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The HeartMate Risk Score (HMRS), a simple clinical prediction rule based on the patients' age, albumin, creatinine, and the international normalized ratio of the prothrombin time (PT-INR), is correlated with mortality in the cohort of left ventricular assist device (LVAD) recipients. However, in an aging society, an LAVD is indicated for only a small proportion of patients with acute heart failure (AHF), and whether the HMRS has prognostic implications for unselected patients with AHF is unknown. This study aimed to assess the prognostic value of HMRS categories on admission in patients with AHF. We analyzed 339 hospitalized patients with AHF who had albumin, creatinine, and the PT-INR recorded on admission. The patients were categorized as follows: the High group (HMRS > 2.48, n = 131), Mid group (HMRS of 1.58–2.48, n = 97) group, and Low group (HMRS < 1.58, n = 111). The endpoints of this study were all-cause death and readmission for heart failure (HF). During a median follow-up of 247 days, 24 (18.3%) patients died in the High group, 7 (7.2%) died in the Mid group, and 8 (7.2%) died in the Low group. In a multivariable analysis adjusted for highly imbalanced baseline variables, a high HMRS was independently associated with survival, with a hazard ratio of 2.90 (95% confidence interval 1.42–5.96, P = 0.004). With regard to the composite endpoint of all-cause death and readmission for HF, the Mid group had a worse prognosis than the Low group, and the High group had the worst prognosis. A high HMRS on admission is associated with all-cause mortality and readmission for HF, and a mid-HMRS is associated with readmission for HF after AHF hospitalization. The HMRS may be a valid clinical tool to stratify the risk of adverse outcomes after hospitalization in unselected patients with AHF. [ABSTRACT FROM AUTHOR]

Continuous monitoring software, T3, has an integrated index called the inadequate oxygen delivery index 50% (IDO2-50) which displays a probability that the mixed venous saturation is below a user-selected threshold of 30–50%. The primary aim of this study was to determine the correlation of the IDO2-50 with a measured venous saturation. The secondary aim of this study was to characterize the hemodynamic factors that contributed to the IDO2-50. This single-center, retrospective study aimed to characterize the correlation between IDO2-50 and inferior vena cava (IVC) saturation. A Bayesian Pearson correlation was conducted to assess the correlation between the collected variables of interest, with a particular interest in the correlation between the IDO2-50 and the IVC saturation. Receiver operator curve (ROC) analysis to assess the ability of the IDO2-50 to identify when the venous saturation was less than 50%. Bayesian linear regression was done with the IDO2-50 (dependent variable) and other independent variables. A total of 113 datasets were collected across 15 unique patients. IDO2-50 had moderate correlation with the IVC saturation (correlation coefficient − 0.569). The IDO2-50 had a weak but significant correlation with cerebral near-infrared spectroscopy (NIRS) values, a weak but significant correlation with heart rate, and a moderate and significant correlation with arterial saturation. ROC analysis demonstrated that the IDO2-50 had a good ability to identify a venous saturation below 50%, with an area under the curve of 0.797, cutoff point of 24.5 with a sensitivity of 81%, specificity of 66%, positive predictive value of 44%, and negative predictive value of 91%. Bayesian linear regression analysis yielded the following model: 237.82 + (1.18 × age in months) − (3.31 × arterial saturation) − (1.92 × cerebral NIRS) + (0.84 × heart rate). The IDO2 index has moderate correlation with IVC saturation. It has good sensitive and negative predictive value. Cerebral NIRS does appear to correlate better with the underlying venous saturation than the IDO2 index. [ABSTRACT FROM AUTHOR]

To determine the effectiveness of using earplugs and eye masks on the melatonin and cortisol levels of patients hospitalized in cardiac critical care units (CCUs). The research population of this study included all patients with acute coronary syndrome hospitalized in the CCU of Shahid Rajaei Hospital affiliated with to Alborz University of Medical Sciences. A total of 60 patients were selected by the available sampling method based on the inclusion criteria and then were divided into 2 control and intervention groups by block randomization method with blocks of 4 (n = 30 in the intervention group, and n = 30 in the control group). Patients in the intervention groups used blindfolds and earmuffs during the night sleep for 3 nights, but patients in the control group received the routine care. Cortisol and melatonin levels of both groups were measured at 8 am, using the urine samples. The findings of the 2 groups were compared and statistically analyzed by SPSS software version 16. The findings showed no significant difference between the 2 groups in terms of demographic characteristics and clinical variables. The intervention had no effect on the cortisol level of patients in the intervention group (P = .24). After the intervention, a statistically significant difference was observed between the control and intervention groups in terms of the melatonin level in the nocturnal urine (P ≤ .001). A statistically significant difference was also observed between the 2 groups in terms of the time taken for patients to fall asleep (P ≤ .001) and the number of times waking up at night (P ≤ .001). The use of earplugs and eye masks had no impact on the level of cortisol hormone, but it affected the level of melatonin hormone and the sleep quality of patients hospitalized in the CCU. [ABSTRACT FROM AUTHOR]

Background and Objectives Study Design and Methods Results Conclusion Cold‐stored whole blood (CS‐WB) in paediatric cardiac surgery is making a resurgence, given its identified benefits compared to conventional blood component therapy (CT).A single‐centre retrospective study was conducted from January 2018 to October 2018 by including children <18 years of age undergoing cardiac surgery requiring cardiopulmonary bypass. ABO‐compatible CS‐WB from non‐directed random donors was leukoreduced with platelet‐sparing filters and compared with CT.Fifty‐seven patients (30, 53% CS‐WB; 27, 47% CT) were studied. Patient demographics were similar, although CT patients were cooled to a lower intra‐operative temperature. Blood product requirements 24 h post operation were less in the CS‐WB group (11.1 vs. 26.7 mL/kg, p = 0.048). Twelve (40%) patients in the CS‐WB cohort had more than one donor exposure versus 25 (93%) in the CT group (p < 0.001). CT patients compared to CS‐WB patients had a greater decrease in pre‐operative versus 48‐h post‐operative haemoglobin, platelets and prothrombin time. Patients who received CT compared to CS‐WB had a trend towards higher median (interquartile range [IQR]) chest‐tube output (mL/kg/h) in the first 4 h post cardiac intensive care unit (ICU) admission (2.1 [0.8, 3] vs. 1.6 [0.8, 2.2], p = 0.197). There was no difference in antifibrinolytic use, length of stay, sepsis, acute kidney injury or wound infection. Survival to discharge was similar.CS‐WB in paediatric cardiac surgery may reduce donor exposure and improve haemostatic balance. Future multi‐centre prospective studies are needed to validate these findings and identify patients who would benefit from CS‐WB in paediatric cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: A consistent referral system and patient patronage are the primary connections between the three tiers in the healthcare delivery system. Patients were scheduled to visit primary care clinics for the first time. Subsequently, patients are moved to more distinguished healthcare facilities to receive additional care. Objectives: This study aims to investigate the reasons behind patients' transfer from primary and secondary care to tertiary care, as well as the critical factors that influence these referrals. Methods: This study employs a mixed‐methods approach to explore factors determining referral service provision across primary, secondary, and tertiary healthcare levels. Along with conducting semi‐structured interviews with healthcare professionals, we systematically examined a wealth of retrospective data on 1331 referred patients from 130 health facilities, including patient records, demographics, referral status, and clinical presentation. All statistical analysis was processed in R, and Corel Draw 12 was also used for graphical illustration. Results: Healthcare facilities referred most emergencies to several departments, including the cardiac care unit, medical, urology, intensive care unit/emergency, obstetrics and gynaecology, children's, orthopaedic, and psychiatry. The percentage of all cases referred is displayed ward‐by‐ward; the intensive care unit/emergency wards have a high referral ratio of 65.51%, while the obstetrics and gynaecology wards have an 18.40% referral ratio. Conclusion: There is a need for increased government investments to strengthen the capacity, human resources, and availability of equipment in primary, secondary, and tertiary public health facilities to deliver quality services in order to reduce the patient referral ratio. Key Points: Formalizing and institutionalizing the referral system and retraining all health‐care professionals.Reduce the epidemic's negative effects on social services, health systems, and the economy.Physicians must diligently perform systematic treatment for referral cases. [ABSTRACT FROM AUTHOR]

