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Resumen: Introducción: Los receptores de trasplante cardiaco no están libres de contagio de SARS-CoV-2. Su estado inmunocomprometido los convierte de alto riesgo a la infección. La gravedad clínica de presentación es incierta, su mortalidad en trasplante de corazón aún no está determinada. Material y métodos: Estudio observacional, retrospectivo. De marzo 2020 a febrero de 2021 se reunieron pacientes trasplantados de corazón, con positividad a qRT-PCR a SARS-CoV-2. Se valoraron las siguientes variables: edad, sexo, tiempo de trasplante al momento de infección, mortalidad, hospitalización, requerimiento de oxígeno extra, comorbilidades, severidad de la infección. Resultados: Se reunieron 8 pacientes positivos a SARS-CoV-2, con edad promedio de 53,8 ± 7,6 años, una mujer (12,5%) y siete varones (87,5%), tiempo promedio de trasplante 72,8 ± 38,0 meses. Mortalidad de un paciente (12,5%), fue hospitalizado, siete se atendieron en domicilio; tres (37,5%) requirieron de oxígeno suplementario. Las comorbilidades presentadas fueron: diabetes mellitus, 87,5%; hipertensión arterial, 87,5%; obesidad, 25%. La presentación clínica fue severa en 1 paciente (12,5%), moderado 2 (25%) y leve en 5 pacientes (62,5%). Conclusión: A pesar de las comorbilidades presentadas, la infección por SARS-CoV-2 en pacientes trasplantados de corazón se presentó como cuadro clínico leve a moderado que pudiera atribuirse a un efector protector ocasionado por los inmunosupresores que reciben. Abstract: Background: Heart transplant recipients do not escape SARS-CoV-2 infection, their immunocompromised status puts them at high risk for infection. The clinical severity of presentation is uncertain, its mortality in heart transplant patients has not yet been determined. Material and Methods: Observational, retrospective. From March 2020 to February 2021, heart transplant recipients with qRT-PCR positivity to SARS-CoV-2-2 were gathered. The following variables were assessed: age, sex, time of transplantation at the time of infection, mortality, hospitalization, extra oxygen requirement, comorbidities, and severity of infection. Results: Eight SARS-CoV-2 positive patients were gathered, aged 53.8 ± 7.6 years. One female patient (12.5%) and 7 males (87.5%), mean transplantation time 72.8 ± 38.0 months. Mortality was 12.5% (one patient who was hospitalized).Seven patients were treated at home; 3 (37.5%) required supplemental oxygen.Comorbidities were diabetes mellitus 87.5%, arterial hypertension 87.5%, obesity: 25%, the clinical presentation was severe in 1 patient (12.5%), moderate in 2 (25%) and mild in 5 patients (62.5%). Analysis: SARS-CoV-2 infection in heart transplant recipients presents a mild to moderate clinical picture, despite the comorbidities presented. It could be that theimmunosuppressant taken prior to the surgery confers a protective effect.

BACKGROUND American Indian (AI) children are at increased risk for severe disease during lower respiratory tract infection (LRTI). The reasons for this increased severity are poorly understood. The objective of this study was to define the clinical presentations of LRTI and highlight the differences between AI and non-AI previously healthy patients under the age of 24 months. METHODS We performed a retrospective chart review between October 2010 and December 2019. We reviewed 1245 patient charts and 691 children met inclusion criteria for this study. Data records included demographics, clinical, laboratory data, and illness outcomes. RESULTS Of 691 patients, 120 were AI and 571 were non-AI. There was a significant difference in breast-feeding history (10% of AI vs. 28% of non-AI, P < 0.0001) and in secondhand smoke exposure (37% of AI vs. 21% of non-AI, P < 0.0001). AI children had increased length of hospitalization compared with non-AI children (median of 3 vs. 2 days, P < 0.001). In addition, AI children had higher rates of pediatric intensive unit admission (30%, n = 37) compared with non-AI children (11%; n = 67, P < 0.01). AI children also had higher rates (62.5%, n = 75) and duration of oxygen supplementation (median 3 days) than non-AI children (48%, n = 274, P = 0.004; median 2 days, P = 0.0002). On a multivariate analysis, AI race was an independent predictor of severe disease during LRTI. CONCLUSIONS AI children have increased disease severity during LRTI with longer duration of hospitalization and oxygen supplementation, a higher rate of oxygen requirement and Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation pediatric intensive care unit admissions, and a greater need for mechanical ventilation. These results emphasize the need for improvement in health policies and access to health care in this vulnerable population.

This post hoc analysis of the Adaptive Coronavirus Disease 2019 (COVID-19) Treatment Trial-1 (ACTT-1) shows a treatment effect of remdesivir (RDV) on progression to invasive mechanical ventilation (IMV) or death. Additionally, we create a risk profile that better predicts progression than baseline oxygen requirement alone. The highest risk group derives the greatest treatment effect from RDV.

Decompression illness (DCI) is well known in compressed-air diving but has been considered anecdotal in breath-hold divers. Nonetheless, reported cases and field studies of the Japanese Ama, commercial or professional breath-hold divers, support DCI as a clinical entity. Clinical characteristics of DCI in Ama divers mainly suggest neurological involvement, especially stroke-like cerebral events with sparing of the spinal cord. Female Ama divers achieving deep depths have rarely experienced a panic-like neurosis from anxiety disorders. Neuroradiological studies of Ama divers have shown symptomatic and/or asymptomatic ischaemic lesions situated in the basal ganglia, brainstem, and deep and superficial cerebral white matter, suggesting arterial insufficiency. The underlying mechanism(s) of brain damage in breath-hold diving remain to be elucidated; one of the plausible mechanisms is arterialization of venous nitrogen bubbles passing through right to left shunts in the heart or lungs. Although the treatment for DCI in Ama divers has not been specifically established, oxygen breathing should be given as soon as possible for injured divers. The strategy for prevention of diving-related disorders includes reducing extreme diving schedules, prolonging surface intervals and avoiding long periods of repetitive diving. This review discusses the clinical manifestations of diving-related disorders in Ama divers and the controversial mechanisms.

The objective of the study was to develop and validate a prediction model that identifies COVID-19 patients at risk of requiring oxygen support based on five parameters: C-reactive protein (CRP), hypertension, age, and neutrophil and lymphocyte counts (CHANeL). This retrospective cohort study included 221 consecutive COVID-19 patients and the patients were randomly assigned randomly to a training set and a test set in a ratio of 1:1. Logistic regression, logistic LASSO regression, Random Forest, Support Vector Machine, and XGBoost analyses were performed based on age, hypertension status, serial CRP, and neutrophil and lymphocyte counts during the first 3 days of hospitalization. The ability of the model to predict oxygen requirement during hospitalization was tested. During hospitalization, 45 (41.8%) patients in the training set (n = 110) and 41 (36.9%) in the test set (n = 111) required supplementary oxygen support. The logistic LASSO regression model exhibited the highest AUC for the test set, with a sensitivity of 0.927 and a specificity of 0.814. An online risk calculator for oxygen requirement using CHANeL predictors was developed. “CHANeL” prediction models based on serial CRP, neutrophil, and lymphocyte counts during the first 3 days of hospitalization, along with age and hypertension status, provide a reliable estimate of the risk of supplement oxygen requirement among patients hospitalized with COVID-19.

