 was defined as low CCI and CCI ≥ 4 was defined as high CCI. Propensity score matching (PSM) with the 1:1 nearest neighbour matching method and the caliper value of 0.02 was used to match the baseline characteristics of patients with high CCI and low CCI to reduce the confounding bias. In‐hospital mortality, ICU admission, hypoglycemia, hypokalemia, acute kidney injury, length of stay (LOS), and hospitalisation expense between low CCI and high CCI were compared and assessed. Univariate and multivariate regression were applied to estimate the impact of CCI on in‐hospital and other clinical outcomes. Outcome: One hundred twenty‐one hyperglycemic crisis (HC) patients died with a mortality rate of 7.3%. After PSM, compared with low CCI, patients with high CCI suffered higher in‐hospital mortality, ICU admission, LOS, and hospitalisation expenses. After multivariate regression, age (aOR: 1.12, 95% confidence interval [CI]: 1.06−1.18, p < 0.001), CCI(aOR: 4.42, 95% CI: 1.56−12.53, p = 0.005), uninsured (aOR: 22.32, 95% CI: 4.26−116.94, p < 0.001), shock (aOR: 10.57, 95% CI: 1.41−79.09, p = 0.022), mechanical ventilation (aOR: 75.29, 95% CI: 12.37−458.28, p < 0.001), and hypertension (aOR: 4.34, 95% CI: 1.37−13.82, p = 0.013) were independent risk factors of in‐hospital mortality of HC patients. Besides, high CCI was an independent risk factor for higher ICU Admission (aOR: 5.91, 95% CI: 2.31−15.08, p < 0.001), hypoglycemia (aOR: 2.19, 95% CI:1.01−4.08, p = 0.049), longer LOS (aOR: 1.23, 95% CI: 1.19−2.27, p = 0.021), and higher hospitalisation expense (aOR: 2089.97, 95% CI: 193.33−3988.61, p = 0.031) of HC patients. Conclusion: CCI is associated with in‐hospital mortality, ICU admission, hypoglycemia, LOS, and hospitalisation expense of HC patients. CCI could be an ideal indicator to identify, monitor, and manage chronic comorbidities among HC patients. [ABSTRACT FROM AUTHOR]

Introduction: Although prior studies indicate that a QTc > 500 ms on a single baseline 12‐lead electrocardiogram (ECG) is associated with significantly increased risk of arrhythmic events in long QT syndrome (LQTS), less is known about the risk of persistent QT prolongation. We sought to determine QTc persistence and its prognostic effect on breakthrough cardiac events (BCEs) among pediatric patients treated for LQTS. Methods: We performed a retrospective analysis of 433 patients with LQTS evaluated, risk‐stratified, and undergoing active guideline‐based LQTS treatment between 1999 and 2019. BCEs were defined as arrhythmogenic syncope/seizure, sudden cardiac arrest (SCA), appropriate VF‐terminating ICD shock, and sudden cardiac death (SCD). Results: During the median follow‐up of 5.5 years (interquartile range [IQR] = 3–9), 32 (7%) patients experienced a total of 129 BCEs. A maximum QTc threshold of 520 ms and median QTc threshold of 490 ms were determined to be strong predictors for BCEs. A landmark analysis controlling for age, sex, genotype, and symptomatic status demonstrated models utilizing both the median QTc and maximum QTc demonstrated the highest discriminatory value (c‐statistic = 0.93–0.95). Patients in the high‐risk group (median QTc > 490 ms and maximum QTc > 520 ms) had a significantly lower BCE free survival (70%–81%) when compared to patients in both medium‐risk (93%–97%) and low‐risk (98%–99%) groups. Conclusions: The risk of BCE among patients treated for LQTS increases not only based upon their maximum QTc, but also their median QTc (persistence of QTc prolongation). Patients with a maximum QTc > 520 ms and median QTc > 490 ms over serial 12‐lead ECGs are at the highest risk of BCE while on guideline‐directed medical therapy. [ABSTRACT FROM AUTHOR]

Background: On 7 October 2023, hundreds of armed Hamas fighters breached the security border fence and entered Israel from the Gaza Strip. More than 1400 Israeli citizens were murdered, and 239 individuals were kidnapped. Many Israeli citizens experienced these occurrences as psychologically traumatic events that caused stress and uncertainty. Objectives: The present study aimed to examine the relationship between exposure to war (in more distant circles), intolerance of uncertainty (IU) and disengaged coping on acute stress symptoms (ASS). First, we examined whether exposure to war and IU were directly associated with ASS. Second, we tested the mediating role of disengaged coping in the relationship among war exposure, IU and ASS. Methods: This cross‐sectional study involved 393 Israeli citizens. Participants answered questionnaires on exposure to war, IU, coping strategies and ASS. Results: The study results indicate that higher exposure and higher levels of IU were directly associated with more intensive ASS, and this association was partially mediated by higher use of disengaged coping strategies. Conclusions: Individuals during wartime are at risk of experiencing high levels of ASS and developing ASD. However, degree of exposure to war alone was not associated with ASS, but it was related to personal resources and coping strategies. [ABSTRACT FROM AUTHOR]

The article discusses case studies which show bacteremia and/or fungemia after examining peripheral blood smears, especially in critically ill individuals with non-specific symptoms. The patients studied include a 31-year-old woman who was hospitalized for investigation of coma presented with vaginal bleeding, a 27-year-old man with poor limb movement and limb convulsions for two days, and a 53-year-old male patient with progressively reduced consciousness following head, neck and chest trauma.

Niger is afflicted with high rates of poverty, high fertility rates, frequent environmental crises, and climate change. Recurrent droughts and floods have led to chronic food insecurity linked to poor maternal and neonatal nutrition outcomes in vulnerable regions. We analyzed maternal and neonatal nutrition trends and subnational variability between 2000 and 2021 with a focus on the implementation of policies and programs surrounding two acute climate shocks in 2005 and 2010. We used four sources of data: (a) national household surveys for maternal and newborn nutritional indicators allowing computation of trends and differences at national and regional levels; (b) document review of food security reports; (c) 30 key informant interviews and; (d) one focus group discussion. Many food security policies and nutrition programs were enacted from 2000 to 2020. Gains in maternal and neonatal nutrition indicators were more significant in targeted vulnerable regions of Maradi, Zinder, Tahoua and Tillabéri, from 2006 to 2021. However, poor access to financial resources for policy execution and suboptimal implementation of plans have hindered progress. In response to the chronic climate crisis over the last 20 years, the Nigerien government and program implementers have demonstrated their commitment to reducing food insecurity and enhancing resilience to climate shocks by adopting a deliberate multisectoral effort. However, there is more that can be achieved with a continued focus on vulnerable regions to build resilience, targeting high risk populations, and investing in infrastructure to improve health systems, food systems, agriculture systems, education systems, and social protection. Key messages: Niger is ranked as the most vulnerable country in the world for exposure and sensitivity to the negative effects of disasters and climate change. Acute environmental shocks in 2005 and 2010 elevated government and development partner responses to the 'food security crises'.Multisectoral policy and program investments in vulnerable regions played a meaningful role in improving food security and subsequently maternal and neonatal nutrition but progress is slow or stagnant.The Nigerien government, program implementers, and donors should prioritize investments in infrastructure and shock resilience to improve health systems, food systems, agriculture systems, education systems, and social protection, particularly in high risk populations. [ABSTRACT FROM AUTHOR]

The article discusses a series of clinical cases involving a syndrome characterized by bradycardia, renal failure, shock, and hyperkalemia in dementia patients. It emphasizes the implications of atrioventricular nodal blockers in exacerbating these conditions. It mentions the study originates from the Department of Medicine at Haradoi Hospital, Fukuoka, Japan, authored by Toru Maruyama, Seiji Kondo, and Hideyuki Nomura.