Objective: Limited data exists regarding prostanoid (PGI2) use in critically ill patients with pulmonary hypertension. (PH) in the pediatric cardiac intensive care unit (CICU) setting. Materials and Methods: Single center, retrospective study of patients with diagnosis of PH who received continuous PGI2 and were admitted to CICU from January/2015 to April/2022. Data collected included patient demographics and clinical characteristics including diagnosis, etiology of PH, vasoactive and ventilatory support, length of stay, and survival. Type, initial, maximum, and final dose of PGI2 as well as hemodynamic data was obtained. Data reported as mean ± standard deviation. Significance taken p value < 0.05. Results: 24 patients received PGI2 therapy at a mean age of 3.1 years, range (0–16.6 years). PGI2 was in the form of IV epoprostenol in 12 patients, IV treprostinil in 6, and SQ treprostinil in 6 patients. Mean initial dose was 2.79 ng/kg/min, max dose 18.75 ng/kg/min, and mean duration of therapy was 38.5 days. At PGI2 initiation, 21 (87.5%) were on vasoactive infusions, 19 (79.2%) mechanically ventilated (MV), and 6 (25%) were on extracorporeal membrane oxygenation (ECMO). The in-hospital mortality rate was 37.5% (n = 9). Patients MV and on ECMO support had higher risk of death (p = 0.04, and < 0.01, respectively). Conclusion: PGI2 therapy was tolerated in approximately 50% of patients with the most common side effect being hypotension leading to discontinuation in 1/3rd of patients. Ongoing evaluation of the benefits of PGI2 for patients in the CICU setting will help better identify patient selection, type, and dosing of PGI2. [ABSTRACT FROM AUTHOR]

Background and Aim: Complementary therapies, such as aromatherapy, were used to manage acute and chronic symptoms of diseases. Anxiety symptoms and deviations in vital signs are frequently manifest in patients admitted to the cardiac care unit (CCU). This study aimed to evaluate the impact of citrus aurantium and chamomile aromas on anxiety levels and vital signs of patients hospitalized in CCU. Methods: In this clinical research trial (CRT), a total of 76 hospitalized patients in the CCU were randomly assigned to two groups. The intervention group received aromatherapy using a blend of chamomile and citrus aurantium essences at a ratio of 2:0.5 on an eye pad. They inhaled the aromas from a distance of 10 cm for three nights. Vital signs were recorded every 6 h. Spielberger's anxiety questionnaire was administered before and after the intervention. Data were analyzed using independent t‐tests, paired t‐tests, Chi‐square tests, Fisher's exact tests, and the generalized estimating equation (GEE) approach. Results: Before the aromatherapy, the mean (SD) scores of state and trait anxiety in the intervention group were 57.9 (11.4) and 50 (12.5) respectively, after the intervention, these scores decreased to 35.3 (8.4) and 38.5 (8.2), and the paired t‐test revealed a significant difference between them (p < 0.001). Before the intervention there was no significant difference in the mean scores of state and trait anxiety between the two groups, (p > 0.05), however following the intervention, a significant difference was observed (p < 0.001). Additionally, the intervention resulted in the recovery of patients' heart rate. Conclusions: The results showed, application of citrus aurantium and chamomile aromas significantly lower anxiety levels and enhance the hemodynamic status of patients in the CCU. It may be suggested as a beneficial nursing intervention for these patients. [ABSTRACT FROM AUTHOR]

Introduction: Limited real-world data exist regarding cardiovascular outcomes in post-COVID-19 individuals following discharge, particularly within the Asian Indian population. This study aims to explore the association between prior COVID-19 history and in-hospital outcomes in acute myocardial infarction patients. Methods: Hospital database was searched for the patients who were diagnosed with Acute myocardial infarction (AMI) and were grouped according to absence (Group-A) or presence (Group-B) of history of severe COVID-19 hospitalization at least 3 months prior to the index event of AMI. Study primary endpoint was defined as major adverse cardiovascular events (MACE) comprising of Re-AMI, stroke, death (3P) and acute decompensated heart failure (4P), which were analyzed between these 2 study groups. Results: Of 10,581 consecutive patients of AMI, 5.33% (n = 564/10,581) patients had prior history of severe SARS-CoV-2 hospitalization beyond 3 months of index AMI. Past severe Covid-19 patients presenting with AMI were more likely to be younger (59.12+1 1.23 years vs. 52.01 +10.05 years) and younger than 40 years of age. Patients in Group B demonstrated a notably higher prevalence of diabetes, hypertension, higher Killip class, and lower presenting LVEF compared to Group A. In-hospital cardiac arrest, stroke, heart failure and all-cause death were significantly higher in Group B patients. Higher unadjusted odds ratio for in hospital death OR = 5.78 (2.56-10.23), 3-P MACE OR = 2.33 (1.23-8.65) and 4-P MACE OR = 2.58 (1.36-5.43) were found in patients with prior history of COVID-19. After adjusting for comorbidities, the ratio for in-hospital MACE was found to be non-significant. Conclusion: Conventional risk factors and presence of comorbidities in individuals with prior history of COVID-19 hospitalization increased the risk of both 3P and 4P MACE during AMI. [ABSTRACT FROM AUTHOR]

Aims: Hospitalized patients with heart failure (HF) are a heterogeneous population, with multiple phenotypes proposed. Prior studies have not examined the biological phenotypes of critically ill patients with HF admitted to the contemporary cardiac intensive care unit (CICU). We aimed to leverage unsupervised machine learning to identify previously unknown HF phenotypes in a large and diverse cohort of patients with HF admitted to the CICU. Methods: We screened 6008 Mayo Clinic CICU patients with an admission diagnosis of HF from 2007 to 2018 and included those without missing values for common laboratory tests. Consensus k‐means clustering was performed based on 10 common admission laboratory values (potassium, chloride, anion gap, blood urea nitrogen, haemoglobin, red blood cell distribution width, mean corpuscular volume, platelet count, white blood cell count and neutrophil‐to‐lymphocyte ratio). In‐hospital mortality was evaluated using logistic regression, and 1 year mortality was evaluated using Cox proportional hazard models after multivariable adjustment. Results: Among 4877 CICU patients with HF who had complete admission laboratory data (mean age 69.4 years, 38.4% females), we identified five clusters with divergent demographics, comorbidities, laboratory values, admission diagnoses and use of critical care therapies. We labelled these clusters based on the characteristic laboratory profile of each group: uncomplicated (25.7%), iron‐deficient (14.5%), cardiorenal (18.4%), inflamed (22.3%) and hypoperfused (19.2%). In‐hospital mortality occurred in 10.7% and differed between the phenotypes: uncomplicated, 2.7% (reference); iron‐deficient, 8.1% [adjusted odds ratio (OR) 2.18 (1.38–3.48), P < 0.001]; cardiorenal, 10.3% [adjusted OR 2.11 (1.37–3.32), P < 0.001]; inflamed, 12.5% [adjusted OR 1.79 (1.18–2.76), P = 0.007]; and hypoperfused, 21.9% [adjusted OR 4.32 (2.89–6.62), P < 0.001]. These differences in mortality between phenotypes were consistent when patients were stratified based on demographics, aetiology, admission diagnoses, mortality risk scores, shock severity and systolic function. One‐year mortality occurred in 31.5% and differed between the phenotypes: uncomplicated, 11.9% (reference); inflamed, 26.8% [adjusted hazard ratio (HR) 1.56 (1.27–1.92), P < 0.001]; iron‐deficient, 33.8% [adjusted HR 2.47 (2.00–3.04), P < 0.001]; cardiorenal, 41.2% [adjusted HR 2.41 (1.97–2.95), P < 0.001]; and hypoperfused, 52.3% [adjusted HR 3.43 (2.82–4.18), P < 0.001]. Similar findings were observed for post‐discharge 1 year mortality. Conclusions: Unsupervised machine learning clustering can identify multiple distinct clinical HF phenotypes within the CICU population that display differing mortality profiles both in‐hospital and at 1 year. Mortality was lowest for the uncomplicated HF phenotype and highest for the hypoperfused phenotype. The inflamed phenotype had comparatively higher in‐hospital mortality yet lower post‐discharge mortality, suggesting divergent short‐term and long‐term prognosis. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to determine the value of the Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and CardShock scoring systems in predicting the risk of in‐hospital, 30 day and 3 year mortality in patients with cardiogenic shock (CS). Methods: This was a single‐centre observational study conducted between May 2016 and December 2017. Data from consecutive patients with CS admitted to the intensive cardiac care unit (ICCU) were included in the analysis. Results: The study group comprised 63 patients with CS {median age 71.0 [interquartile range (IQR), 59–82]; 42 men}: 32 patients with ischaemic and 31 with non‐ischaemic aetiology. The median APACHE II, SOFA and CardShock scores were 13 (IQR, 9.9–19.0) points, 8.0 (IQR, 6.0–10.0) points and 3.0 (IQR, 2.0–5.0) points, respectively. The in‐hospital, 30 day and 3 year mortality rates were 39.7%, 41.3% and 77.8%, respectively. APACHE II and SOFA scores were significantly higher in the group of patients who died at 30 days (P = 0.043 and P = 0.045, respectively). The CardShock score was higher in patients with CS who died in hospital (P = 0.007) and within 30 days (P = 0.004). No score was statistically significant for 3 year mortality. Area under the curve (AUC) analysis showed that the CardShock score had the highest value in predicting in‐hospital and 30 day mortality relative to APACHE II and SOFA, with a cut‐off score of 5 points [AUC: 0.70; 95% confidence interval (CI): 0.59–0.81; P = 0.001] and 4 points (AUC: 0.71; 95% CI: 0.60–0.82; P < 0.001), respectively. The Bayesian Weibull model demonstrated the utility of all scales in estimating short‐term risk in patients with CS, with the impact of APACHE II and SOFA on patient life expectancy decreasing to a non‐significant level at approximately 32 days and CardShock at 33 days. The forest plots derived from the Bayesian logistic regression analysis show significant estimated coefficients with 94% highest density interval (HDI) for in‐hospital and 30 day mortality. The use of invasive or non‐invasive ventilation, a higher heart rate and a less negative fluid balance showed an unfavourable prognosis. Survival was associated with being in the pre‐CS class, with a higher glomerular filtration rate and a higher platelet count. Conclusions: APACHE II and SOFA could be used for the risk stratification of patients with CS admitted to the ICCU. CardShock proved to be a more appropriate tool for assessing short‐term prognosis in patients with CS of all aetiologies, suggesting that there is potential for its promotion for use in daily clinical practice. [ABSTRACT FROM AUTHOR]