Introducción: La bronquiolitis está entre las principales causas de morbilidad en menores de 24 meses. Objetivo: Determinar la efectividad de los esquemas de terapia respiratoria respecto al tiempo de estancia hospitalaria y requerimiento de oxígeno en menores de 2 años, ingresados con bronquiolitis en el Hospital Metropolitano desde enero del 2014 a diciembre del 2019. Método: Estudio analítico retrospectivo, 546 pacientes con bronquiolitis y oxigenoterapia. El análisis univariado de variables cuantitativas se describió con media, el de variables cualitativas con frecuencias. Análisis inferencial realizado con ANOVA y prueba post-hoc de Bonferroni. Se consideró estadísticamente significativo p menor a 0,05. Resultados: 58,4% fueron de sexo masculino, la edad más frecuente fue de 29 días a 11 meses 29 días (70%), el período con mayor número de hospitalizaciones fue entre diciembre y mayo. El tiempo promedio de oxigenoterapia fue 1.03 días, la estancia hospitalaria 1.37 días, el principal agente etiológico fue el virus sincitial respiratorio (VSR) mediante inmunocromatografía (63,8%) y PCR (51%). El VSR prolonga la estancia hospitalaria y oxigenoterapia (p=0,001 y p=0,031). Los esquemas de terapia respiratoria: a) solución hipertónica, b) salbutamol más bromuro de ipratropio y c) salbutamol alternado con bromuro de ipratropio más salbutamol, se asociaron con menor estancia hospitalaria (1 a 3 días) (p=0.016). 28.8% de pacientes recibieron antibioticoterapia, evidenciándose prolongación del tiempo de estancia hospitalaria (p=0.000); los corticoides prolongaron la oxigenoterapia (p=0,004). Conclusión: emplear los tres esquemas descritos previamente, disminuye la estancia hospitalaria.

Case Presentation A 75-year-old man was referred to our institution for worsening dyspnea, decreased activity tolerance, myalgias, and an increase in oxygen requirement. Nine months before the initial referral, the patient presented to an outside hospital for acute hypoxemic respiratory failure requiring a right-sided video-assisted thoracoscopic surgery (VATS) lung biopsy that disclosed organizing pneumonia (OP). He was treated with a prolonged steroid course starting at 1 mg/kg daily and tapered over 6 months to a baseline of 20 mg of prednisone daily and continuous oxygen (2 L/min). Prior attempts to further reduce prednisone resulted in worsening dyspnea, fevers, and myalgias. Despite optimal medical treatment for 3 months, he presented to our institution with progressive dyspnea, an increased oxygen requirement to 6 L/min, fatigue, and muscle weakness.

AIM To investigate the characteristics of infants with neonatal encephalopathy (NE) receiving therapeutic hypothermia (TH) who developed late onset oxygen requirement during or after rewarming. METHODS Infants were stratified by receiving (a) new onset isolated oxygen requirements during or after rewarming; (b) no respiratory support during hospital stay; and (c) invasive and/or non-invasive respiratory support before or during cooling. RESULTS Of 136 infants treated with TH, 49 (36%) did not require any respiratory support, and 78 (57.4%) received invasive or non-invasive support before or during cooling. Nine infants (6.6%) developed late onset oxygen requirement. The late onset oxygen requirement started at median age of 3.8 days (IQR 3.6-5.2) and ended at median 7.5 days (IQR 5.8-12.7). Total hours of O2 exposure were median 62.0 (IQR 24.4-112.6). Maximum support was low-flow nasal cannula from 100% oxygen source with a flow rate of 40-250 mL/min. Infants in this group had higher Apgar scores, milder metabolic acidosis and no seizures. Three infants had diagnostic investigations without significant findings. CONCLUSION A small percentage of neonates with NE developed late onset oxygen requirement during or after rewarming. Late oxygen requirement was associated with evidence of less severe perinatal hypoxia-ischaemia.

Recent evidence showed greater efficacy of tocilizumab (TCZ) in the subgroups of COVID-19 patients who presented with symptoms for less than 7 days and in those only receiving oxygen. We retrospectively analyzed a compassionate use cohort to determine the best timing for TCZ injection. We showed no association between the timing of injection after symptom onset and the efficacy of TCZ on mortality. We then investigated whether the oxygen level at the time of TCZ injection impacted the mortality rate. Our study finally suggested that TCZ could be less effective when oxygen requirement is >11 L/min and we hypothesized that earlier administration could be associated with better outcome. However, randomized clinical trials are required to confirm this hypothesis.

Hyperbaric oxygen therapy (HBOT) is a well-established treatment for a variety of conditions. Hyperbaric oxygen therapy is the administration of 100% oxygen breathing in a pressure vessel at higher than atmospheric pressure (1 atmosphere absolute = 101 kPa). Typically, treatment is given daily for between 1 and 2 h at pressures of 2.0 to 2.8 ATA, depending on the indication. Sporting injuries are often treated over 3 to 10 sessions. Hyperbaric oxygen therapy has been documented to be effective and is approved in 14 medical indications by the Undersea and Hyperbaric Medical Society, including, but not limited to, carbon monoxide poisoning, compromised skin grafts and flaps, crush injuries, necrotizing soft tissue infections, and nonhealing ulcers with arterial insufficiencies. Recently, HBOT for sports musculoskeletal injuries is receiving increased attention. Hyperbaric oxygen therapy may allow injured athletes to recover faster than normal rehabilitation methods. Any reduction in collegiate and professional athletes' rehabilitation period can be financially significant for top-level sports teams; however, further research is required to confirm HBOT's benefits on sports musculoskeletal injuries. The purpose of this review to discuss the current understanding of HBOT as a treatment modality for common musculoskeletal injuries in sport medicine. Moreover, we will highlight the advantages and disadvantages of this modality, as well as relevant clinical and research applications.