Background: The role of triggers in the occurrence of appropriate implantable cardioverter‐defibrillator (ICD) shocks due to ventricular tachyarrhythmias is not well known. The aim of the study was to assess the prevalence of trigger factors in appropriate ICD shocks and to analyze their prognostic impact on clinical outcome. Methods: A total of 710 consecutive patients of a prospective single‐center ICD‐registry who received a first appropriate ICD shock between 2000 and 9/2021 were analyzed. Results: In 35% of ICD patients with first ICD shock, at least one of the following triggers was found: Ischemia (22%), Compliance (9%), Decompensation (38%), Stress (12%), Technical (5%), Electrolyte/endocrinological disorder (22%) and Medication side effects (4%). The trigger factors can be summarized under the acronym ICD‐STEMi. The prospective application of the ICD‐STEMi scheme increased the rate of identified triggers from 32% to 56% (p <.001). Patients with triggered first ICD shock had an increased 5‐year mortality rate (50% vs. 38%, p <.001). Patients with triggers did not show different mortality outcomes or recurrent ICD shocks whether they received arrhythmia therapy or not. Conclusions: The evaluation of trigger factors after the occurrence of ICD shocks is mandatory and can be systematically evaluated using the acronym ICD‐STEMi. Systematic evaluation of triggers using the ICD‐STEMi scheme can identify triggers in about half of ICD patients with first appropriate ICD shock. Patients with triggered ICD shock have a 12% higher 5‐year mortality rate. [ABSTRACT FROM AUTHOR]

SLICE is an algorithm for the integration of point‐of‐care ultrasound in the assessment and resuscitation of the shocked or breathless patient. It aims to determine the patient's fluid status, and identify reversible causes for the patient's clinical picture. SLICE stands for 'In a patient who is Shocked/Short of breath, scan the Lungs, IVC, Cardiac and Extra regions as indicated'. Its key advantages are that it explicitly guides resuscitative fluid management, can be performed rapidly and by clinicians with a broad range of sonographic experience, and can be used in a broad range of clinical scenarios. Its use has been successfully taught and implemented in routine clinical practice at our local institution. [ABSTRACT FROM AUTHOR]

Background: One characteristic of alcohol use disorder is compulsive drinking or drinking despite negative consequences. When quinine is used to model such aversion‐resistant drinking, female rodents typically are more resistant to punishment than males. Using an operant response task where C57BL/6J responded for ethanol mixed with quinine, we previously demonstrated that female mice tolerate higher concentrations of quinine in ethanol than males. Here, we aimed to determine whether this female vulnerability to aversion‐resistant drinking behavior is similarly observed with footshock punishment. Methods: Male and female C57BL/6J mice were trained to respond for 10% ethanol in an operant task on a fixed‐ratio three schedule. After consistent responding, mice were tested in a punishment session using either a 0.25 mA or 0.35 milliamp (mA) footshock. To assess footshock sensitivity, a subset of mice underwent a flinch, jump, and vocalize test in which behavioral responses to increasing amplitudes of footshock (0.05 to 0.95 mA) were assessed. In a separate cohort of mice, males and females were trained to respond for 2.5% sucrose and responses were punished using a 0.25 mA footshock. Results: Males and females continued to respond for 10% ethanol when paired with a 0.25 mA footshock. Females alone continued to respond for ethanol when a 0.35 mA footshock was delivered. Both males and females reduced responding for 2.5% sucrose when punished with a 0.25 mA footshock. Footshock sensitivity in the flinch, jump, and vocalize test did not differ by sex. Conclusions: Females continue to respond for 10% ethanol despite a 0.35 mA footshock, and this behavior is not due to differences in footshock sensitivity between males and females. These results show that female C57BL/6J mice are generally more resistant to punishment in an operant self‐administration paradigm. The findings add to the literature characterizing aversion‐resistant alcohol‐drinking behaviors in females. [ABSTRACT FROM AUTHOR]

The article reviews the controversies and evidence surrounding the common emergency department (ED) procedure of arterial line insertion. It discusses the indications for the procedure, such as continuous blood pressure monitoring, and the lack of evidence of its benefit on mortality and morbidity. It also highlights the contraindications and complications of arterial line insertion, including serious complications that are rare but possible.

Background: Implantable cardioverter defibrillators (ICDs) offer effective therapy for the prevention of sudden cardiac death (SCD) due to ventricular arrhythmias. However, inappropriate shocks have detrimental effects on survival and quality of life. The addition of hemodynamic monitoring may be useful in discriminating clinically important ventricular arrhythmias. Objective: In this study, we assess the ability of laser Doppler flowmetry to assess the hemodynamic effect of paced atrial and ventricular arrhythmias using mean arterial blood pressure as the reference. Methods: In this acute human study in patients undergoing an elective electrophysiological study, laser Doppler flowmetry, arterial blood pressure, and surface ECG were acquired during high‐rate atrial and ventricular pacing to simulate supraventricular and ventricular tachycardias. Results: Arterial blood pressure and laser Doppler flow signals correlated well during atrial and ventricular pacing (rho = 0.694, p <.001). The hemodynamic impairment detected by both methods was greater during ventricular pacing than atrial pacing (–1.0% vs. 19.0%, p <.001). Laser Doppler flowmetry performed better than rate alone to identify hemodynamic impairments. Conclusion: In this acute study, laser Doppler flowmetry tissue perfusion served as a good surrogate measure for arterial pressure, which could be incorporated into future ICDs. [ABSTRACT FROM AUTHOR]

Background: Appropriate implantable cardioverter‐defibrillator (ICD) shocks are associated with an increased risk of mortality and heart failure (HF) events. The first appropriate shock may occur late after implantation. However, whether the timing of the first appropriate shock influences prognosis is unknown. This study aimed to evaluate the clinical significance of the timing of the first appropriate shock in patients with ICD. Methods: This retrospective and observational study enrolled 565 consecutive ICD patients. Patients who received an appropriate shock were divided into the early group (first appropriate shock <1 year after ICD implantation) and late group (first appropriate shock ≥1 year after ICD implantation). All‐cause mortality was compared between the two groups. Results: Over a median follow‐up of 5.6 years, 112 (19.8%) patients received an appropriate shock, including 32 patients (28.6%) in the early group and 80 patients (71.4%) in the late group. Comparisons of baseline characteristics at ICD implantation revealed that the late group was more likely to receive cardiac resynchronization therapy (66.3% vs. 31.3%, p < 0.001), ICD for primary prevention (60.0% vs. 31.3%, p = 0.001), and angiotensin‐converting enzyme inhibitor or angiotensin‐receptor blocker treatment (88.8% vs. 71.9%, p = 0.028). Survival after shock was significantly worse in the late group than in the early group (p = 0.027). In multivariable Cox proportional hazards analysis, the late group had an increased risk of all‐cause mortality compared with the early group (HR: 2.22; 95% CI 1.01–4.53; p = 0.029). In both groups, the most common cause of death was HF. Conclusions: Late occurrence of the first appropriate ICD shock was associated with a worse prognosis compared with early occurrence of the first appropriate shock. Cardiac death was the most common cause of death in patients who experienced late occurrence of the first appropriate ICD shock, resulting from HF in most cases. [ABSTRACT FROM AUTHOR]

The aim of this study is to explore qualitatively bereavement experiences of family members who have lost a significant other to coronavirus disease 2019 (COVID‐19) in relation to mourners' needs and resources. Twenty individuals bereaved by the first wave of COVID‐19 from the most heavily impacted Italian region were interviewed via video call between 1 and 3 months after their loss. Through a thematic analysis, four main themes were identified: reconstructions of the loss experience, responses to grief, resources and looking forward. The suddenness of the death and lack of farewell by means of a funeral prevented participants from realizing the loss and undertaking a meaning‐making process. When anger was the main reaction to the loss, mourners focussed all their attention on denouncing medical and government institutions. Acceptance occurred particularly in those who found a way to share their grief and use it as a turning point. Participants relied mainly on informal support offered virtually, but mourners may have sought out in‐person comfort in the long term. The results of this study propose new insights for COVID‐19 bereavement support and trace the path for health promotion within a community shook by a communal grief experience. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement [ABSTRACT FROM AUTHOR]