Background Respiratory muscle function can be affected in patients with heart failure. Ultrasound can be used to assess diaphragm, the main inspiratory muscle. Speckle tracking imaging is an imaging technology providing the evaluation of tissue deformation during contraction. We aimed to evaluate the contribution of traditional echography and 2D speckle tracking imaging in the evaluation and monitoring of patients with acute heart failure (AHF). Case summary We report a series of four cases of AHF. Diaphragm ultrasound coupled with diaphragm 2D speckle tracking imaging was performed at admission and after decongestive therapy, in cardiac intensive care unit. Patients, at admission, disclosed higher diaphragm 2D strain value and higher diaphragm inspiratory motion value in the context of higher cardiac loading that significantly decrease after decongestive therapy, except for one patient. Diaphragm motion remained less than 10 mm (weakness), despite medical therapy in Cases 2, 3, and 4. Among them, 3 months later, one patient (Case 3) experienced an episode of AHF. Discussion Diaphragm ultrasound coupled with diaphragm 2D speckle tracking imaging is feasible and may be used to monitor respiratory status patients with AHF. [ABSTRACT FROM AUTHOR]

Uncertainty is a known barrier to effective communication during family meetings in the pediatric cardiac intensive care unit (CICU), however, limited data has characterized patterns of communication during these meetings, limiting our ability to make best practice recommendations to clinicians. To characterize how uncertainty is communicated by cardiac critical care teams during family meetings, to characterize family responses to uncertainty, and to explore how expressions of uncertainty impact specific responses. We conducted a retrospective study of 58 family meetings recorded in a pediatric CICU. Participants were families of patients admitted to the CICU and members of the interprofessional CICU team. We coded uncertainty statements expressed by clinicians and family responses to uncertainty statements. Codes were extracted and analyzed for thematic content. We identified three themes around which clinicians expressed uncertainty: prognosis, treatment trajectories, and discharge planning. Expressions were most frequently unburied (62.3%) and implicit (66.5%). Five themes were identified within family responses to uncertainty: Brief acknowledgment (36.7%); clarification (30.0%); summary (12.3%); child information (12.3%); and emotions, preferences, and reflections (8.6%). Brief acknowledgements often followed lengthy, complex medical information provided by clinicians. Families often responded to implicitly communicated uncertainty by summarizing, clarifying, and providing additional details about their experiences, observations, and preferences. Our results encourage clinicians to communicate uncertainty in an unburied and explicit manner, which may reduce the burden on families to engage in effective communication strategies, such as clarifying and summarizing opaquely stated information. [ABSTRACT FROM AUTHOR]

Background/Objectives: Numerous risk factors of cardiac diseases are influenced by health behaviours. An individual's health behaviours, somatic symptoms and even cardiac outcomes can be influenced by their personality. The aim of this study was to analyse the influence of personality traits on the knowledge and health behaviour of cardiac patients. Methods: The study was conducted at the Independent Public Voivodship Hospital in Szczecin on 180 patients in the invasive cardiology wards and the intensive cardiac care unit between July and September 2019. A self-developed questionnaire and the NEO-Five-Factor Inventory-3 (NEO-FFI) and Health Behaviour Inventory (HBI) standardised tools were used. Results: Respondents mostly linked the occurrence of cardiovascular disease with smoking (87.22%) and hypertension (85.56%). A large majority of the respondents (68.44%) knew the correct recommended values for blood pressure. This was also the case for total cholesterol—only 20.56% of the patients did not know the correct levels. Respondents experienced more difficulty in adhering to preventive measures—only 27.22% followed a low-fat diet and only half controlled their weight. The overall HBI scale score was 5.93 sten, which indicates an average score. The most intense personality trait among the respondents was extraversion (5.79), while the least intense was agreeableness (4.12). Neuroticism was found to be negatively correlated (p < 0.05) with healthy eating habits and a positive mental attitude. Extroverts, on the other hand, are more likely to take preventive action. Older and non-working individuals are more likely to exhibit health-promoting behaviours in all HBI categories (p < 0.05). Conclusions: The personality traits that have the greatest impact on health behaviour are extraversion, agreeableness and conscientiousness. Health practises also depend on gender, age and work activity. Further research on more diverse groups is needed. [ABSTRACT FROM AUTHOR]

The article in Circulation discusses the case of a 22-year-old Black male patient with no prior medical history who presented with symptoms of acute systolic heart failure. The patient was diagnosed with Kearns-Sayre syndrome (KSS) and a pathogenic mutation in the PKP2 gene, which is associated with dilated cardiomyopathy. The patient underwent heart transplantation after being stabilized on mechanical support, and his postoperative course was uncomplicated. The case highlights the importance of considering multiple diagnoses in complex cardiac conditions and the significance of genetic testing in accurate diagnosis and management. [Extracted from the article]

Background: Acute lung injury (ALI) is a serious and common complication that occurs in children with congenital heart disease after cardiopulmonary bypass (CPB) surgery, leading to higher mortality rates and poorer prognosis. Currently, there is no reliable predictive strategy for CPB-associated lung injury (CPB-ALI) in infants. Certain characteristics of the gut microbiota could potentially serve as biomarkers for predicting the development of CPB-ALI. Methods: We conducted 16S rRNA sequencing to analyze the characteristics of the intestinal microbiota in healthy controls and infants with CHD admitted to the hospital. The CHD infants were divided into CPB-ALI and non-ALI (CPB-NALI) groups based on postoperative outcomes. Bacterial functional pathway prediction analysis was performed using PIRCUSt2, and the gut microbiota composition associated with immune status was determined with heatmap. Random forest regression models and ROC curves were utilized to predict the occurrence of CPB-ALI. Results: Our study revealed significantly different microbiota compositions among three groups (CON, CPB-ALI, and CPB-NALI). The microbiota diversity was low in the CPB-ALI group with high pathogen abundance and significant decrease in Bacteroides, while the opposite was observed in the CPB-NALI group. The microbiota dysbiosis index was high in the CPB-ALI group, with its dominant microbiota significantly associated with multiple metabolic pathways. Additionally, CPB-ALI patients showed high levels of inflammatory cytokines IL-8 and HMGB1 in their serum, with high expression of IL-8 being associated with Enterobacteriaceae. Further correlation analysis showed that the differences in gut bacterial taxonomy were related to the occurrence of ALI, length of stay in the cardiac care unit, and ventilation time. It is noteworthy that Escherichia Shigella performed best in distinguishing CPB-ALI patients from non-ALI patients. Conclusions: Our study suggests that postoperative ALI patients have distinct gut microbiota upon admission compared to non-ALI patients after surgery. Dysbiosis of the gut microbiota may potentially impact the progression of ALI through metabolic pathways, quorum sensing, and the levels of inflammatory factors expressed in the serum. Escherichia Shigella represents a potential predictive factor for the occurrence of ALI in CHD infants after surgery. Acute lung injury, congenital heart disease, cardiopulmonary bypass surgery, gut microbiota, biomarker [ABSTRACT FROM AUTHOR]