P19 Figure 1Results119 COVNA patients identified (female 65 (55%);77 (66%) BAME;median age 51 years, IQR 38–62, range 16–88). Over half (55%) were between the ages 40 and 69. COVNA patients were relatively free from co-morbidity: 104 (87%) had low or intermediate risk ISARIC 4C scores;all had Charlson co-morbidity score of less than 9 representing low 10 year mortality.Median length of stay on VCW was 3 days (IQR 3–8, range 0–15);median number of calls undertaken was 3 (IQR 2–5, range 0–9).32 (27%) COVNA patients returned to ED, 8 of whom were discharged home with an overall admission rate 20%. Re-presentations within 5/7 were predominantly COVID related (20/23;87%). After 5 days, there were no attendances with worsening pneumonitis (figure 1). The commonest route for re-attendance was self-referral (17/32;53%) of whom 14 were admitted;all 10 persons referred to ED from VCW were admitted.COVNA patients issued with a saturation probe (48%) were more likely to re-present and be admitted (RR 2.2;95% CI 1.03–4.74;p0.0425).2 (1.7%) sustained pulmonary emboli;1 intensive care admission;4 patients died (3% unadjusted mortality).ConclusionsCOVNA patients have low mortality and morbidity from COVID. The VCW model has safely and successfully supported COVNA patients who are deemed fit enough to not require admission (clinical judgment and no oxygen requirement). Ideally, all COVNA patients should be issued with a saturation probe. COVNA patients should be warned that re-presentation and admission may be required. Worsening of symptoms and/or a drop in oxygen saturation should warrant return to ED. This pathway should be continued in COVID endemic phase.

Introduction and ObjectivesThe COVID-19 pandemic required rapid service changes in order to meet the emerging needs of our patients and to reduce pressures on hospital beds. In March 2020 we established one of the first virtual wards with the aim of supporting patients with a continuing oxygen requirement safely at home during their COVID-19 illness.MethodsThe virtual ward was delivered by the integrated care ImpACT+ service. This multi-disciplinary service comprises respiratory consultants, respiratory specialist nurses, physiotherapists, occupational therapists and fitness instructors. Our local criteria for on-boarding included: 10 days post onset of symptoms, oxygen requirement 4L or less and the ability to manage with home monitoring equipment. A mix of telephone and home contacts were offered and daily consultant MDTs undertaken. Therapy team members were up-skilled to support oxygen assessments and weaning regimes to maximise service capacity. A direct electronic referral icon was created on the hospital whiteboard system accompanied by a nurse-led telephone referral service. The scheme was advertised through posters and in-reach work into COVID-19 areas.Results107 patients were managed on our virtual ward since March 2020. This included 99 COVID-19 patients and 8 with other acute respiratory exacerbations. The mean continuous oxygen prescription on discharge was 1.5 L (range 0.5–4L) and for ambulatory purposes 2.4L (1–6L). 55 patients with COVID-19 were discharged on anticoagulation, 33 on steroids and 21 on antibiotics. 8 30-day readmissions, 3 deaths (2 expected). The total number of bed days on the virtual ward was 2010 (mean 21 days) and in total the activity that service delivered included 904 telephone calls and 274 home visits. Service feedback demonstrated a high level of satisfaction with patients commenting that they valued being at home with support during their recovery.ConclusionsThis service has shown a supported discharge Covid-19 oxygen weaning service is a valuable initiative to relieve pressures on the acute hospital service and provide high quality care to facilitate early discharge from hospital. This virtual ward highlighted the value of having an integrated respiratory team and extension of this model to other respiratory conditions should be possible with considered adaptions.

Background Adult SOT recipients with COVID‐19 have higher mortality rates when compared to general population. There is paucity of data on outcomes in pediatric SOT recipients. Methods This is a cross‐sectional study investigating the prevalence of COVID‐19 infection and outcomes in pediatric SOT (heart, liver, and kidney) recipients. We extracted demographic and clinical characteristics and COVID‐19 testing (PCR or [Ab] test) results from medical records. Clinical characteristics were compared between patients who were positive for COVID‐19 (PCR or Ab) and those who did not, using Mann‐Whitney, Student's t test, or chi‐square test. p value

Background & objectivesEstablishing concrete evidence on the effect of vaccination on the severity of SARS CoV-2 infections in real-world situations is the need of the hour. This study aims to estimate the effectiveness of Covid 19 vaccines in preventing the new and severe SARS CoV-2 infections.DesignCross-sectional studySetting& ParticipantsWe did this cross-sectional study among the 4565 patients consecutive adult inpatients admitted in the Covid 19 wards of a tertiary care hospital from May 7, 2021, to October 7, 2021, during the second wave of the Covid 19 pandemic. Information on basic demographic variables, RT PCR status, vaccination status, outcome and clinical severity of illness were obtained from the electronic hospital patient records.ResultsOnly 4% of the study participants had prior vaccination. The type of vaccine and number of doses didn’t have any protective effect against the new SARS CoV-2 infection and breakthrough infection. Fully vaccinated RTPCR positive patients had an 82% reduction in the need for ICU admission (OR 0.09; AOR 0.18, CI (0.04 to 0.8), P 0.05).ConclusionVaccination doesn’t protect against new SARS Cov-2 infection and breakthrough infection however significant protection was documented against severe SARS Cov-2 infection. The protective effect shown by the vaccines in preventing the severe form of SARS Cov-2 infection among fully vaccinated patients was 82%. Vaccination coverage should be increased urgently to halt the impending wave of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

The use of sildenafil leads to an improvement in oxygenation and has the potential to reduce mortality in severe persistent pulmonary hypertension of neonates (PPHN). Mild PPHN in term neonates often prolongs the duration of oxygen requirement without other major morbidities, thereby increasing the length of hospital stay. We present a case series of eight term neonates with clinical and echocardiographic evidence of mild PPHN, in whom treatment with oral sildenafil resulted in early clinical improvement. It was observed that neonates could be weaned off from oxygen inhalation after a mean (SD) 53.1 (11.8) h of starting oral sildenafil as their oxygen saturation was maintained between 93 and 95% in room air. Infants could be discharged home after a median (IQR) 10 (7.5–12) days and oral sildenafil could be stopped after a median duration of 1.4 (1–1.8) months. All infants tolerated oral sildenafil well without any major adverse events.

Lung ultrasound (LUS) plays a critical role in the SARS-CoV-2 pandemic. Evidence is mounting on its utility to diagnose, assess the severity and as a triage tool in the ED. Sonographic features correlate well to computed tomography (CT) chest findings and a bedside LUS performed by a trained clinician along with clinical examination, could be an alternative to chest X-ray and CT chest in these highly infectious patients. In this article, we have described a step-by-step approach to LUS in COVID patients and the CLUE (COVID-19 LUS in the ED) protocol, which involves an anatomical parameter, the severity of lung changes, objectively scored using the validated LUS scoring system and a physiological parameter, oxygen requirement. We believe this CLUE protocol can help risk-stratify patients presenting to ED with suspected COVID-19 and aid clinicians in making appropriate disposition decisions.