The World Music School community is a Non‐Government Organisation (NGO) that teaches music and organises events internationally around dance and music activities. This case study investigates community connectivity and resilience development in the World Music School (WMS) Helsinki community of practice and the Shanghai WMS community of interest. Using a social ecological system approach, the community structures and relationships were explored and supported by the literature. In particular, the research focused on the feedback loops at different levels within each community structure. The WMS core activities are viewed as inclusive and human connectivity enhancers. Focusing on human connectivity, the research investigated the 'what' and 'why' of the NGO's involvement in building its community structure as it revealed what is essential for community resilience. This research discusses how connections between shocks and disturbances within the community systems were identified and the various outcomes when identifying and approaching acute weakness within the community structures. This case study examines how the WMS communities enhance community resilience across a complex social system starting at the individual level and then extending to physically close environmental relationships. These complex community structures provided a lens to focus on identifying the initial stages for resilient community connectivity. Observing these connections provided a basis for developing a synthesised model based on discussions in previous literature reviews. The processes involved with the model development included the critical roles, impacts and evolution of the World Music School community. This article argues that systemic change can happen when small but fundamental changes are longitudinally obtained through bottom‐up approaches. The WMS communities have displayed the potential to make a difference towards connectivity and subsequent community resilience, beginning with the individual and extending to the overall social ecological system level. [ABSTRACT FROM AUTHOR]

Background: Takotsubo syndrome is a clinical syndrome characterized by an acute and transient left ventricular systolic dysfunction related to an emotional or physical stressful event. Case presentation: During the Covid‐19 pandemic, five cases of Takotsubo syndrome in hospitalized, mechanically ventilated patients due critical SARS‐CoV‐2 infection have been identified at our institution. Here we present the electrocardiographic, echocardiographic and angiographic characteristics of this case series. All cases were initially suspected by echocardiography performed due an abnormal electrocardiogram, troponin elevation or clinical deterioration. Conclusion: A high index of suspicion should be sought to identify Takotsubo syndrome and other cardiac complications associated with SARS‐CoV‐2 infection. [ABSTRACT FROM AUTHOR]

Background: The American College of Surgeons requires trauma centers to use six minimum criteria (ACS‐6) for full trauma team activation: hypotension, gunshot wound to the neck or torso, Glasgow Coma Scale (GCS) score < 9, respiratory compromise, transfers receiving blood transfusion, or physician discretion. Our goal was to evaluate the effect of adding varying shock index (SI) thresholds to the ACS‐6 in an adult trauma population with the hypothesis that SI would significantly improve sensitivity at the expense of an acceptable decrease in specificity. Methods: We performed a secondary analysis of EMS and trauma registry data from an urban Level I trauma center. Consecutive patients > 15 years of age were included from 1993 through 2006. SI at thresholds of ≥0.8, ≥0.85, ≥0.9, and ≥1 were evaluated. Primary outcome was emergency operative (within 1 h of arrival) or procedural (cricothyrotomy or thoracotomy) intervention (EOPI); secondary outcomes were Injury Severity Score (ISS) > 15, ISS > 24, a composite of EOPI or ISS > 15, and urgent operative intervention (within 4 h). Results: A total of 20,872 patients were included, 27% with an ISS > 15 and 5% who underwent EOPI. Sensitivity and specificity of the ACS‐6 alone for EOPI were 86% (95% confidence interval [CI] = 84% to 88%) and 81% (95% CI = 80% to 81%), respectively. Inclusion of SI thresholds of 0.8, 0.85, 0.9, and 1 resulted in sensitivities of 95% (95% CI = 93% to 96%), 93% (CI = 91% to 94%), 92% (95% CI = 90% to 93%), and 90% (95% CI = 88% to 92%), respectively, and specificities of 52% (95% CI = 51% to 52%), 59% (95% CI = 58% to 59%), 64% (95% CI = 64% to 65%), and 72% (95% CI = 71% to 73%), respectively. Similar trends were found for each secondary outcome. Conclusion: The addition of SI to the ACS‐6 for trauma team activation increased sensitivity for EOPI with a larger decrease in specificity across all thresholds. Inclusion of a SI threshold of ≥0.9 closely aligns with under‐ and overtriage benchmarks in this trauma registry cohort using a strict definition of trauma team activation need. [ABSTRACT FROM AUTHOR]

Objective: Patients intubated in the ED are at an increased risk of post‐intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. Methods: This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre‐ and post‐intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre‐ and post‐intubation was the primary measure of haemodynamic stability. Results: From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre‐intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose‐dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. Conclusion: Propofol was associated with post‐intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post‐intubation hypotension. [ABSTRACT FROM AUTHOR]

Aim: To assess the efficacy and safety of metaraminol infusions in comparison to other vasopressors in critically ill patients with shock with regard to hospital mortality, effect on haemodynamics (mean arterial pressure or systolic blood pressure), duration of vasopressor use, and adverse events. Data sources: A systematic review was conducted in eight electronic databases and nine trial registers from inception to 17 March 2021. Study selection: Studies included randomised or non‐randomised controlled trials, and retrospective or prospective observational studies of critically ill adult patients admitted to the intensive care unit or emergency department with shock of any aetiology and who received metaraminol via continuous infusion compared to patients who received other vasopressors. Results: Out of 1387 eligible articles, three observational studies and one controlled trial were included involving a total of 54 patients. Study patients had different types of shock including septic (n = 28), cardiogenic (n = 21), hypovolemic (n = 3) and neurogenic shock (n = 2). All studies compared metaraminol to noradrenaline and were of poor quality and high risk of bias. There was no difference in hospital mortality or effect on mean arterial pressure or systolic blood pressure between metaraminol and noradrenaline in any of the studies. None of the studies reported the duration of vasopressor use or adverse drug events such as extravasation or tissue injury. Conclusion: There is limited and low‐quality efficacy and safety data to support the use of metaraminol over other vasopressors in critically ill patients with shock. Future clinical trials are needed before this agent is routinely used in this patient population. [ABSTRACT FROM AUTHOR]

Background: Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets. Methods: Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI‐associated events (TIAEs), oxygen desaturation (SpO2 < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED. Results: A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7–108] months) than that for ICU TIs (15 [3–91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = –1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = –0.3%, 95% CI = –2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = –3.4%, 95% CI = –5.9 to –0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs. Conclusions: While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED. [ABSTRACT FROM AUTHOR]

Introduction: Transthoracic echocardiography (TTE) is a standard procedure for emergency physicians (EPs). Transesophageal echocardiography (TEE) is known to have great utility in patients who are critically ill or in cardiac arrest and has been used by some EPs with specialized ultrasound (US) training, but it is generally considered outside the reach of the majority of EPs. We surmised that all of our EPs could learn to perform focused TEE (F‐TEE), so we trained and credentialed all of the physicians in our group. Methods: We trained 52 EPs to perform and interpret F‐TEEs using a 4‐h simulator‐based course. We kept a database of all F‐TEE examinations for quality assurance and continuous quality feedback. Data are reported using descriptive statistics. Results: Emergency physicians attempted 557 total F‐TEE examinations (median = 10, interquartile range = 5–15) during the 42‐month period following training. Clinically relevant images were obtained in 99% of patients. EPs without fellowship or other advanced US training performed the majority of F‐TEEs (417, 74.9%) and 94.3% (95% confidence interval [CI] = 91.4%–96.3%) had interpretable images recorded. When TTE and TEE were both performed (n = 410), image quality of TEE was superior in 378 (93.3%, 95% CI = 89.7%–95%). Indications for F‐TEE included periarrest states (55.7%), cardiac arrest (32.1%), and shock (12.2%). There was one case of endotracheal tube dislodgement during TEE placement, but this was immediately identified and replaced without complication. Conclusion: After initiating a mandatory group F‐TEE training and credentialing program, we report the largest series to date of EP‐performed resuscitative F‐TEE. The majority of F‐TEE examinations (75%) were performed by EPs without advanced US training beyond residency. [ABSTRACT FROM AUTHOR]