Background: Cardiovascular diseases (CVD) are one of the leading causes of mortality and morbidity worldwide. Among them the spectrum of ischemic heart disease which encompass stable ischemic heart disease, unstable angina, NSTEMI & STEMI is the commonest cause. Coronary no-reflow is a frequent phenomenon that develops in patients with ST-segment elevation myocardial infarction during reperfusion therapy. In this study, we focused on to assess the prevalence of coronary no reflow in STEMI patients undergoing primary PCI. Methodology: This study was conducted in patients in Cath lab, Coronary Care Unit and different wards of the department of Cardiology in Apollo Multispecialty Hospital Limited during the period of 18 months spanning from November 2021 to April 2023. Consecutive patients of STEMI who had undergone PPCI were enrolled in this study. The patients to be included are those with STEMI above age=18 years. They were divided into no reflow and normal flow and their characteristics were studied. Results: The prevalence of no reflow was 9.93%. Majority of the patients had age more than 60 years (55%) whereas 45% of the patients were younger than 60 years with males (71%) and females (29%). Common associated condition with patients undergoing percutaneous coronary intervention in present study was hypertension (86%), dyslipidemia (80%) and diabetes mellitus (93%). TIMI thrombus scale and Myocardial blush grade (MBG) was significantly higher in patients with hypertension. There was a significant difference found in TIMI thrombus scale and MBG between diabetic and non-diabetic patients. There were significant differences found in mean LVEF in respect to myocardial blush grade (MBG). Conclusion: The TIMI thrombus scale and myocardial blush grade was found to be higher in patients with no reflow undergoing PCI. The prevalence of no reflow after primary PCI is 9.93%. The co morbidities like DM, hypertension and dyslipidemia were more common among these patients. [ABSTRACT FROM AUTHOR]

Free-living amoebae (FLA) are isolated from the hospital environments and known as Trojan horses for medical essential microorganisms. This study aimed to investigate the prevalence and the presence of FLA and two critical agents of nosocomial infections, in the hospital wards. Sixty samples were collected from four communities and cultured onto non-nutrient agar (NNA). After total DNA extraction, FLA were characterized using PCR and sequencing. The presence of Candida albicans and Staphylococcus aureus was evaluated using real-time and conventional PCR, respectively. Acanthamoeba sp. was characterized in 30 (50%) samples. Two (6.6%) and one (3.3%) samples were positive for Vahlkampfiidae and Vermamoeba vermiformis, respectively. S. aureus was detected in 13 (43.3%) of samples, while none of them were positive for methicillin-resistant gene. C. albicans DNA was detected in one (3.3%) FLA-positive sample. The isolation of FLA from hospital suggests an essential role these eukaryotes in the inter-ward circulation of nosocomial infections. [ABSTRACT FROM AUTHOR]

Background: Delirium, which is prevalent in critical care settings, remains underexplored in acute coronary syndrome (ACS) patients in the cardiac intensive care unit (CICU). Aim: To investigate the prevalence and clinical significance of delirium in patients with ACS admitted to the CICU. Study Design: A prospective study (n = 106, mean age 74.2 ± 5.7 years) assessed delirium using the confusion assessment method‐intensive care unit (CAM‐ICU) tool in 21.7% of ACS patients during their CICU stay. Baseline characteristics, geriatric conditions and clinical procedures were compared between delirious and nondelirious patients. The outcomes included in‐hospital mortality, 30‐day and 6‐month mortality, acute adverse events and length of CICU stay and hospital stay (LOS). Results: Delirious patients who were older and had a higher incidence of coronary artery disease underwent more complex procedures (e.g., pacemaker placement). Multivariate analysis identified central venous catheter insertion, urinary catheterization and benzodiazepine use as independent predictors of delirium. Delirium was correlated with prolonged LOS (p <.001) and increased in‐hospital, 30‐day and 6‐month mortality (p <.001). Conclusions: Delirium in ACS patients in the CICU extends hospitalization and increases in‐hospital, 30‐day and 6‐month mortality. Early recognition and targeted interventions are crucial for mitigating adverse outcomes in this high‐risk population. Relevance to Clinical Practice: This study highlights the critical impact of delirium on outcomes in hospitalized patients with ACS in the CICU. Delirium, often overlooked in ACS management, significantly extends hospitalization and increases mortality rates. Nurses and physicians must be vigilant in identifying delirium early, particularly in older ACS patients or those with comorbidities. Recognizing independent predictors such as catheterization and benzodiazepine use allows for targeted interventions to reduce delirium incidence. Integrating routine delirium assessments and preventive strategies into ACS management protocols can improve outcomes, optimize resource utilization and enhance overall patient care in the CICU setting. [ABSTRACT FROM AUTHOR]

Background: Low titer group O whole blood (LTOWB) is commonly used for severe bleeding in trauma patients. LTOWB may also benefit young children requiring cardiac surgery with cardiopulmonary bypass (CPB) at risk of severe bleeding. Study Design and Methods: In this retrospective study, children <2 years old who underwent cardiac surgery with CPB were included. Comparisons were performed between those receiving component therapy (CT) versus those receiving LTOWB plus CT (LTOWB+CT). Outcomes included drainage tube (DT) output and total transfusion volumes. Optimization‐based weighting was used for adjusted analyses between groups. Results: There were 117 patients transfused with only CT and 127 patients transfused with LTOWB+CT. In the LTOWB+CT group, 66 were Group non‐O and 61 were Group O. Total transfusion volumes given from the start of the operation until the first 24 h in the cardiac intensive care unit was a median (IQR) 41 (10, 93) mL/kg in the CT group and 48 (28, 77) mL/kg in the LTOWB+CT group, (p =.28). Median (IQR) DT output was 22 (15–32) in CT versus 22 (16–28) in LTOWB+CT groups, (p =.27). There were no differences in death, renal failure and a composite of death and renal failure between the two groups, but there were statistically fewer re‐explorations for bleeding in the LTOWB+CT group (p <.001). Conclusions: The use of LTOWB appears to be safe in <2 years old undergoing cardiac surgery and may reduce re‐explorations for severe bleeding. Large trials are needed to determine the efficacy and safety of LTOWB in this population with severe bleeding. [ABSTRACT FROM AUTHOR]

Introduction: With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. The aim of this study was to analyze the complications in contemporary emergency department (ED) patients with ACS and to map patient management. Methods: This observational study was a secondary analysis of data collected in the ESC-TROP trial (NCT03421873) that included 26,545 consecutive chest pain patients ≥18 years at five Swedish EDs. Complications were defined as the following within 30 days: death, cardiac arrest, cardiogenic shock, pulmonary edema, severe ventricular arrhythmia, high-degree atrioventricular (AV) block that required a pacemaker, and mechanical complications such as papillary muscle rupture, cardiac tamponade, or ventricular septum defects (VSDs). Complications were identified via diagnosis and/or intervention codes in the database, and manual chart review was performed in cases with complications. Results: Of all 26,545 patients, 2,463 (9.3%) were diagnosed with ACS, and 151 of these (6.1%) suffered any complication within 30 days. Mean age was higher in patients with (79.2 years) than without (69.4 years) complications, and more were female (39.7% vs. 33.0%). Eighty-four (3.4% of all ACS patients) patients died, 33 (1.3%) had cardiac arrest, 22 (0.9%) respiratory failure, 13 (0.5%) high-degree AV block, 10 (0.4%) cardiogenic shock, 12 (0.5%) severe ventricular arrhythmia, and 2 each (<0.1%) had VSD or cardiac tamponade. Almost 30% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 80 (53%) of the patients with complications underwent coronary angiography and 62 (41%) were revascularized with percutaneous coronary intervention or coronary artery bypass grafting. Conclusion: With current care, serious complications occurred in only 6 out of 100 ACS patients, and 2 of these complications were present already at the ED. Four out of 10 ACS patients with complications were not admitted to the CCU/ICU and about half did not undergo coronary angiography. Further research is needed to improve risk assessment in ED ACS patients, which may allow more effective use of cardiac monitoring and hospital resources. [ABSTRACT FROM AUTHOR]