INTRODUCTION: Recently, portable dry electroencephalographs (dry-EEGs) have indexed cognitive workload, fatigue, and drowsiness in operational environments. Using this technology this project assessed whether significant changes in brainwave frequency power occurred in response to hypoxic exposures as experienced in military aviation.METHODS: There were 60 (30 women, 30 men) student Naval Aviators or Flight Officers who were exposed to an intense (acute) high-altitude (25,000 ft) normobaric hypoxic exposure, and 20 min later, more gradual (insidious) normobaric hypoxic exposure up to 20,000 ft while flying a fixed-wing flight simulation and monitored with a dry-EEG system. Using MATLAB, EEG frequencies and power were quantified and analyzed. Cognitive performance was also assessed with a cognitive task validated under hypoxia. Normobaric hypoxia and O₂ saturation (Spo₂) were produced and monitored using the Reduced Oxygen Breathing Device (ROBD2).RESULTS: Significant Spo₂ decreases were recorded at acute 25K and insidious 20K simulated altitudes. Significant power decreases were recorded in all frequencies (alpha, beta, gamma, and theta) and all channels with acute 25K exposures. Gamma, beta, and theta frequency power were significantly decreased with insidious 20K exposures at most of the channels. The frequency power decreases corresponded to significant decreases in cognitive performance and flight performance. Most importantly, frequency power suppressions occurred despite 42% of the volunteers not perceiving they were hypoxic in the acute phase, nor 20% in the insidious phase.DISCUSSION: Results suggest EEG suppression during acute/insidious hypoxia can index performance decrements. These findings have promising implications in the development of biosensors that mitigate potential in-flight hypoxic physiological episodes.Rice GM, Snider D, Drollinger S, Greil C, Bogni F, Phillips J, Raj A, Marco K, Linnville S. Dry-EEG manifestations of acute and insidious hypoxia during simulated flight. Aerosp Med Hum Perform. 2019; 90(2):92-100.

High-flow nasal oxygen has been shown to provide effective pre-oxygenation and prolong apnoeic time during intubation attempts in non-pregnant patients. We aimed to compare pre-oxygenation using high-flow nasal oxygen (30-70 l.min-1 oxygen flow) via nasal prongs with standard 15 l.min-1 oxygen breathing via a tight-fitting facemask. Forty healthy parturients were randomly allocated to these two groups, and furthermore each patient underwent the selected pre-oxygenation method with both 3-min tidal volume breathing and 30s tidal breathing followed by eight vital capacity breaths. With 3-min tidal volume breathing, the respective estimated marginal means for high-flow nasal oxygen and standard flow rate facemask pre-oxygenation were 87.4% (95%CI 85.5-89.2%) and 91.0% (95%CI 89.3-92.7%), p = 0.02; with eight vital capacity breaths the estimated marginal means were 85.9% (95%CI 84.1-87.7%) and 91.8% (95%CI 90.1-93.4%, p < 0.0001). Furthermore, high-flow nasal oxygen did not reliably achieve a mean end-tidal oxygen concentration ≥ 90% compared with the standard flow rate facemask. In this physiological study, high-flow nasal oxygen pre-oxygenation performed worse than standard flow rate facemask pre-oxygenation in healthy term parturients.

A 64-year-old man with a history of long-term cigarette smoking (>36 pack-years) and diagnosis of chronic obstructive pulmonary disease (COPD) (forced expiratory volume in 1s (FEV1): 47% predicted; FEV1/forced vital capacity: 61% predicted) was referred to an outpatient pulmonary rehabilitation programme [1]. The patient exhibited gas trapping at rest (residual volume/total lung capacity (TLC): 167% predicted; inspiratory capacity (IC)/TLC: 29%) and reported exertional dyspnoea at grade 3 on the 1–5 Medical Research Council scale [2]. The patient's medication included bronchodilators and inhaled steroids. The patient poorly tolerated the cardiopulmonary exercise test (sustained at 75% of his peak exercise capacity, WRpeak). This was demonstrated by substantially reduced endurance time (6 min 30 s), profound dynamic hyperinflation (reduction in IC from rest by 232 mL), moderate exertional hypoxaemia (arterial oxygen saturation measured by pulse oximetry (SpO2) 87%) and reported severe breathlessness as the predominant reason for terminating exercise (i.e. score of 8 on the 1–10 Borg scale [3]) (table 1)., In COPD patients the ergogenic effect of heliox or oxygen breathing might be related both to improvements in ventilatory parameters (that lessen dyspnoea) and to enhanced oxygen delivery to respiratory and locomotor muscles http://bit.ly/2JlJBTc

Bronchopulmonary dysplasia (BPD) is a leading cause of mortality and morbidity in premature infants with significant lifelong respiratory and neurodevelopmental sequelae into adulthood.1 Since it was first described in 1967, the pathophysiological understanding of BPD has evolved with advances in neonatal practice, such as the use of surfactant and maternal antenatal steroids. As the care of extremely premature infants improves, more immature infants born during the late canalicular and early saccular phases of lung development are surviving, altering the pathophysiology of BPD and diagnostic criteria.2 There is an ongoing debate on the optimal method of diagnosing and classifying BPD. The current 2018 National Institute of Child Health and Human Development BPD definition3 adopts a treatment-based, semiquantitative approach. Very premature infants with abnormal chest X-ray findings are classified into three grades of BPD depending on oxygen requirement and type of respiratory support required over three consecutive days around 36 weeks of corrected gestational age (CGA). Hence, differences in oxygen and ventilation strategies among clinicians and centres may lead to inconsistencies in BPD definition and classification. Impaired pulmonary gas exchange is a cardinal feature of BPD. A pathophysiological-based approach in defining BPD by measuring pulmonary gas exchange in very preterm infants may offer a physiological assessment of BPD severity at the parenchymal level.2 The rightward shift of the oxyhaemoglobin dissociation …

Objective Ensuring an efficient response to COVID-19 requires a degree of inter-system coordination and capacity management coupled with an accurate assessment of hospital utilization including length of stay (LOS). We aimed to establish optimal practices in inter-system data sharing and LOS modeling to support patient care and regional hospital operations. Materials and Methods We completed a retrospective observational study of patients admitted with COVID-19 followed by 12-week prospective validation, involving 36 hospitals covering the upper Midwest. We developed a method for sharing de-identified patient data across systems for analysis. From this, we compared 3 approaches, generalized linear model (GLM) and random forest (RF), and aggregated system level averages to identify features associated with LOS. We compared model performance by area under the ROC curve (AUROC). Results A total of 2068 patients were included and used for model derivation and 597 patients for validation. LOS overall had a median of 5.0 days and mean of 8.2 days. Consistent predictors of LOS included age, critical illness, oxygen requirement, weight loss, and nursing home admission. In the validation cohort, the RF model (AUROC 0.890) and GLM model (AUROC 0.864) achieved good to excellent prediction of LOS, but only marginally better than system averages in practice. Conclusion Regional sharing of patient data allowed for effective prediction of LOS across systems; however, this only provided marginal improvement over hospital averages at the aggregate level. A federated approach of sharing aggregated system capacity and average LOS will likely allow for effective capacity management at the regional level.