Aims: The COVID‐19 pandemic resulted in a decrease in patients' follow‐up and interventions with cardiovascular disease. In Portugal, the consequences on emergent pacemaker implantation rates are largely unknown. We sought to analyze the impact of the COVID‐19 pandemic on emergent pacemaker implantation rate and patient profile. Methods: We retrospectively reviewed the clinical profile of the 180 patients who had pacemakers implanted in our hospital in an emergent setting from March 18, 2020, to May 17, 2020 ("lockdown") and May 19 to July 17, 2020 ("postlockdown"). This data was then directly compared to the homologous periods from the year before. Results: Urgent pacemaker implantation rates during "lockdown" was lower than its homologous period (−23.7%), and cases in "postlockdown" were significantly increased (+106.9% vs. "lockdown"; +13.2% vs. May–July 2019). When comparing "lockdown" and "postlockdown," there was a tendency for a higher number of temporary pacemaker use (p =.076). Patients during "lockdown" were 7.57 times more likely to present with hypotension/shock (odds ratio 7.57; p =.013). We also noted a higher tendency for hypotension on presentation during "lockdown" (p =.054) in comparison to 2019. In comparison to its homologous 2019 period, "postlockdown" saw more patients presenting with bradycardia (p =.026). No patients were admitted to the emergency department during "lockdown" for anomalies detected on ambulatory tests. Conclusion: Our data show that the COVID‐19 pandemic had a real impact on urgent pacemaker implantation. Patients with bradyarrhythmias are at particular risk for severe complications and should seek medical care regardless of the pandemic. [ABSTRACT FROM AUTHOR]

Introduction: Electromagnetic interference (EMI) from left ventricular assist devices (LVADs) can cause implantable cardioverter‐defibrillator (ICD) oversensing. We sought to assess the frequency of inappropriate shocks/oversensing due to LVAD‐related EMI and prospectively compare integrated (IB) versus dedicated bipolar (DB) sensing in patients with LVADs. Methods: Single‐center study in LVAD patients with Medtronic or Abbott ICDs between September 2017 and March 2020. We excluded patients that were pacemaker dependent. Measurements were obtained of IB and DB sensing and noise to calculate a signal‐to‐noise ratio (SNR). Device checks were reviewed to assess appropriate and inappropriate sensing events. Results: Forty patients (age 52 ± 14 years, 75% men, 38% ischemic cardiomyopathy) were included with the median time between LVAD implantation and enrollment of 6.7 months (2.3, 11.4 months). LVAD subtypes included: HeartWare (n = 22, 55%), Heartmate II (n = 10, 25%), and Heartmate III (n = 8, 20%). Over a follow‐up duration of 21.6 ± 12.9 months after LVAD implantation, 5% of patients (n = 2) had oversensing of EMI from the LVAD (both with HeartWare LVADs and Abbott ICDs) at 4 days and 10.8 months after LVAD implantation. Both patients underwent adjustment of ventricular sensing with resolution of oversensing and no further events over 5 and 15 months of further follow‐up. The SNR was similar between IB and DB sensing (50 [29–67] and 57 [41–69], p = 0.89). Conclusion: ICD oversensing of EMI from LVADs is infrequent and can be managed with reprogramming the sensitivity. There was no significant difference in the R‐wave SNR with IB versus DB ICD leads. [ABSTRACT FROM AUTHOR]

Purpose: To create a conceptual framework for skin injuries developing in patients whose lives are severely compromised or who are expected to die within a short period of time. To name and classify these types of skin injuries. To describe the clinical features of the different types of skin injuries that may occur in terminally ill and/or dying patients. Design: A sequential design with several different phases (a literature review, a nominal group, and a consensus conference) was used. Methods: Six experts with extensive knowledge of these types of injuries were selected for the nominal group. The traditional eight‐phase nominal group technique was followed. The consensus conference consisted of participants voting on different options based on the statements elaborated with the expert panel summarizing the best scientific evidence available. Findings: Using all these elements, a conceptual framework was constructed to identify skin injuries associated with severe life‐threatening situations (SI‐SLTSs), defined as unpredictable and therefore unpreventable injuries indicating a serious threat to life or even imminent death. These injuries can occur in two forms: (a) as skin injuries associated with multiple organ dysfunction syndrome (SI‐MODSs) or (b) as skin injuries associated with severe vasoconstriction (SI‐ESVs). SI‐MODSs develop very quickly and suddenly. They progress from superficial to deep stages abruptly, even within hours. The severity of the injuries does not reflect the care provided to the patient. Individuals suffering from these injuries have an irreversible clinical condition. SI‐ESVs also appear in individuals who are in a very critical, even terminal, clinical condition. They are frequently treated in the ICU and may exhibit severe vasoconstriction due to their disease process (e.g., shock), sometimes exacerbated by vasoconstriction caused by various drugs (e.g., noradrenaline). Conclusions: We have developed a conceptual framework for skin injuries developing in patients whose lives are severely compromised or who are expected to die within a short period of time and have named them SI‐SLTSs, distinguishing between SI‐MODSs and SI‐ESVs. Clinical relevance: This new conceptual framework may help clinicians understand the mechanisms and the pathophysiology of skin injuries that develop in terminally ill and/or dying patients associated with multi‐organ failure. Through this new framework these injuries can be identified and differentiated from pressure injuries or other dependence‐related skin lesions. [ABSTRACT FROM AUTHOR]

The article presents a case study of a woman aged in her 70s who was diagnosed with COVID-19 and transferred to the hospital (Oita University Hospital, Oita, Japan) because of persistent dyspnea for 3 days. She had several pre-existing cardiovascular diseases, including patent foramen ovale and ventricular septal defect. It notes that she was successfully treated for acetaminophen induced non-anaphylactic shock.

Background: Late‐onset circulatory collapse (LCC) is a serious complication in preterm infants and is increasing in Japan. The underlying pathophysiology is thought to be relative adrenal insufficiency and it is more likely to develop at a young gestational age (GA) and in low birthweight (BW) infants. BW to placental weight ratio (BPR) is an index of pregnancy outcomes and early neonatal morbidity. We aimed to analyze the relationship between LCC and potential predicting factors including BPR. Methods: This retrospective study included 261 singletons born before 32 weeks of gestation between 2007 and 2017. Perinatal data, including the placental weight and BPR, were collected from medical records and were assessed for their relationship with LCC. Propensity score analysis was performed and matched factors were GA and BW. Results: Sixty‐seven infants (25.7%) had LCC (median GA 27.4 weeks). GA and BW differed significantly between the LCC and non‐LCC groups (P < 0.001, respectively). The placental weight and BPR of the LCC group were significantly lower than those of the non‐LCC group, while Z‐score of BPR did not differ significantly between the groups. After propensity score matching, there was a significant difference in the incidence of severe intraventricular hemorrhage (grades III–IV; P = 0.042), but no differences in BPR and Z‐score of BPR between the groups. Conclusion: In the propensity score analysis matched for GA and BW, there was no significant difference in perinatal factors including BPR between the LCC and non‐LCC groups, except for incidence of severe intraventricular hemorrhage. [ABSTRACT FROM AUTHOR]