The article discusses a study on personalized fluid management in critically ill heart failure patients using unsupervised learning to identify four distinct patient phenotypes. The study utilized two databases for training and validation, extracting 47 variables to classify patients into phenotypes with unique clinical profiles. The findings suggest phenotype-specific fluid management strategies based on demographic factors, laboratory parameters, and interventions, with a machine learning model achieving high predictive performance. The study highlights the importance of individualized fluid balance strategies for critically ill heart failure patients. [Extracted from the article]

Background: Low voltage areas (LVA) are pivotal in atrial fibrillation (AF) pathogenesis, influencing local left atrial LA excitation and perpetuating AF occurrences. While pulmonary vein isolation (PVI) with cryo‐balloon (CB) ablation is effective for AF, it doesn't provide insights into the LA substrate or detect LVA, which affects ablation success rates. This study examines whether LA voltage and LVAs can be anticipated by analyzing the voltage signal amplitude at the coronary sinus (CS) catheter, which is standard in CB and radiofrequency ablation procedures. Methods: A retrospective analysis of 284 patients with recurrent AF undergoing RF catheter ablation was conducted at a high‐volume EP center in Germany. The correlation between LA voltage and LVA with the CS signal was explored. Results: The signal amplitude in the CS significantly correlated with voltage in LA walls, particularly in the proximal CS (correlation coefficient ρ = 0.81, p < 0.001). A CS signal cut‐off of 1.155 mV effectively predicted severe atrial LVAs (>40%) with a sensitivity of 90.7% and a specificity of 100%. While a threshold of 1.945 mV identified patients with no significant atrial LVAs (<5%) with a sensitivity of 88% and a specificity of 50% (AUC: 0.81, 95% CI: 0.71–0.89, p < 0.001). Conclusion: The CS signal amplitude is associated with the LA voltage. Due to its potential as a diagnostic tool for atrial LVAs, the signal amplitude in the CS could provide valuable information about the LA substrate, especially when 3D mapping is not feasible. [ABSTRACT FROM AUTHOR]

Objective: To determine frequency of postoperative hyperglycemia in children who underwent repair of Congenital Cardiac Defects (CCDs) in a tertiary care hospital of Pakistan. The other objective was to compare outcomes in children with versus without postoperative hyperglycemia who underwent repair of CCDs in a tertiary care hospital of Pakistan. Methods: A descriptive study was conducted at the Cardiac Intensive Care Unit (CICU), Aga Khan University Hospital (AKUH), Karachi, Pakistan from October 3, 2020, to April 2, 2021. A total of 185 patients aged one month-18 years admitted to CICU underwent elective surgical repair of CCDs meeting the eligibility criteria were included. Glucose monitoring was collected at immediate, 4th and 8th postoperative hours on the first day and once daily on postoperative days Two and Three to assess hyperglycemia. Data including age, weight, gender, pre-operative diagnosis, type of surgery and variables such as CICU stay, duration of hospital stay and duration of mechanical ventilation were recorded. Results: The mean age of the patients was 40.40±48.63 months. Out of 185 patients, 115 (62.2%) were male while 70 (37.8%) were female. Hyperglycemia was found to be in 182 (98.4%) patients. Out of 182 hyperglycemic patients, 53 (28.6%) had moderate hyperglycemia while 129 (69.7%) had severe hyperglycemia. Mean duration of hospital stays was 9.24±7.45, mean duration of pediatric CICU stays was 141.61±169.02 hours and mean duration of mechanical ventilation was 80.59±98.54 hours. Conclusion: Hyperglycemia is a frequent finding in children who underwent repair of CCDs, and it is not significantly associated with duration of mechanical ventilation, length of hospital and CICU stay. [ABSTRACT FROM AUTHOR]

Objective: Many patients who are attended by paramedics do not require conveyance to an emergency department (ED). Our study focuses on comparing the characteristics and outcomes of patients who were advised to follow up with a general practitioner (GP) by an attending paramedic with those of patients who were discharged at scene or transported to hospital. Methods: This was a retrospective data linkage cohort study of ambulance, ED, hospital admission, and death records for all adults attended by paramedics in Victoria, Australia between the 1st of January 2015 and 30th of June 2019. Patients were excluded if they presented in cardiac arrest, resided in a residential aged care facility, or were receiving palliative care services. Outcomes of interest included reattendance by ambulance, ED presentation; and, a high acuity outcome which we defined as a patient who (1) presented to ED and received an Australasian Triage Scale of category 1 (Resuscitation) or 2 (Emergency) AND was admitted to a ward OR (2) was admitted to an Intensive Care Unit, Coronary Care Unit or Catheter laboratory (regardless of triage category) OR (3) died. Outcomes of interest were considered within 48-h of initial EMS attendance. Results: A total of 1,777,950 cases were included in the study of which 3.1% were referred to a GP, 9.0% were discharged at scene without a follow-up recommendation, and 87.9% were transported to hospital. Patients referred to a GP were more likely than those discharged at scene to subsequently present to an ED within 48 h of their attendance (5.3% vs 3.8%). However, GP referral was not associated with any change to high acuity outcome (0.3% vs 0.2%) or ambulance reattendance (6.0% vs 6.0%) compared to discharge at scene. The only factors that were associated with ambulance reattendance, ED presentation, and a high acuity outcome were male gender and elevated temperature. Conclusions: Despite increasing low and medium-acuity casework in this EMS system, paramedic referral to a GP is not common practice. Referring a patient to a GP did not reduce the likelihood of patients experiencing a high acuity outcome or recalling an ambulance within 48 h, suggesting opportunity exists to refine paramedic to GP referral practices. [ABSTRACT FROM AUTHOR]

The classification of cardiogenic shock (CS) has evolved from a singular cold-and wet-hemodynamic profile. Data from registries and clinical trials have contributed to a broader recognition that although all patients with CS have insufficient cardiac output leading to end organ hypoperfusion, there is considerable variability in CS acuity, underlying etiologies, volume status, and systemic vascular resistance. Mixed CS can be broadly categorized as CS with at least 1 additional shock state. Mixed CS states are now the second leading cause of shock in contemporary coronary intensive care units, but there is little high-quality evidence to guide routine care, and there are no standardized classification frameworks or well-established hemodynamic definitions. This primer summarizes the current epidemiology and proposes a classification framework and invasive hemodynamic parameters to guide categorization that could be applied to help better phenotype patients captured in registries and trials, as well as guide management of mixed CS states. [ABSTRACT FROM AUTHOR]

Background Aim Methods Results Conclusions Relevance to Clinical Practice After acute myocardial infarction, the prevalence of anxiety and depression is quite high in patients because of severe chest pain, distance from relatives, unfamiliar environment and orientation problems.To assess the effect of listening to the voice recordings of relatives of patients with acute myocardial infarction who were treated in the coronary intensive care unit (ICU) on chest pain, anxiety and depression parameters of the patients.In the study, which was conducted as a randomized controlled trial, voice recordings of the family members of the patients were created and played to the patients through a music pillow. The study was carried out with 60 patients, 30 experimental and 30 control groups. Three tests were applied to the patients 15 min before, and 15 and 30 min after the application. The data of the study were collected using the Patient Introduction Form, Hospital Anxiety Depression Scale, Visual Analogue Scale and Patient Follow‐up Form.It was found that there was a significant decrease in the anxiety level of the patients in the intervention group after listening to the audio recording (p < .001, 95% CI: −3.796; −0.070). However, there was no significant difference between the pain and depression scores of the control and intervention groups (p > .05).In the ICUs of patients with acute myocardial infarction, it may be recommended to play audio recordings of their relatives to reduce the severity of anxiety.In the intensive care setting, the use of voice recordings of relatives can be used as an effective, non‐pharmacological intervention to reduce anxiety in patients with acute myocardial infarction. This approach may potentially improve overall recovery by reducing patient anxiety in the intensive care setting. [ABSTRACT FROM AUTHOR]