Antibody detection of prior SARS-CoV-2 infection depends on severity, assay, and timing with implications for serosurveillance., Interpretation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serosurveillance studies is limited by poorly defined performance of antibody assays over time in individuals with different clinical presentations. We measured antibody responses in plasma samples from 128 individuals over 160 days using 14 assays. We found a consistent and strong effect of disease severity on antibody magnitude, driven by fever, cough, hospitalization, and oxygen requirement. Responses to spike protein versus nucleocapsid had consistently higher correlation with neutralization. Assays varied substantially in sensitivity during early convalescence and time to seroreversion. Variability was dramatic for individuals with mild infection, who had consistently lower antibody titers, with sensitivities at 6 months ranging from 33 to 98% for commercial assays. Thus, the ability to detect previous infection by SARS-CoV-2 is highly dependent on infection severity, timing, and the assay used. These findings have important implications for the design and interpretation of SARS-CoV-2 serosurveillance studies.

In our study, procalcitonin was associated with both antibiotic use and duration in patients with COVID-19, as well as established biochemical markers of COVID-19 disease severity and oxygen requirement, suggesting a potential role for procalcitonin in COVID-19 antimicrobial stewardship.

Background: During the COVID-19 pandemic, restrictive measures can reduce physical activity. The purpose of this study was to evaluate predisease physical activity and current functional capacity in patients with and without the presence of pneumonia and oxygen requirement in Turkish survivors of COVID-19. Methods: Among the COVID-19 patients admitted to the hospital, 100 patients were selected. Data about predisease physical activity (by short-form International Physical Activity Questionnaire), oxygen requirement and presence of pneumonia, and current functional capacity (by the 6-min walking test) were collected. Continuous and categorical variables were compared with the Mann–Whitney U and χ2 test, respectively (P Results: The predisease physical activity levels and current functional capacity of patients with pneumonia and oxygen requirement were significantly lower than patients without pneumonia and oxygen requirement (P P > 0.05). Pneumonia and oxygen requirement was more common in the older adults (P r = .530, P = .000) and current functional capacity (r = −.346, P = .000) and predisease physical activity level with current functional capacity (r = .523, P = .001). Conclusion: The physical activity level may be related to the severity of COVID-19 disease.

Background: An important component of a pandemic like Covid 19 is to triage patients in order to prevent medical establishments from getting overwhelmed. The objective of our study is to find whether an initial HRCT chest can help triage patient by determining their oxygen requirement, the place of treatment, laboratory parameters and the risk of mortality and to compare 3 CT scoring systems (0-20 model, 0-25 model and percentage of involved lung) to find if one is a better predictor of prognosis than the other. Methods: This was a prospective observational study conducted at a Tertiary care hospital in Mumbai, India. Data collected included baseline demographics, days from swab positivity to CT scan, comorbidities, place of treatment, laboratory parameters, oxygen requirement and mortality. We divided the patients into mild, moderate and severe based on 3 criteria - 20 point CT score (OS1), 25 point CT score (OS2) and opacity percentage (OP). CT scans were analyzed using CT pneumonia analysis prototype software (Siemens Healthcare version 2.5.2, Erlangen, Germany). Findings: 740 patients were included in our study. All the 3 scoring systems showed a significant positive correlation with oxygen requirement, place of admission and death. No correlation with the laboratory parameters could be found. Based on ROC analysis a score of 4 for OS1, 9 for OS2 and 12.7% for OP was determined as the cut off for oxygen requirement. Interpretation: An early CT scan in patients affected with Covid 19 is predictive of the oxygen requirement of the patient. As severity scores increase the chances of requirement of higher oxygen and intubation increase. The severity scoring system can be based on lobar involvement and scored 0-20 or 0-25 or based on percentage of lung involved, as they are all predictive of oxygen requirement. CT severity scoring using an automated deep learning software programme is a great boon for determining oxygen requirement and triage. Funding Statement: No grant from any funding agency was received for this research. Declaration of Interests: We do not report and conflict of interest. Ethics Approval Statement: The Ethics Committee waived the need for ethical clearance and informed consent for this non-interventional study.

Hypersensitivity pneumonitis has historically been treated with immunosuppression, but recently nintedanib was approved for the treatment of progressive fibrotic HP. One limitation of INBUILD is that the only immunosuppression (IS) permitted at the time of enrollment was glucocorticoids at a dose of less than 20mg per day, so the additive effect of antifibrotic (AF) therapy to IS in HP remains unclear. We present 5 cases of patients with HP for whom AF therapy was added to IS. Trends observed in the cohort include reduced decline in FVC, oxygen requirement, and symptoms in the year after adding AF to IS in 4 of the 5 patients. All 5 patients (100%) in our series demonstrated progression in the year prior to initiation of antifibrotic based on criteria outlined in the INBUILD trial, but only 1 of 5 (20%) progressed in the year after AF. There was a significant decrease in the rate of relative decline in % predicted FVC in the 12 months after initiation of antifibrotic compared to the 12 months prior to antifibrotic (0.4% ±7.6 vs −17.5% ±7.6, p = 0.0495). Compared to the 12 months prior to antifibrotic therapy, fewer patients met criteria for progression in the 12 months after initiating antifibrotic therapy (p = 0.048). Similarly, fewer patients met criteria for progression in the 6 months after initiating antifibrotic therapy compared to the 6 months prior (p = 0.048). A larger study with control groups on IS alone and AF alone is needed to confirm the role of AF therapy in combination with IS in patients with HP.

A 62-year-old man presented with worsening dyspnoea, haemoptysis and reduced exercise tolerance. He was found to be hypoxaemic with bilateral basal opacification on chest imaging, but inflammatory markers, respiratory virus PCR and sputum culture demonstrated no signs of infection. The patient reported having initially mild, yet progressive, symptoms since he started vaping 14 months previously. He was treated with oxygen therapy, supportive care and cessation of vaping. Chest imaging at discharge showed marked improvement of previous bilateral opacification and the patient returned to baseline exercise tolerance, with no oxygen requirement. Vaping is becoming more common in the UK and this case demonstrates the importance of considering electronic vaping-associated lung injury in cases of non-infective lung injury.

Introduction Ibuprofen disappeared from the pharmacy shelves during the 2019 coronavirus (COVID-19) pandemic. However, a while later, information circulated that ibuprofen should be avoided as it could worsen COVID-19 symptoms. The aim of our study was to assess the association of acute and chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) with worse COVID-19 outcomes. Methods We did a prospective cohort study between April 12 and June 1, 2020. Adults consecutively diagnosed with COVID-19 were included. Information on NSAID use was collected through a telephone questionnaire, and patients were followed up for COVID-19 infection outcomes, including death, admission, severity, time to clinical improvement, oxygen requirement and length of stay. Results Acute use of ibuprofen was not associated with a greater risk of mortality relative to non-use (adjusted hazard ratio [HR] 0.632 [95% CI 0.073–5.441; P = 0.6758]). Chronic NSAID use was also not associated with a greater risk of mortality (adjusted HR 0.492 [95% CI 0.178–1.362; P = 0.1721]). Acute ibuprofen use was not associated with a higher risk of admission compared to non-NSAID users (adjusted odds ratio OR 1.271; 95% CI 0.548–2.953). NSAID users did not have a significantly longer time to clinical improvement or length of stay. Conclusion Acute or chronic use of ibuprofen and other NSAIDs was not associated with worse COVID-19 disease outcomes. Electronic supplementary material The online version of this article (10.1007/s40121-020-00363-w) contains supplementary material, which is available to authorized users.