Sengstaken–Blakemore tubes (SBTs) are rarely used in Australia, because of improved access to endoscopy and interventional radiology, as well as overall lower rate of variceal haemorrhage from improvements in primary prophylaxis. SBT's use is associated with significant rate of serious complications, such as oesophageal perforation, mucosal necrosis, aspiration pneumonia and respiratory compromise secondary to external compression of the trachea. As such, SBT is currently only recommended for use in life‐threatening variceal haemorrhage, where endoscopic, embolization and pharmacologic therapy have been unsuccessful or are unavailable. No data exist for its use in Australasia but one area that it could be indicated is for hemodynamically unstable patients in remote setting, where long transfer times often means delayed access to endoscopy. We present a case of SBT insertion in retrieval medicine and discuss placement in the management of an unstable upper gastrointestinal bleed, complicating factors such as lack of radiology to confirm balloon position, the impact of flight altitude on balloon pressures, the maintenance of traction in flight and logistics of long flight times across the state of Queensland. This is the first case report of SBT use in the Australian aeromedical environment. It is also the first one where SBT has been used for duodenal bleeding, although the source of bleeding was unknown prior to insertion. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 30-year-old Caucasian female with with past medical history of multifocal ectopic Purkinje related premature contractions syndrome. Topics include presence of scar on cardiac magnetic resonance imaging and family history of sudden cardiac death (SCD) receiving a subcutaneous implantable cardioverter-defibrillator (S-ICD); and S-ICD constituting a novel approach for prevention of SCD resulting from ventricular arrhythmias in selected patients.

Background: Although the shock index (SI) (heart rate/systolic blood pressure) and heart rate (HR) are a helpful indicator in the management of postpartum blood loss, there are few reports of SI in pregnant women complicated with hypertensive disorders in pregnancy (HDP). The purpose of this study was to examine whether SI and HR would be a clinically helpful indicator, and to detect the cutoff value for judging abnormal obstetric bleeding. Methods: This was a retrospective case–control study in 107 patients with HDP in a singleton tertiary perinatal medical facility. The values of postpartum highest SI (peak SI) and highest HR (peak HR), and the amount of bleeding until peak SI and peak HR were retrospectively examined and analyzed. We used the receiver operating characteristic analysis to assess the diagnostic value of peak SI and peak HR for judging abnormal obstetric bleeding. Results: Peak SI and peak HR were significantly related to the amount of bleeding up to peak SI and up to peak HR. The cutoff values of peak SI with blood loss volumes above 500 ml, 1000 ml, and 1500 ml were 0.77, 0.76, and 0.99, respectively. The cutoff values of peak HR with blood loss volumes above 500 ml, 1000 ml, and 1500 ml were 97, 98, and 103, respectively. Conclusion: In cases of pregnant women complicated with HDP, both SI and HR were probably useful indicators in the management of postpartum blood loss. Further prospective trials are warranted to confirm these results. [ABSTRACT FROM AUTHOR]

Background: Subcutaneous implantable cardioverter defibrillators (S‐ICDs) avoid complications secondary to transvenous leads, but inappropriate shocks (ISs) are frequent. Furthermore, IS data from patients with Brugada syndrome (BrS) with an S‐ICD are scarce. Objective: We aimed to establish the frequency and predictors of IS in this population. Methods: We analyzed the clinical and electrocardiographic characteristics, automated screening test data, device programming, and IS occurrence in adult patients with BrS with an S‐ICD. Results: Thirty‐nine patients were enrolled (69% male, mean age at diagnosis 46 ± 13 years, mean age at implantation 48 ± 13 years). During a mean follow‐up of 26 ± 21 months, 18% patients experienced IS. Patients with IS were younger at the time of diagnosis (36 ± 8 vs. 48 ± 13 years, p =.018) and S‐ICD implantation (38 ± 9 vs. 50 ± 23 years, p =.019) and presented with spontaneous type 1 Brugada electrocardiogram pattern more frequently at diagnosis or during follow‐up (71% vs. 25%, p =.018). During automated screening tests, patients with IS showed lower QRS voltage in the primary vector in the supine position (0.58 ± 0.26 vs. 1.10 ± 0.35 mV, p =.011) and lower defibrillator automated screening score in the primary vector in the supine (123 ± 165 vs. 554 ± 390 mV, p =.005) and standing (162 ± 179 vs. 486 ± 388 mV, p =.038) positions. Age at diagnosis was the only independent predictor of IS (hazard ratio = 0.873, 95% confidence interval: 0.767–0.992, p =.037). Conclusion: IS was a frequent complication in patients with BrS with an S‐ICD. Younger age was independently associated with IS. A more thorough screening process might help prevent IS in this population. [ABSTRACT FROM AUTHOR]

Background: Current guidelines recommend defibrillation testing (DT) performance in patients with a subcutaneous implantable cardioverter defibrillator (S‐ICD), theoretically to reduce the amount of ineffective shocks. DT, however, has been proven unnecessary in transvenous ICD and real‐world data show a growing trend in avoidance of DT after S‐ICD implantation. Methods: All patients undergoing S‐ICD implant at nine associated Italian centers joining in the ELISIR registry (ClinicalTrials.gov Identifier: NCT04373876) were enrolled and classified upon DT performance. Long‐term follow‐up events were recorded and compared to report the long‐term efficacy and safety of S‐ICD implantations without DT in a real‐world setting. Results: A total of 420 patients (54.0 ± 15.5 years, 80.0% male) were enrolled in the study. A DT was performed in 254 (60.5%) patients (DT+ group), while in 166 (39.5%) was avoided (DT− group). Over a median follow‐up of 19 (11–31) months, a very low rate (0.7%) of ineffective shocks was observed, and no significant differences in the primary combined arrhythmic outcome were observed between the two groups (p =.656). At regression analysis, the only clinical predictor associated with the primary combined outcome was S‐ICD placement for primary prevention (odds ratio: 0.42; p =.013); DT performance instead was not associated with a reduction in primary outcome (p =.375). Conclusion: Implanting an S‐ICD without DT does not appear to impact the safety of defibrillation therapy and overall patients' survival. [ABSTRACT FROM AUTHOR]

Contraception is recommended for a certain period following a hysterotomy; however, no consensus exists on the required duration of contraception. A 21‐year‐old female was brought to the emergency room in a state of shock due to intraperitoneal bleeding. An emergency laparoscopic cornuostomy indicated for ruptured interstitial pregnancy was performed. Despite contraception, the patient got pregnant 1.5 months after surgery. At 16 weeks of gestation, threatened uterine rupture was suspected, as magnetic resonance imaging (MRI) revealed hematogenous amniotic fluid and a subchorionic hematoma near the interstitial portion of the fallopian tube. An MRI at 21 weeks showed hematoma shrinkage and disappearance of the hematogenous amniotic fluid. At 37 weeks, an elective cesarean section was performed, which resulted in a live birth. Pregnancy shortly after surgery is a risk factor for uterine rupture. In such cases, MRI could be useful in the evaluation of threatened uterine ruptures. [ABSTRACT FROM AUTHOR]

Factors associated with acute malnutrition are complex and wide‐ranging particularly in developing countries. In Mozambique, contextual factors associated to children acute malnutrition are yet to be fully investigated and the evidences used to better inform prevention programme. The objective of this study is to identify key factors associated with acute malnutrition among 6‐ to 59‐month‐old children living in nine districts in rural Mozambique assessed in the 2018 seasonal nutrition assessment. We analysed Standardized Monitoring and Assessment for Relief and Transition (SMART) nutrition survey data of 1,116 children from three districts and rapid nutrition assessment (RNA) data of 3,884 children from six districts of Mozambique. We used a multiple logistic regression analysis to respond to the research question. Experiencing diarrhoea [odds ratio (OR) = 4.54; P = 0.001] was the only variable associated with acute malnutrition from the SMART survey dataset, whereas in the RNA, fever (OR = 3.0; P = 0.000) access to sanitation (OR = 0.118; P = 0.037), experiencing shock in the household (OR = 0.5; P = 0.020), diarrhoea (OR = 2.41; P = 0.001) and cough (OR = 1.75; P = 0.030) were the variables with significant association to acute malnutrition. We believe that the findings were influenced by the proportion of acute malnutrition in each survey type. Study findings confirm the association between acute malnutrition and child's health outcomes that are generally linked to poor living conditions and independent effects of shocks. This highlights the need for policy and programme to implement integrated, cross‐sectoral approaches to tackling child acute malnutrition, particularly addressing community level conditions such as water and sanitation. [ABSTRACT FROM AUTHOR]