Immunotherapy is increasingly used in advanced non-small-cell lung cancer (NSCLC), offering a significant anti-tumor response, as well as causing rising immune-related adverse effects. The incidence of immune checkpoint inhibitorinduced myocarditis-myositis-myasthenia gravis is increasing and particularly concerning due to its high mortality rate. Prompt recognition, diagnosis, and management are crucial. A 40-year-old patient, diagnosed with stage IV nononcogene addicted lung adenocarcinoma, with nivolumab-ipilimumab-chemotherapy as first-line treatment, developed a rare myocarditis-myositis-myasthenia gravis overlap syndrome. Following the treatment, the patient presented with flu-like symptoms and chest pain and subsequently transferred to the cardiac intensive care unit. The physical examination revealed a visual acuity deficit, diplopia, ophthalmoparesis, ptosis, mydriasis, dysphagia, dyspnea, headache, nausea, dry mouth, asthenia, myalgia, and muscle weakness. Imaging and laboratory tests confirmed the triad, showing an elevation of hs-cTnI and CK and positive results for anti-SAE1 and anti-PL-7 Abs. ECG revealed ST segment elevation and RBBB. The echo showed hyperechogenicity of the inferolateral wall, pericardial detachment, and thickening. The cardiac MRI demonstrated hypokinesia, edema, subepicardial LGE, and pericardial effusion. Muscle biopsy revealed muscle fiber necrosis and regeneration with B and T lymphocytic endomysial inflammatory infiltrate and expression of MHC-I. Treatment with oral prednisone, pyridostigmine, and IV Igs was started due to poor clinical response followed by methylprednisolone. Despite stopping immunotherapy, the patient continued to benefit from it, as highlighted on subsequent reevaluation CT scans by partial disease response, and as the patient was in complete remission, we decided to resume chemotherapy by omitting immunotherapy. At the radiological control following the four cycles of double CHT and during CHT maintenance, there was a further reduction of the disease. This report aims to raise awareness among physicians about these serious side effects. A multidisciplinary approach led to clinical improvement and early intervention, optimizing patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Platelets play a key role in the natural history of aortic stenosis (AS) and after transcatheter aortic valve implantation (TAVI). An echo-based staging system stratifies patients with severe AS into 5 groups according to the associated cardiac damage phenotype. We aimed to correlate these AS stages with platelet indices in post-TAVI patients. Methods: Patients with severe AS who underwent TAVI and were admitted to intensive cardiac care unit (ICCU) were prospectively identified and divided into 5 groups according to extra-valvular cardiac damage [no extravalvular cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage (Stage 4)]. Baseline characteristics and complete blood count including mean platelet volume (MPV) and immature platelet fraction (IPF) were collected within 2 h after the procedure and analyzed in relation to aortic stenosis staging. Results: A total of 220 patients were included. The mean age was 81 years old and 112 (50.9%) were female. Two (1%) patients were classified in stage 0; 34 (15%) in stage 1; 48 (22%) in stage 2; 49 (22%) in stage 3 and 87 (40%) in stage 4. Higher mean MPV values were correlated with higher AS staging (10.8 fL, 11 fL, 11.3 fL and 10.8 fL in stages 1, 2, 3 and 4, respectively, P = 0.02) as well as lower hemoglobin values (12 mg/dl, 11.6 mg/dl, 11 mg/dl and 11.3 mg/dl in stages 1, 2, 3 and 4, respectively P = 0.04). Mean IPF values were 5.3%, 5.58%, 5.57% and 4.83% in stage 1, 2, 3 and 4, respectively (P = 0.4). In a multivariate logistic regression model only MPV (OR = 2.6, P = 0.03) and body mass index (BMI) (OR = 1.17, P = 0.004) were correlated with higher staging (0–3) of AS. Conclusions: Although IPF and MPV levels increased in stages 0–3, there was a decrease in indices in stage 4, (probably due to bone marrow dysfunction) in this end-stage population. Higher levels of MPV and lower levels of hemoglobin were independently correlated with higher stages (0–3) of AS. [ABSTRACT FROM AUTHOR]

This consensus statement emerges from collaborative efforts among leading figures in critical care cardiology throughout the United States, who met to share their collective expertise on issues faced by those active in or pursuing contemporary critical care cardiology education. The panel applied fundamentals of adult education and curriculum design, reviewed requisite training necessary to provide high-quality care to critically ill patients with cardiac pathology, and devoted attention to a purposeful approach emphasizing diversity, equity, and inclusion in developing this nascent field. The resulting paper offers a comprehensive guide for current trainees, with insights about the present landscape of critical care cardiology while highlighting issues that need to be addressed for continued advancement. By delineating future directions with careful consideration and intentionality, this Expert Panel aims to facilitate the continued growth and maturation of critical care cardiology education and practice. • CCC is a burgeoning specialty that requires advanced training. • Critical care training for a critical care cardiologist should be no fewer than 12 months. • Standardization of training goals and competencies are next steps for developing the CCC field. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to assess the prevalence of coma among patients in critical care units in Chile. We also aimed to provide insight into the demographic characteristics, etiologies, and complications associated with coma. Methods: A single day cross-sectional study was conducted through a national survey of public and private hospitals with critical and intensive cardiac care units across Chile. Data were collected using an online questionnaire that contained questions regarding critically ill patients' information, demographic characteristics, etiology and duration of coma, medical complications, and support requirements. Results: A total of 84% of all health facilities answered, accounting for a total of 2,708 patients. The overall coma prevalence was 2.9%. The median age of the comatose patients was 61 years (interquartile range 50–72) and 66.2% were male. The median coma duration was five days (interquartile range 2–9). Cerebral hemorrhage was the most common etiology, followed by severe hypoxic-ischemic encephalopathy, acute ischemic stroke, and traumatic brain injury. A total of 48.1% of coma patients experienced acute and ongoing treatment complications, with pneumonia being the most common complication, and 97.4% required support during comatose management. Conclusions: This study provides an overview of the prevalence of coma in Chilean critical and cardiac care units. Coma is a common condition. Comatose patients frequently experience medical complications during their hospitalization. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness of high sensitive CRP and Procalcitonin in admitted patients of Farooq Hospital Lahore, Pakistan. Study Design: Prospective study. Setting: Farooq Hospital Westwood, Lahore. Period: November 2023 to January 2024. Methods: The admitted patients of intensive care units, medical and cardiac care units, with acute kidney infection, chronic kidney disease, diabetes mellitus, hypertension, coronary artery bypass grafting, gastroenteritis, chronic obstructive pulmonary disease, liver disease, hepatitis, and bacterial infections were included. Serum albumin, highsensitive C-reactive protein (hs-CRP), and procalcitonin were analyzed by automated analyzers. Data was analyzed by using SPSS (v.25.0). Results: Among 73 patients, 83.56% were critical and 16.44% stable. It was found that the critical patients were in the range of 61 to 90 years of age. The hs-CRP and procalcitonin levels were non-significantly correlated with age group. The hs-CRP exhibited higher sensitivity than procalcitonin in critical patients (AUC: 0.872 vs. 0.725). Likewise, serum albumin had a significant association with patients having critical conditions (AUC: 0.685). Moreover, it was found that hs-CRP and procalcitonin have a significant association with the period of patient stay in the hospital. Conclusion: The present study concluded that in critically ill patients having high levels of procalcitonin and hs-CRP had longer hospital stay and both biomarkers are equally important in the treatment of critically ill admitted patients. [ABSTRACT FROM AUTHOR]