BackgroundWith the rising number of new cases of COVID-19, understanding the oxygen requirement of severe patients assists in identifying at risk groups and in making an informed decision on building hospitals capacity in terms of oxygen facility arrangement. Therefore, the study aimed to estimate time to getting off supplemental oxygen therapy and identify predictors among COVID-19 patients admitted to Millennium COVID-19 Care Center in Ethiopia.MethodsA prospective observational study was conducted among 244 consecutively admitted COVID-19 patients from July to September, 2020. Kaplan Meier plots, median survival times and Log-rank test were used to describe the data and compare survival distribution between groups. Cox proportional hazard survival model was used to identify determinants of time to getting off supplemental oxygen therapy, where hazard ratio (HR), P-value and 95%CI for HR were used for testing significance and interpretation of results.ResultsMedian time to getting off supplemental oxygen therapy among the studied population was 6 days (IQR, 4.3-20.0). Factors that affect time to getting off supplemental oxygen therapy were age group (AHR=0.52,95%CI=0.32,0.84, p-value=0.008 for ≥70 years) and shortness of breath (AHR=0.71,95%CI=0.52,0.96, p-value=0.026).ConclusionsAverage duration of supplemental oxygen therapy requirement among COVID-19 patients was 6 days and being 70 years and older and having shortness of breath were found to be associated with prolonged duration of supplemental oxygen therapy requirement. This result can be used as a guide in planning institutional resource allocation and patient management to provide a well-equipped care to prevent complications and death from the disease.

Hypoxia training is normally performed using the hypobaric simulation method in hypobaric chambers. The method entails disadvantages such as a lack of appropriate workplaces, high financial and personnel demands, and also the risk of decompression sickness and other dysbarisms. A safer alternative is the normobaric method of simulating a hypoxic environment - the so-called Reduced Oxygen Breathing Method (ROBM). The ROBM is less demanding in terms of finance and personnel, and the risk of decompression sickness is eliminated. In this review paper, the authors analyze and compare methods of testing pilots for resistance to hypoxia: i.e. using hypobaric and normobaric simulations of hypoxic environment. The results show that the normobaric method will significantly enhance the level of safety of aeromedical training while increasing its effectiveness. The risk of decompression sickness and other dysbarisms is zero in the normobaric method, and minimized if combination of hypobaric and normobaric Combined Altitude and Depleted Oxygen (CADO) methods are applied. Based on the findings, a new breathing depleted air mixture (BDAM) model of aeromedical training of military pilots is proposed to be safer, more efficient, and less demanding in terms of finance and personnel than the current forms of training. The results of the paper also indicate the possibilities of making this training more accessible to civilian pilots and thus they can contribute to the desirable improvement in aviation safety training.

Community acquired pneumonia is the leading cause of death from infection. Early identification of severe pneumonia allows early intervention and improves outcomes for patients. We have demonstrated that pneumonia-specific tools were superior to other risk stratification methods in predicting 30-day mortality; however, CURB65 has limited ability to predict 30-day mortality in our study(1). We sought to develop a risk stratification tool which was a better predictor of mortality. Using a dataset previously described (1) we used a combination of univariate and multivariate analysis to identify factors significantly associated with 30-day mortality; age, respiratory rate, oxygen requirement,temperature,urea,albumin, neutrophil:lymphocyte ratio, blood pH and lactate. The first set of data on admission was used. 1271 cases were available for scoring. ROC analysis demonstrated an AUC of 0.811 for BCAPS, CURB65 generated an AUC of 0.69. In summary we have generated a simple bedside tool which is able to accurately predict 30-day mortality in CAP at the point of admission to hospital. This tool requires further validation in external sites and larger databases to ensure generalisability. (1): PMID:31258921

A new set of underwear and protective clothing with phase change materials (PCM) for mine rescuers has been developed in order to increase their safety of work. It includes PCM pouches absorbing excess heat from the body. In order to evaluate thermal load of mine rescuers, physiological tests were carried out for three variants of possible use of the developed set of clothing: for mine rescuers wearing only the underwear with PCM, for a set of underwear and protective clothing, and for a complete set of clothing with closed-circuit compressed oxygen breathing apparatus. Tests were performed in difficult microclimate conditions, reflecting the typical working conditions of rescuers that cause a significant thermal load. The use of outer clothing shortened safe time of exposure to such conditions by about 36%, while the addition of respiratory protective device to this set further shortened this time to a lesser extent (by another 13%).

Introduction Whilst the use of combustible tobacco products continues to decline in the United States, the use of e-cigarettes has seen an explosive rise in recent years. In 2019 an outbreak on EVALI was seen across the country, highlighting the fact that e-cigarettes may not be as harmless as previously perceived. Case description A 22-year-old male came to the emergency department complaining of vomiting and shortness of breath. Patient reported using a “pod” a day of a “JUUL” e-cigarette. Patient's oxygen requirement continued to increase and was eventually shifted to the intensive care unit and mechanically ventilated. After a course of intravenous glucocorticoids, the patient was successfully weaned off the mechanical ventilation to oral glucocorticoids and discharged. Discussion Our patient's clinical course can be described as a “classic” case of EVALI. But in contrast to previously reported cases, our patient did not use e-cigarettes known to contain vitamin E acetate or THC two common substances implicated in EVALI. Our patient exclusively used a JUUL e-cigarette at a rate much higher than the typical user. The widespread use of JUUL and e-cigarettes especially amongst the younger demographics is especially concerning. Conclusion Research efforts must be directed towards the substances utilized in e-cigarettes, and their use should be actively discouraged.

We report a case of a 61-year-old male who had recently been discharged home after contracting COVID-19 during an extended hospital admission. He presented to the emergency department after episode of sudden onset central chest pain and D-dimer was 390 mcg/L on admission. The patient was initially managed for acute coronary syndrome, however within twenty-four hours of admission the patient desaturated to 74% on room air and required 15L oxygen. CT Pulmonary Angiogram showed right lower lobe segmental pulmonary emboli and extensive COVID-19 lung changes. Subsequently, acute coronary syndrome treatment was stopped, and the patient treated for pulmonary embolus. Following this, his oxygen requirement improved significantly, and the patient stabilised within one week. Emerging data and clinical evidence suggests an increased risk and prevalence of venous thromboembolic events in COVID-19, particularly in patients with more severe disease. It is currently unclear how long this increased risk persists. This case report highlights the importance of risk stratification of patients on discharge from hospital, to determine who requires extended thromboprophylaxis on discharge. Going forward, clinical trials are needed to evaluate the duration and dose of thromboprophylaxis in high-risk patients, and aid the formation of clearer guidelines for clinicians.