Background: Patients with post‐infarct cardiomyopathy and ventricular arrhythmias (VT) necessitating implantable cardioverter defibrillators (ICD) are at risk of recurrent shocks with increased morbidity. Methods: A comprehensive search of electronic databases for all randomized clinical trials that evaluated the role of catheter ablation as a preventive strategy at the time of secondary prevention ICD implantation was performed. We calculated hazard ratios (HR) and 95% confidence intervals (CI) using random‐effects model. Results: Four trials were identified with a total of 505 patients (average age 66.4 ± 9.0 years; 87.7% were male). Preventive ablation was associated with a significant reduction in appropriate device therapies (shocks and/or anti‐tachycardia therapy) (HR = 0.62; 95% CI = 0.46‐0.82; P <.01), sustained VT (HR = 0.74; 95% CI = 0.55‐0.99; P =.04) compared to control. There were no differences in inappropriate device shocks (HR = 0.80; 95% CI = 0.38‐1.71), all‐cause death (HR = 0.93; 95% CI = 0.53‐1.64), cardiac death (HR = 0.63; 95% CI = 0.29‐1.36), arrhythmic death (HR = 0.26; 95% CI = 0.05‐1.31), or cardiac hospitalization (HR = 0.79; 95% CI = 0.57‐1.11) between strategies. Preventive ablation was associated with improved SF‐36 physical component (mean difference = 2.81; 95% CI‐0.53‐5.10; P =.02), but not the mental component (mean difference = 1.30; 95% CI = ‐2.06‐4.66). Conclusion: Among patients with post‐infarct cardiomyopathy and VT, preventive catheter ablation at the time of ICD implantation is associated with a significant reduction of appropriate ICD therapy and sustained VT, and improvement in the physical component of quality‐of‐life, but no reduction in mortality. [ABSTRACT FROM AUTHOR]

A 52‐year‐old man experienced a subcutaneous implantable cardioverter‐defibrillator (S‐ICD) inappropriate shock due to electrode tip decubitus. The device, implanted two years before with a three‐incision technique, was extracted, and a new electrode was implanted along the contralateral parasternal line with a two‐incision technique, in a one‐stage procedure. One‐year follow‐up was eventless. Early S‐ICD electrode extraction and reimplantation during the same procedure is effective and should be considered as soon as initial signs of decubitus appear to avoid inappropriate shocks. A two‐incision technique should be preferred to reduce the risk of electrode tip decubitus. [ABSTRACT FROM AUTHOR]

Objective: The objective was to systematically identify and summarize out‐of‐hospital measures of circulatory compromise as diagnostic predictors of serious injury, focusing on measures usable by emergency medical services to inform field triage decisions. Methods: We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from 1996 through August 2017 for published literature on individual circulatory measures in trauma. We reviewed reference lists of included articles for additional relevant citations. Measures of diagnostic accuracy included sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Indicators of serious injury included resource need, serious anatomic injury, and mortality. We pooled estimates when data permitted. Results: We identified 114 articles, reporting results of 111 studies. Measures included systolic blood pressure (sBP), heart rate (HR), shock index (SI), lactate, base deficit, and HR variability. Pooled out‐of‐hospital sensitivity estimates were sBP < 90 mm Hg = 19% (95% confidence interval [CI] = 12% to 29%), HR ≥ 110 beats/min = 28% (95% CI = 20% to 37%), SI > 0.9 = 37% (95% CI = 22% to 56%), and lactate > 2.0 mmol/L = 74% (95% CI = 48% to 90%). Pooled specificity estimates were sBP < 90 mm Hg = 95% (95% CI = 91% to 97%), HR ≥ 110 beats/min = 85% (95% CI = 74% to 91%), SI > 0.9 = 85% (95% CI = 72% to 92%), and lactate > 2.0 mmol/L = 62% (95% CI = 51% to 72%). Pooled AUROCs included sBP = 0.67 (95% CI = 0.58 to 0.75), HR = 0.67 (95% CI = 0.56 to 0.79), SI = 0.72 (95% CI = 0.66 to 0.77), and lactate = 0.77 (95% CI = 0.67 to 0.82). Strength of evidence was low to moderate. Conclusions: Out‐of‐hospital circulatory measures are associated with poor to fair discrimination for identifying trauma patients with serious injuries. Many seriously injured patients have normal circulatory measures (low sensitivity), but when present, the measures are highly specific for identifying patients with serious injuries. [ABSTRACT FROM AUTHOR]

Many patients with severe coronavirus disease 2019 (COVID-19) remain unresponsive after surviving critical illness. Although several structural brain abnormalities have been described, their impact on brain function and implications for prognosis are unknown. Functional neuroimaging, which has prognostic significance, has yet to be explored in this population. Here we describe a patient with severe COVID-19 who, despite prolonged unresponsiveness and structural brain abnormalities, demonstrated intact functional network connectivity, and weeks later recovered the ability to follow commands. When prognosticating for survivors of severe COVID-19, clinicians should consider that brain networks may remain functionally intact despite structural injury and prolonged unresponsiveness. ANN NEUROL 2020;88:851-854. [ABSTRACT FROM AUTHOR]

Background: To date, few studies have explored cases of implantable cardioverter defibrillator (ICD) shock delivery with the intent of understanding patients' educational and supportive needs. Aims and objectives: To explore patient experiences as lived before, during and after one or more shocks. Design A descriptive qualitative study carried out between 2016 and 2017. Methods: Semi‐structured face‐to‐face audio‐recorded interviews were performed and analysed using a content analysis methodology. Results: A total of 50 patients (average age = 68.3 years; largely male = 49; 98%) were interviewed. Four themes emerged: (a) "Feeling surprised vs. alerted by the changes inside me"; (b) "Living an intense, mono‐dimensional vs. living a multidimensional storm experience", (c) "Facing the event vs. being supported"; and (d) "Living a drama vs. being used to it". Conclusions: Findings suggest that ICD use can trigger negative physical and emotional effects in patients. Moreover, nurses should recognize patients' educational needs according to the stage of adaptation that each patient is experiencing with the aim of tailoring appropriate supportive interventions. Relevance to clinical practice: Therefore, it is necessary to consider the psychological needs of patients by integrating these into clinical care at different levels (emergency department, hospital ward, home). Specific structured support aimed at helping patients overcome intense negative experiences is suggested, especially in the first stage of the adaptation process. Nurses should also ensure that appropriate education programmes with adequate follow‐up interventions are offered to improve the experience of living with an ICD. In addition, patient‐reported outcomes should be routinely collected from patients with an ICD. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is common in hospitalized and critically ill children. Apart from primary kidney disease, etiologies of AKI are usually related to systemic disease and nephrotoxic insult. This study examines the incidence, characteristics, and mortality risks of AKI in critically ill children without primary renal disease or previously known chronic kidney disease. Methods: A retrospective cohort study was conducted of patients aged 1–18 years, diagnosed with AKI (excluding severe glomerulonephritis and previously known chronic kidney disease) in pediatric intensive care units between 2013 and 2016. Acute kidney injury was defined according to the Kidney Disease Improving Global Outcomes classifications. Cox proportional hazards regression analysis was employed to assess the relationship between the risk factors and mortality. Results: Of 1,377 pediatric intensive care unit patients, 253 (18.4%) developed AKI and only 169 (12.3%) who did not have previously known renal disease were included. Of these 169 AKI patients, the mean age was 8.1 ± 4.7 years; 88 (52.1%) patients were male; and 60 (35.5%) patients had AKI stage 3. The most common etiologies of AKI were sepsis (76.9%) and shock (64.5%). Fifty‐three (31.4%) of those patients died during admission. The risk factors for death were the need for mechanical ventilation (adjusted hazard ratio, 17.82; 95% CI, 2.41–132.06) and AKI stage 3 (adjusted hazard ratio, 2.32; 95% CI, 1.07–5.00). Conclusions: Acute kidney injury in critically ill children without previously known renal disease was approximately two‐thirds of the overall incidence. The risk factors of in‐hospital death were the use of mechanical ventilation, and AKI stage 3. [ABSTRACT FROM AUTHOR]