Background: Concerns have been raised regarding proton pump inhibitor (PPI) use and risk of severe coronavirus disease 2019 (COVID‐19). Observational studies have yielded heterogeneous results and were subject to important methodological limitations. Aims: To examine the association between the receipt of PPIs and risk of COVID‐19 hospitalizations and severe in‐hospital outcomes or death. Methods: Case–control study among Medicare fee‐for‐service beneficiaries 66+ years old with gastroesophageal reflux disorder (GERD). Within this population, we identified cases by an incident hospital discharge diagnosis of COVID‐19 from April 1 to December 11, 2020, using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) U07.1, and randomly selected up to 10 controls per case, matched on date and neighborhood. We defined PPI use as a prescription providing ≥15 days of supply in the 30 days before admission, with H2‐receptor antagonist (H2RA) use as the reference to account for indication. We analyzed uncomplicated hospitalizations and hospitalizations with severe outcomes (intensive/coronary care unit admission, invasive mechanical ventilation, or death), estimating odds ratios (ORs), and 95% confidence intervals (CIs) with multinomial conditional logistic regression adjusted for demographics, comorbidities, chronic medications, and health care utilization. Results: We matched 25,867 uncomplicated and 12,954 severe hospitalized COVID‐19 cases to 146,972 and 73,104 controls, respectively. Cases tended to be older and have more comorbidities. Relative to H2RA use, we found no association of PPI use with uncomplicated COVID‐19 hospitalization (OR 0.99, 95% CI 0.93–1.06) or severe COVID‐19 hospitalization (OR 1.00, 95% CI 0.91–1.10). Conclusions: Relative to H2RA use, PPI use was not associated with uncomplicated or severe COVID‐19 hospitalizations among Medicare beneficiaries with GERD. [ABSTRACT FROM AUTHOR]

Objective: To assess differences in right ventricular function between the primary angioplasty and pharmacoinvasive groups using echocardiographic parameters. Method: Observational, retrospective, and cross-sectional study conducted on 111 patients in a cardiac care unit, where ventricular function was evaluated through transthoracic echocardiography. Results: There were no significant differences in right ventricular function parameters (TAPSE, FAC, S’ wave, RV Tei index, right V/A coupling) between both groups. As a notable finding, the pharmacoinvasive group exhibited better LVEF and smaller volumes at the end of diastole and systole. Conclusions: In patients with STEMI undergoing the pharmacoinvasive strategy compared to those receiving primary angioplasty, there is no significant difference in the main right ventricular function parameters assessed by transthoracic echocardiography. [ABSTRACT FROM AUTHOR]

Background: In hospitals, medication errors are common and potentially harmful resulting in unintentional discrepancies. The study's central goal is to assess the clinical pharmacy services' role in cardiovascular disease inpatients. Methods: The current study was a prospective study conducted on one hundred patients admitted to the CVU and CCU in Libya. The patients were classified - into two main groups (I - and II), where the guidelines of clinical pharmacy - were applied only in Group II. Each group is subdivided - into three subgroups with equal numbers of patients. As follows: (Gp a: ten outpatients, Gp b: twenty-five inpatients, Gp c: fifteen patients admitted to CCU. Results: By using clinical pharmacy guidelines, the patients in group I were 28 (56%) had angina pectoris, 28 (56%) responded to treatment, 20 (40%) had complications, and 8 (16%) died; while the patients in group II were 15 (30%) had angina pectoris, 43 (86%) respond to treatment, 7 (14%) had complications and 1 (2%) died. So, the results reported a dramatic decrease in the morbidity rates in all groups that undergo guidelines of clinical pharmacy. Conclusion: The application of clinical aspects of clinical pharmacy is outstanding in CVU and CCU in Libya. [ABSTRACT FROM AUTHOR]

Acute coronary syndrome is a chronic illness that influences physical and psychological health and well-being and requires continuous treatment and effective self-care. This two-group quasi-experimental study investigated the effectiveness of the Self-Care Support Program for People with Acute Coronary Syndrome. Sixty participants were purposively recruited from medical wards of a university-affiliated hospital in Bangkok, Thailand. A Self-Care Support Program based on Orem's self-care theory was integrated with a motivational interviewing approach. The experimental group (n = 30) received the 4-week intervention program with the usual care, while the comparison group (n = 30) received only usual care. Instruments for data collection included a Demographic and Health Data Form, the Self-Care Behavior for Acute Coronary Syndrome Questionnaire, the Veterans Specific Activity Questionnaire, and the Rehospitalization Record Form. Data analysis was performed using descriptive statistics, Chi-square test, Fisher's exact test, and two-way repeated measures analysis of variance. Results revealed that the experimental group had significantly improved self-care behavior and functional ability immediately and four weeks after program completion (week 8), compared to the comparison group. There was no difference in rehospitalization between the two groups. Nurses with advanced skills in motivational training can use this program to promote effective self-care practices, improve functional ability, and reduce rehospitalization. Further study using randomized controlled trials and other settings is needed before it can be widely used. [ABSTRACT FROM AUTHOR]

Introduction: Cardiogenic shock is severe circulatory failure that results in significant in-hospital mortality, related morbidity, and economic burden. Patients with cardiogenic shock are at high risk for atrial and ventricular arrhythmias, particularly within the subset of patients with an overlap of cardiogenic shock and cardiac arrest. Areas covered: This review article will explore the prevalence, definition, management, and outcomes of common arrhythmias in patients with cardiogenic shock. This review will describe the pathophysiology of arrhythmia in cardiogenic shock and the impact of inotropic agents on increased arrhythmogenicity. In addition to medical management, focused assessment of mechanical circulatory support, radiofrequency ablation, deep sedation, and stellate ganglion block will be provided. Expert opinion: We will navigate the limited data and describe the prognostic impacts of arrhythmia. Finally, we will conclude the review with a discussion of prevention strategies, research limitations, and future research directions. [ABSTRACT FROM AUTHOR]

Background: There is limited data on the association between inflammation and the formation of early left ventricular thrombus (LVT) following ST‐elevation myocardial infarction (STEMI). This study aimed to explore the predictive value of several inflammatory biomarkers for LVT formation following STEMI. Methods and Results: Our cohort included 2534 consecutive patients admitted to the cardiac intensive care unit (CICU) with STEMI. The final analysis included 51 patients with LVT and 102 patients without LVT, matched for age, sex, anterior infarct and ejection fraction. Upon admission, patients with LVT had higher white blood cell counts (WBC) (12.8 ± 7 vs. 12.4 ± 4 ×103/µL, p = 0.01), higher absolute neutrophil counts (10.5 ± 4 vs. 8.6 ± 4 ×103/µL, p = 0.003), neutrophil‐to‐lymphocyte ratio (8.2 ± 6 vs. 4.8 ± 4, p = 0.04), and C‐reactive protein (CRP) levels (35.9 ± 62 vs. 18.6 ± 40 mg/L, p = 0.04). Peak values for WBC and CRP were also higher in the LVT group (17.8 ± 8 vs. 14.6 ± 5 ×103/µL, p = 0.003 and 95.8 ± 82 vs. 64.2 ± 76 mg/L, p = 0.02, respectively). In univariate regression analysis, WBC upon admission (OR: 1.12, 95% CI: 1.02–1.21, p = 0.02), peak WBC (OR: 1.09, 95% CI: 1.02–1.17, p = 0.009), neutrophil count upon admission (OR: 1.15, 95% CI: 1.04–1.26, p = 0.004), and peak CRP (OR: 1.01, 95% CI: 1–1.01, p = 0.03) predicted LVT formation, which was also evident in multivariate regression models. Conclusion: WBC and neutrophil counts upon admission, as well as peak WBC and CRP, have additional predictive value for LVT formation following STEMI, beyond classical risk factors. [ABSTRACT FROM AUTHOR]

Background: Heart rate variability (HRV) is the fluctuation in the time intervals between adjacent heartbeats. HRV is a measure of neurocardiac function that is produced by dynamic autonomic nervous system (ANS) processes and is a simple measure that estimates cardiac autonomic modulation. Methods: The study included 108 patients admitted to the Coronary Intensive Care Unit with acute myocardial infarction (AMI) who did not undergo primary percutaneous transluminal coronary angioplasty (PTCA) or systemic thrombolysis and followed conservative management. All patients underwent detailed clinical, biological, and paraclinical assessments, including evaluation of HRV parameters and echocardiographic measurements. The analysis of RR variability in both time and frequency domains indicates that the negative prognosis of patients with AMI is associated with an overall imbalance in the neuro-vegetative system. The HRV parameters were acquired using continuous 24 h electrocardiogram (ECG) monitoring at a baseline, after 1 month, and 6 months. Results: Our analysis reveals correlations between alterations in HRV parameters and the increased risk of adverse events and mortality after AMI. The study found a significant improvement in HRV parameters over time, indicating better autonomic regulation post-AMI. The standard deviation of all RR intervals (SDNN) increased significantly from baseline (median 75.3 ms, IQR 48.2–100) to 1 month (median 87 ms, IQR 55.7–111) and further to 6 months (median 94.2 ms, IQR 67.6–118) (p < 0.001 for both comparisons). The root mean square of successive difference of RR (RMSSD) also showed significant increases at each time point, from baseline (median 27 ms, IQR 22–33) to 1 month (median 30.5 ms, IQR 27–38) and from 1 month to 6 months (median 35 ms, IQR 30–42) (p < 0.001 for all comparisons), indicating enhanced parasympathetic activity. Moreover, changes in HRV parameters have been associated with impaired left ventricle ejection fraction (LVEF) and global longitudinal strain (GLS), indicating a relationship between autonomic dysfunction and myocardial deformation. GLS values improved from a baseline median of −11% (IQR 5%) to −13% (IQR 4%) at 6 months (p < 0.001), reflecting better myocardial function. Conclusions: HRV parameters and cardiac performance analysis, especially using GLS, offer a solid framework for evaluating recovery and predicting adverse outcomes post-MI. [ABSTRACT FROM AUTHOR]