Photoplethysmography (PPG) is a valuable technique for noninvasively evaluating physiological parameters. However, traditional PPG devices have significant limitations in high-motion and low-perfusion environments. To overcome these limitations, we investigated the accuracy of a clinically novel PPG site using SPYDR&reg, a new PPG sensor suite, against arterial blood gas (ABG) measurements as well as other commercial PPG sensors at the finger and forehead in hypoxic environments. SPYDR utilizes a reflectance PPG sensor applied behind the ear, between the pinna and the hairline, on the mastoid process, above the sternocleidomastoid muscle, near the posterior auricular artery in a self-contained ear cup system. ABG revealed accuracy of SPYDR with a root mean square error of 2.61% at a 70&ndash, 100% range, meeting FDA requirements for PPG sensor accuracy. Subjects were also instrumented with SPYDR, as well as finger and forehead PPG sensors, and pulse rate (PR) and oxygen saturation (SpO2) were measured and compared at various reduced oxygen profiles with a reduced oxygen breathing device (ROBD). SPYDR was shown to be as accurate as other sensors in reduced oxygen environments with a Pearson&rsquo, s correlation &gt, 93% for PR and SpO2. In addition, SPYDR responded to changes in SpO2 up to 50 s faster than PPG measurements at the finger and forehead.

OBJECTIVE To further validate the use of the Modified Tal Score (MTS), a clinical tool for assessing bronchiolitis severity, by physicians with varying experience and training levels, and to determine the ability of the MTS to predict bronchiolitis severity. METHODS This prospective cohort study included infants of

Purpose Use projection-resolved OCT angiography to investigate the autoregulatory response in the 3 parafoveal retinal plexuses under hyperoxia. Design Prospective cohort study. Participants Nine eyes from 9 healthy participants. Methods One eye from each participant was scanned using a commercial spectral-domain OCT system. Two repeated macular scans (3 × 3 mm2) were acquired at baseline and during oxygen breathing. The split-spectrum amplitude-decorrelation algorithm was used to detect blood flow. The projection-resolved algorithm was used to suppress projection artifacts and resolve blood flow in 3 distinct parafoveal plexuses. The Wilcoxon signed-rank test was used to compare baseline and hyperoxic parameters. The coefficient of variation, intraclass correlation coefficient, and pooled standard deviation were used to assess the reliability of OCT angiography measurements. Main Outcome Measures Flow index and vessel density were calculated from the en face angiograms of each of the 3 plexuses, as well as from the all-plexus inner retinal slab. Results Hyperoxia induced significant reduction in the flow index (−11%) and vessel density (−7.8%) of only the deep capillary plexus (P Conclusions Projection-resolved OCT angiography was able to show that the retinal autoregulatory response to hyperoxia affects only the deep capillary plexus, but not the intermediate capillary plexus or superficial vascular complex.

A 79-year-old woman presented with a week-long history of shortness of breath. She had a background of idiopathic pulmonary fibrosis (IPF) which was stable and had not required any antifibrotic treatment. A month prior to this presentation, she was admitted with COVID-19 pneumonia, with maximal oxygen requirement of 2 L, but was discharged without need for supplemental oxygen. On readmission, she was found to have severe, rapidly progressive pulmonary fibrosis. After all precipitating causes were ruled out, it was felt her recent COVID-19 infection was the exacerbating factor causing progression of pulmonary fibrosis. COVID-19 infection has been hypothesised to cause long term pulmonary fibrosis, but this is the first case highlighting COVID-19 infection as the causative agent exacerbating IPF.

Introduction Inside chamber attendants rescuing survivors from a pressurised, distressed submarine may themselves accumulate a decompression obligation which may exceed the limits of Defense and Civil Institute of Environmental Medicine tables presently used by the Royal Australian Navy. This study assessed the probability of decompression sickness (PDCS) for medical attendants supervising survivors undergoing oxygen-accelerated saturation decompression according to the National Oceanic and Atmospheric Administration (NOAA) 17.11 table. Methods Estimated probability of decompression sickness (PDCS), the units pulmonary oxygen toxicity dose (UPTD) and the volume of oxygen required were calculated for attendants breathing air during the NOAA table compared with the introduction of various periods of oxygen breathing. Results The PDCS in medical attendants breathing air whilst supervising survivors receiving NOAA decompression is up to 4.5%. For the longest predicted profile (830 minutes at 253 kPa) oxygen breathing at 30, 60 and 90 minutes at 132 kPa partial pressure of oxygen reduced the air-breathing-associated PDCS to less than 3.1 %, 2.1% and 1.4% respectively. Conclusions The probability of at least one incident of DCS among attendants, with consequent strain on resources, is high if attendants breathe air throughout their exposure. The introduction of 90 minutes of oxygen breathing greatly reduces the probability of this interruption to rescue operations.

The greatest danger faced by divers who use oxygen-enriched gas mixtures is central nervous system oxygen toxicity (CNS-OT). CNS-OT is characterised by convulsions resembling grand-mal epileptic seizures, which may terminate in drowning and death. Elevated arterial levels of carbon dioxide (CO(2)) (hypercapnia) represent a major risk factor for CNS-OT when breathing hyperoxic gas mixtures. To reduce the risk of a diver being involved in a CNS-OT incident due to hypercapnia, candidates for combat diving are examined at our institute using a routine physiological training procedure, in which they are tested for CO(2) detection and retention. We present the case of a candidate for combat diving, who unexpectedly exhibited signs typical of CNS-OT while breathing pure oxygen under normobaric conditions with > 3 kPa inspired CO(2). Severe headache and nausea, as well as facial muscle twitching, appeared during one of these routine tests. Subsequent medical examination including neurological tests, magnetic resonance imaging and an electroencephalogram were unremarkable. To the best of our knowledge, an event such as this has never previously been published in the medical literature. We present a discussion of the case, and a review of the relevant literature regarding CO(2) as a risk factor for the development of CNS-OT

Materials Research Letters 7(3), 117 - 123 (2019). doi:10.1080/21663831.2018.1561535, The HfO2-based resistive random access memory (RRAM) is one of the most promising candidatesfor non-volatile memory applications. The detection and examination of the dynamic behavior ofoxygen ions/vacancies are crucial to deeply understand the microscopic physical nature of theresistive switching (RS) behavior. By using synchrotron radiation based, non-destructive and bulksensitivehard X-ray photoelectron spectroscopy (HAXPES), we demonstrate an operando diagnosticdetection of the oxygen ‘breathing’ behavior at the oxide/metal interface, namely, oxygen migrationbetween HfO2 and TiN during different RS periods. The results highlight the significance ofoxide/metal interfaces in RRAM, even in filament-type devices., Published by Taylor & Francis, London [u.a.]