Background: Antitachycardia pacing (ATP), which may avoid unnecessary implantable cardioverter‐defibrillator (ICD) shocks, does not always terminate ventricular arrhythmias (VAs). Mean entropy calculated using cardiac magnetic resonance texture analysis (CMR‐TA) has been shown to predict appropriate ICD therapy. We examined whether scar heterogeneity, quantified by mean entropy, is associated with ATP failure and explore potential mechanisms using computer modeling. Methods: A subanalysis of 114 patients undergoing CMR‐TA where the primary endpoint was delivery of appropriate ICD therapy (ATP or shock therapy) was performed. Patients receiving appropriate ICD therapy (n = 33) were dichotomized into "successful ATP" versus "shock therapy" groups. In silico computer modeling was used to explore underlying mechanisms. Results: A total of 16 of 33 (48.5%) patients had successful ATP to terminate VA, and 17 of 33 (51.5%) patients required shock therapy. Mean entropy was significantly higher in the shock versus successful ATP group (6.1 ± 0.5 vs 5.5 ± 0.7, P =.037). Analysis of patients receiving ATP (n = 22) showed significantly higher mean entropy in the six of 22 patients that failed ATP (followed by rescue ICD shock) compared to 16 of 22 that had successful ATP (6.3 ± 0.7 vs 5.5 ± 0.7, P =.048). Computer modeling suggested inability of the paced wavefront in ATP to successfully propagate from the electrode site through patchy fibrosis as a possible mechanism of failed ATP. Conclusions: Our findings suggest lower scar heterogeneity (mean entropy) is associated with successful ATP, whereas higher scar heterogeneity is associated with more aggressive VAs unresponsive to ATP requiring shock therapy that may be due to inability of the paced wavefront to propagate through scar and terminate the VA circuit. [ABSTRACT FROM AUTHOR]

Background: Programmed long AV delays and intrinsic long first degree AV block may increase risk for competitive atrial pacing (CAP) in devices without CAP avoidance algorithms. Methods: Patients identified with CAP‐induced mode switch episodes were followed clinically from September 2013 to August 2019. Attempts to avoid CAP included shortening of postventricular atrial refractory period (PVARP) or postventricular atrial blanking period (PVAB), or change to AAI or DDI modes. After observing associations with sensor‐driven pacing, rate response was inactivated in a subset. Results: Among 23 patients identified with CAP (22 St Jude Medical [Abbott]; one Boston Scientific Corporation devices), atrial fibrillation (AF) was induced in 12 (52%), lasting 10 seconds to 28 hours and 32 minutes. In one patient with an ICD CAP‐induced AF with rapid ventricular rates that triggered a shock, inducing ventricular fibrillation, syncope, and another shock. Changing AV delays and shortening of PVARP failed to resolve CAP. After noting that all had CAP during sensor‐driven pacing, rate response was inactivated in seven, resolving further device‐induced AF in the three of seven that had prior CAP‐induced AF. In two patients with intact AV conduction, AAI(R) pacing resolved further documentation of CAP. Conclusions: CAP predominantly occurs during sensor‐driven atrial pacing that competes with intrinsic atrial events falling in PVARP. Inactivation of the activity sensor or change to atrial‐based pacing modes (AAI/R) appears to effectively prevent induction of device‐induced atrial proarrhythmia. Ultimately, a corrective algorithm is needed to avoid CAP‐induced proarrhythmia. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is frequently present in patients with heart failure (HF) and an implantable cardioverter‐defibrillator (ICD). This study aims to identify clinical factors associated with a baseline history of AF in ICD recipients, and compares subsequent clinical outcomes in those with and without a baseline history of AF. Methods: We studied 566 consecutive first‐time ICD recipients at an academic center between 2011 and 2018. Logistic regression multivariable analyses were used to identify clinical factors associated with a baseline history of AF at the time of ICD implant. Cox‐proportional hazard regression models were constructed for multivariate analysis to examine associations between a baseline history of AF with subsequent clinical outcomes, including ICD therapies, HF readmission, and all‐cause mortality. Results: Of all patients, 201 (36%) had a baseline history of AF at the time of ICD implant. In multivariate analyses, clinical factors associated with a baseline history of AF included hypertension, valvular heart disease, body weight, PR interval, and serum creatinine level. After multivariate adjustment for potential confounders, a baseline history of AF was associated with an increased risk of anti‐tachycardia pacing (HR = 1.84, 95% CI = 1.19‐2.85, P =.006), appropriate ICD shocks (HR = 1.80, 95% CI = 1.05‐3.09, P =.032), and inappropriate ICD shocks (HR = 3.72, 95% CI = 1.7‐7.77, P =.0001), but not other adverse outcomes. Conclusion: Among first‐time ICD recipients, specific clinical characteristics were associated with a baseline history of AF at the time of ICD implant. After adjustment for potential confounders, a baseline history of AF was associated with a higher risk of all ICD therapies in follow‐up. [ABSTRACT FROM AUTHOR]

Objective: To describe the effect of fluid bolus therapy (FBT) on blood pressure in children with sepsis. Secondary outcomes included the effect of FBT on systemic vascular resistance, shock index and shock phenotype (warm or cold). Methods: This was a prospective observational study in the ED of The Royal Children's Hospital, Melbourne, Australia. Participants were children meeting international consensus criteria for sepsis who received FBT for tachycardia or hypotension. FBT was defined as 10–20 mL/kg of 0.9% saline. Mean blood pressure (MBP) was recorded at baseline, 5 and 60 min after FBT. Total systemic vascular resistance index (TSVRi), shock index, and shock phenotype were derived for each time point. Hypotension was defined as MBP <55 + 1.5 × age (years). Warm shock was defined as TSVRi <800 dyne s/cm5/m2. Results: Fifty fluid boluses were recorded in 41 children. Median MBP was 78 mmHg (interquartile range [IQR] 63–86) at baseline, 72 mmHg (IQR 60–82) at 5 min, and 75 mmHg (IQR 66–84) at 60 min. Hypotension was observed in 16% at baseline, 26% at 5 min and 17% at 60 min. Median TSVRi was 1580 dyne s/cm5/m2 (IQR 1242–2206) at baseline, 1254 dyne s/cm5/m2 (IQR 1027–1787) at 5 min, and 1850 dyne s/cm5/m2 (IQR 1265–2140) at 60 min. Median shock index was 1.60 (IQR 1.34–1.90) at baseline, 1.49 (IQR 1.25–1.76) at 5 min and 1.37 (IQR 1.22–1.61) at 60 min. Two percent of cases had warm shock at baseline, 12% at 5 min and 2% at 60 min. Conclusions: MBP initially decreased following FBT for paediatric sepsis, returning towards baseline over the subsequent 60 min. The utility of FBT for increasing MBP and its effect on patient‐centred outcomes in children with sepsis warrants further exploration. [ABSTRACT FROM AUTHOR]

Background: Advancement of digital technology now allows patients to have access to data from their cardiac implantable electronic devices (CIEDs). However, patients' understanding regarding CIED data and perceived personal usability remain unclear. The present study is a prospective survey to examine patients' understanding of their CIEDs and their perception of what is important. Methods: We screened 400 patients between July and December 2018 who presented to our outpatient clinic for a CIED interrogation. Patients received a one‐page questionnaire asking baseline demographics, their perception about their own knowledge about their device, and multiple‐choice questions in seven basic categories: type of CIED, original indication, functionality, manufacturer, number of active leads, estimated battery life, and number of shocks received. We compared these answers to their interrogation reports to assess accuracy. We also asked participants what they would like to be aware of regarding their CIED. Results: From this cohort, 344 of 400 (86%) (62.9 ± 12.8 years and 64 % males) agreed to take the survey and were included in the analysis. At baseline, 63.2% agreed or strongly agreed that they were knowledgeable about their devices. The overwhelming majority of patients demonstrated CIED knowledge deficits in at least one content area (n = 294, 86%), or more than two content areas (n = 176, 51%). Patients agreed or strongly agreed that they had a desire to have information regarding each of the following: battery life (84%), activity level (79%), heart rate trend (75%), and ventricular arrhythmias (74%). Conclusion: There is a large discrepancy in patients' level of knowledge regarding their CIEDs and their wish to know more details. Future technologies should satisfy providers' goals to educate their patients with basic information and fulfill patients' desire to obtain more data from their CIEDs. [ABSTRACT FROM AUTHOR]

Background: Implantable cardioverter‐defibrillator (ICD) recipients who receive appropriate device therapies have limited survival, and survival benefit in chronic kidney disease (CKD) has been questioned. We examined the association between CKD and survival after cardiac resynchronization therapy (CRT)‐defibrillator tachyarrhythmia therapies. Methods: We compared overall survival after appropriate shocks or anti‐tachycardia pacing in 439 CRT‐defibrillator recipients with left ventricular ejection fraction (LVEF) ≤35%, non‐right bundle‐branch block QRS pattern, and QRS duration >130 ms according to glomerular filtration rate (GFR) at implant, including 31 patients with GFR ≤30, 164 patients with GFR 31‐60, and 244 patients with GFR >60. At least one shock occurred in 302 patients (24 with GFR ≤30, 102 with GFR 31‐60, and 176 with GFR >60). Serial echocardiograms were also compared. Results: Patients were followed 64 months (interquartile range [IQR]: 29‐94) after implant, including 32 months (IQR: 12‐61) after first therapy. Time to first therapy or shock was similar across GFR groups. However, survival after first therapy declined directly with declining GFR (P <.001), with median postshock survival of 90 days for GFR ≤30 (95% confidence of interval [CI]: 0‐233), 612 days (95% CI: 365‐859) for GFR 31‐60, and 1672 days (95% CI: 1396‐1948) for GFR >60. Declining GFR category, ischemic heart disease, diabetes, and increasing age were independently associated with increased postshock mortality. Echocardiographic response was similar across GFR groups and was not associated with post‐therapy survival. Conclusions: Survival after appropriate tachyarrhythmia therapies, particularly shocks, is attenuated in patients with GFR ≤30. This raises concern over potential lack of survival benefit conferred by CRT‐defibrillators versus CRT‐pacemakers in this population. [ABSTRACT FROM AUTHOR]

Background: Due to high failure rates, Medtronic withdrew the Sprint Fidelis lead (SFL) from the market. Passive fixation lead models exhibited better survival than active models, but most studies have limited follow‐up. Aim of this study was to give insights into passive lead survival with a follow‐up of 10 years. Methods: In two large Swiss centers, patients with passive SFLs were identified and data from routine implantable cardioverter defibrillator (ICD) follow‐ups were collected. Patients were censored at time of death, last device interrogation (if lost to follow‐up), time of lead revision (in non‐SFL‐related problems), or at database closure (31th December 2017). We defined lead failure as any of the following: lead fracture with inappropriate discharge; sudden increase in low‐voltage impedance to >1500 or high‐voltage impedance to >100 Ω; >300 nonphysiological short VV‐intervals. Results: We identified 145 patients. Age at implant was 60 ± 12 years with a median follow‐up of 10.2 (interquartile range [IQR]: 5.0‐11.2) years. Thirty‐five percent of patients died after 5.4 ± 2.7 years. A total of 19 leads (13%) failed after 6.7 ± 3.2 years (range: 1.2‐12.0). Overt malfunction with shocks existed in four patients (3%). Cumulative lead survival was 93.1% at 6, 88.2% at 8, 83.8% at 10, and 77.6% at 11 years, respectively, with 35% of implanted leads under monitoring at 10 years. Lead survival fits best a Weibull distribution with accelerating failure rates (k = 1.95, 95% CI 1.32‐2.87, P < 0.001). Conclusions: During very long‐term follow‐up, failure rate of the passive SFL shows an increase resulting in an impaired lead survival of 84% at 10 years. [ABSTRACT FROM AUTHOR]

In case of a single fetal death in monochorionic twin pregnancy, the surviving fetus is thought to become hypovolemic. However, there is no report of any evidence of fetal circulatory insufficiency in such cases. We present a case of a single fetal death in a monochorionic twin pregnancy with type III selective intrauterine growth restriction that involved low fractional shortening, high myocardial performance index, elevated pulsatility index in the middle cerebral artery and fetal ascites. After immediate intrauterine transfusion, each parameter improved promptly. The surviving baby grew up without cardiac and neurological complications. To the best of our knowledge, this is the first report on transient circulatory insufficiency and decreased cardiac function in the surviving fetus. [ABSTRACT FROM AUTHOR]

Point‐of‐care ultrasound is a useful tool for clinicians in the management of patients. Particularly in emergency department, the role of point‐of‐care ultrasound is strongly increasing due to the need for a rapid assessment of critically ill patients and to speed up the diagnostic process. Hand‐carried ultrasound devices are particularly useful in emergency setting and allow rapid assessment of patient even in prehospital setting. This article will review the role of point‐of‐care ultrasonography, performed with pocket‐size devices, in the management of patients presenting with acute onset of undifferentiating dyspnea, chest pain, and shock in emergency department. [ABSTRACT FROM AUTHOR]

Background: Subcutaneous implantable cardioverter‐defibrillator (S‐ICD) is gaining in popularity for primary and secondary prevention of sudden cardiac death. The objective was to evaluate the safety and clinical effectiveness of the S‐ICD for prevention of sudden cardiac death compared to transvenous cardioverter‐defibrillator (TV‐ICD). Methods: A systematic review with meta‐analyses was performed. The electronic databases MEDLINE, EMBASE, SCI, and Cochrane Central Register of Controlled Trials were consulted in March 2018 with no restrictions on publication date. Predefined criteria were used to determine inclusion of studies and to assess their methodologic quality. Results: Ten longitudinal‐observational studies with comparison group presenting moderate methodologic flaws were included (N = 7820). The combination of results indicates that health‐related quality of life is not significantly different between S‐ICD and TV‐ICD groups (Physical health: MD = 2.90; 95% CI = −3.88, 9.68/Mental health: MD = 0.13; 95% CI = −2.11, 2.37). Mortality occurred in 4.4% of S‐ICD patients and 5.9% of TV‐ICD patients died (OR = 0.79; 95% CI = 0.50, 1.24). The incidence of infections (OR = 1.79; 95% CI = 0.93, 3.43) and inappropriate shocks (OR = 1.28, 95% CI = 0.91, 1.78) is not significantly different between both groups. The S‐ICD reduces complications related to electrodes/leads (OR = 0.13, 95% CI = 0.05, 0.29) and has lower electrodes/leads movement compared with TV‐ICD (OR = 0.26; 95% CI 0.10, 0.67). In contrast, pneumothorax is more likely in TV‐ICD than S‐ICD (OR = 0.17; 95% CI = 0.03, 0.97). Conclusions: S‐ICD reduces electrodes/leads movement, electrodes/leads related complications, and pneumothorax. Our study did not demonstrate a statistically significant difference in mortality, health‐related quality of life, and infection rate between S‐ICD and TV‐ICD. [ABSTRACT FROM AUTHOR]