Although cardiac arrest in pregnancy is rare, it is important that all individuals involved in the acute care of pregnant women are suitably trained, because the outcome for both mother and fetus can be affected by the management of the arrest. Perimortem caesarean delivery was first described in 715 BC. Initially the procedure was performed principally for religious or political reasons. Although the potential for fetal survival was proposed, it was rarely successful, probably because the delivery was delayed until maternal death was established. However, in recent decades, case reports have suggested improved maternal as well as fetal survival if perimortem caesarean section was performed rapidly once maternal arrest has occurred. While evidence for this is largely based on case reports, the physiological advantages including removing inferior caval obstruction, and hence improving venous return to the heart, reducing oxygen requirement and improving chest compliance appear compelling. Factors that reduce errors and minimise the delay in performance of caesarean delivery are discussed, in particular the importance of training, organizational factors within a hospital and the use of prompts during an arrest. While evidence is limited, it is probable that both maternal and fetal survival are improved with early delivery by perimortem caesarean delivery. More importantly, no evidence was found from case report reviews that either maternal or fetal survival was worsened. Perimortem caesarean delivery therefore remains a key consideration in the management of maternal arrest from the mid second trimester.

Purpose: Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for patients with acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate associations between ventilatory settings during ECMO for refractory hypoxemia and outcome in ARDS patients. Methods: In this individual patient data meta-analysis of observational studies in adult ARDS patients receiving ECMO for refractory hypoxemia, a time-dependent frailty model was used to determine which ventilator settings in the first 3 days of ECMO had an independent association with in-hospital mortality. Results: Nine studies including 545 patients were included. Initiation of ECMO was accompanied by significant decreases in tidal volume size, positive end-expiratory pressure (PEEP), plateau pressure, and driving pressure (plateau pressure − PEEP) levels, and respiratory rate and minute ventilation, and resulted in higher PaO2/FiO2, higher arterial pH and lower PaCO2 levels. Higher age, male gender and lower body mass index were independently associated with mortality. Driving pressure was the only ventilatory parameter during ECMO that showed an independent association with in-hospital mortality [adjusted HR, 1.06 (95 % CI, 1.03–1.10)]. Conclusion: In this series of ARDS patients receiving ECMO for refractory hypoxemia, driving pressure during ECMO was the only ventilator setting that showed an independent association with in-hospital mortality. © 2016, Springer-Verlag Berlin Heidelberg and ESICM.

Multispectral optoacoustic tomography provides insights into tumor vascular oxygenation with high temporal and spatial resolution non-invasively. New work indicates that a simple oxygen breathing challenge can reveal differences in tumor, potentially as a prognostic biomarker.

Mustard procedure for the correction of transposition of the great arteries (TGA) is associated with a high rate of long-term complications including arrhythmia, systemic right ventricular dysfunction, and baffle obstruction. Desaturation is infrequent and ascites is rare. A 45 year old with TGA

Bronchopulmonary dysplasia (BPD) is a condition marked by prolonged ventilator and oxygen requirement due to underlying arrested lung development. Tracheostomy is a staple in long-term establishment of pediatric airways in this condition, and has many benefits. However, these children's airways can be very tenuous. We present a case of a child with severe BPD who developed extreme bronchospasm during tracheostomy. We also briefly review current literature in the management of such children's airways and potential directions for future management.

INTRODUCTION: Central nervous system oxygen toxicity (CNS-OT) is an uncommon complication of hyperbaric oxygen treatment (HBOT). Different facilities have developed local protocols in an attempt to reduce the risk of CNS-OT. This audit was performed to elucidate which protocols might be of benefit in mitigating CNS-OT and to open discussion on adopting a common protocol for Treatment Table 14 (TT14) to enable future multicentre clinical trials. METHODS: Audit of CNS-OT events between units using different compression profiles for TT14, performed at 243 kPa with variable durations of oxygen breathing and 'air breaks', to assess whether there is a statistical difference between protocols. Data were collected retrospectively from public and private hyperbaric facilities in Australia and New Zealand between 01 January 2010 and 31 December 2014. RESULTS: Eight of 15 units approached participated. During the five-year period 5,193 patients received 96,670 treatments. There were a total of 38 seizures in 33 patients when all treatment pressures were examined. In the group of patients treated at 243 kPa there were a total of 26 seizures in 23 patients. The incidence of seizure per treatment was 0.024% (2.4 per 10,000 treatments) at 243 kPa and the risk per patient was 0.45% (4.5 in 1,000 patients). There were no statistically significant differences between the incidences of CNS-OT using different TT14 protocols in this analysis. CONCLUSIONS: HBOT is safe and CNS-OT is uncommon. The risk of CNS-OT per patient at 243 kPa was 1 in 222 (0.45%; range 0−1%) and the overall risk irrespective of treatment table was 0.6% (range 0.31−1.8%). These figures are higher than previously reported as they represent individual patient risk as opposed to risk per treatment. The wide disparity of facility protocols for a 243 kPa table without discernible influence on the incidence of CNS-OT rates should facilitate a national approach to consensus.

Introduction: the aim of this case report is to present that oral L-citrulline supplementation may attenuate chronic pulmonary hypertension and reduce oxygen requirement in infants with severe bronchopulmonary dysplasia. Important clinical findings: a boy, with a birth weight of 700 g, born by cesarean section after 25 weeks of pregnancy complicated with preeclampsia, was admitted to the neonatal intensive care unit. He was ventilatory dependent for the next 3 months with significantly increased oxygen requirements. A severe stage of bronchopulmonary dysplasia, complicated with increased pulmonary vascular resistance, was diagnosed. Treatment with inhaled nitric oxide and oral sildenafil was included in the therapy of chronic pulmonary hypertension. The results of screening echocardiograms and increased plasma brain natriuretic peptide concentrations, suggested right ventricle dysfunction. The main intervention: at the beginning of the sixth month of hospitalization, oral supplementation of L-citrulline in a single dose of 150 mg/kg/day was introduced and continued for 70 days. During the first 3 weeks after L-citrulline was started, the patient was weaned from mechanical ventilation and he was never intubated again until he was discharged. Plasma brain natriuretic peptide concentrations decreased significantly during the first month of L-citrulline administration and became stable until the termination of L-citrulline supplementation. At discharge, the patient required 22%–25% concentration of oxygen supplemented intermittently, exclusively during feeding. Conclusion: these results indicate that L-citrulline supplementation may deserve coverage as an additional, potentially beneficial alternative in the prophylaxis or therapy of chronic pulmonary hypertension in newborns.