Introduction: Myocardial infarction (MI) is a critical emergency condition that affects all aspects of health. Patients with MI need specialized care in the Coronary care unit (CCU). The main goal of care is to ensure their comfort, which can be significantly affected by their illness and hospitalization. This study aims to explore MI patients' perceptions of support network challenges to ensure comfort in the CCU. Methods: A qualitative approach was adopted, and semi-structured interviews and notes were used for collecting data between 2020 and mid-2021. The participants were 27 MI patients in our country who had been hospitalized in the CCU of the University Heart Hospital. They were selected using purposive sampling. The data were analyzed using conventional content analysis by Graneheim and Lundman. Findings: The results of this research were revealed in the form of a "support network" theme comprising five categories: "Physical support", "Mental occupations", "Presence of peers", "relatives support "and "Spiritual strategies". Conclusion: The study results showed that MI patients, in critical condition, receiving care, and hospitalized in the CCU require continuity in their support network to ensure comfort. The inconsistency between the components of each dimension leads to the challenge of ensuring comfort. [ABSTRACT FROM AUTHOR]

Introduction: Stroke is a potentially debilitating complication of heart valve replacement surgery, with rates ranging from 1 to 10%. Despite advancements in surgical techniques, the incidence of postoperative stroke remains a significant concern, impacting patient outcomes and healthcare resources. This study aims to investigate the incidence, risk factors, and outcomes of in-hospital adverse neurologic events, particularly stroke, following valve replacement. The analysis focuses on identifying patient characteristics and procedural factors associated with increased stroke risk. Methods: This retrospective study involves a review of 417 consecutive patients who underwent SVR between January 2004 and December 2022. The study cohort was extracted from a prospectively recorded cardiac intensive care unit database. Preoperative and perioperative data were collected, and subjects with specific exclusion criteria were omitted from the analysis. The analysis includes demographic information, preoperative risk factors, and perioperative variables. Results: The study identified a 4.3% incidence of postoperative stroke among SVR patients. Risk factors associated with increased stroke susceptibility included prolonged cardiopulmonary bypass time, aortic cross-clamp duration exceeding 90 min, prior stroke history, diabetes mellitus, and mitral valve annulus calcification. Patients undergoing combined procedures, such as aortic valve replacement with mitral valve replacement or coronary artery bypass grafting with AVR and MVR, (OR = 10.74, CI:2.65–43.44, p-value = < 0.001) and (OR = 11.66, CI:1.02–132.70, p-value = 0.048) respectively, exhibited elevated risks. Internal carotid artery stenosis (< 75%) and requiring prolonged inotropic support were also associated with increased stroke risk(OR = 3.04, CI:1.13–8.12, P-value = 0.026). The occurrence of stroke correlated with extended intensive care unit stay (OR = 1.12, CI: 1.04–1.20, P-value = 0.002) and heightened in-hospital mortality. Conclusion: In conclusion, our study identifies key risk factors and underscores the importance of proactive measures to reduce postoperative stroke incidence in surgical valve replacement patients. [ABSTRACT FROM AUTHOR]

Introduction&Objective: Identifying high-risk patients with a poor prognosis in coronary care unit (CCU) patients can assist physicians in providing optimal care and implementing preventive strategies. Leuko-glycaemic index (LGI), synthesized by multiplying the blood glucose level by the leukocyte count, has gained popularity in risk stratification of myocardial infarction patients. In this context, this study was carried out to investigate the relationship between LGI assessed at admission and in-hospital mortality in CCU patients. Methods: This is a multi-center, cross-sectional and observational study. (MORCOR-TURK LGI: Mortality Predictors in Coronary Care in Turkey, ClinicalTrials.gov number NCT05296694). The population of this study consisted of 2917 consecutive patients admitted to the CCU. Blood samples were collected into serum separator tubes in the immediate admission to the CCU. LGI was calculated by multiplying both values and dividing them by a thousand. LGI units were expressed in mg/dl. mm³. The sample was divided into two groups based on the LGI cut-off value of 1.23. Logistic regression analysis was used to find the significant predictors of mortality. Receiver operating characteristics (ROC) curve was to find out the cut-off value of LGI. A p value less than 0.05 was considered to be statistically significant in all analyses. Results: Univariable logistic regression analysis revealed that age, heart failure (HF), LGI, coronary artery disease, hypertension, diabetes mellitus and atrial fibrillation are clinically and statistically significant predictors. Further analysis of these variables using the multivariable logistic regression analysis indicated that age (Odds Ratio [OR]: 1.040, 95% confidence interval [CI]: 1.017-1.063; p=0.001), HF (OR: 2.426, 95% CI: 1.419-4.149; p:0.001) and LGI (OR: 1.349, 95% CI: 1.176-1.549; p<0.001), were independent predictors for the development of in- hospital mortality in CCU. LGI score optimal cut-off value of >3.72 predicted in-CCU mortality with 95.56% sensitivity and 49.19% specificity ([AUC]: 0.659 [95% CI: 0.641--0.676, p<0.001]). Conclusion: LGI, a simple and inexpensive index, was associated with in-hospital mortality in CCU patients. Aggressive treatment strategies should be adopted for these patients with higher LGI upon admission. Prospective studies are needed to clarify the prognostic relevance of LGI and CCU patients' mortality in terms of future cardiovascular events. [ABSTRACT FROM AUTHOR]

Background: Family‐centred care (FCC), while a core value of paediatric hospitals, has not been well‐studied in the paediatric cardiac intensive care unit (PCICU). Aim: To describe parents' perceptions of FCC provided by nurses in the PCICU during their infant's recovery from neonatal cardiac surgery and explore associations of perceptions of FCC on parent post‐traumatic stress (PTS) 4 months post‐discharge. Study Design: Data obtained from a previously conducted randomized clinical trial (RCT) on telehealth home monitoring after neonatal cardiac surgery at three free‐standing paediatric hospitals were analysed from a subset of 164 parents who completed the FCC Scale at hospital discharge, which measures a parent's experience of nursing care that embodies core principles of FCC. The RCT intervention was provided after hospital discharge, having no influence on parent's perception of FCC. The intervention also had no effect on PTS. Results: Perceived FCC was lowest for items 'nurses helped me feel welcomed' and 'nurses helped me feel important in my child's care'. Having 12%–19% points lower perception of FCC at hospital discharge was associated with parent experience of six or more PTS symptoms, at least moderate PTS symptom severity, or PTS disorder diagnosis at 4‐month follow‐up. Every 10% increase in parental perceptions of FCC was associated with less PTS symptoms (β = −0.29, SE = 0.12; p =.02) and lower PTS symptom cluster scores of arousal (β = −0.18, SE = 0.08; p =.02). Conclusions: Parents who perceived lower FCC during their infants' hospitalization were at increased risk for the development of PTS symptoms, more PTS symptom severity and PTS disorder diagnosis 4‐months post‐discharge. Relevance to Clinical Practice: Nurses have a prominent role to support the implementation of FCC for infants with cardiac defects and their parents. FCC may positively influence overall parent mental health and well‐being, reducing the trauma and distress of the PCICU experience. [ABSTRACT FROM AUTHOR]

Background: Limited evidence is available regarding the effect of reflexology on Acute Myocardial Infarction (AMI). The present study evaluated the effect of foot reflexology on fatigue, sleep quality, physiological indices, and electrocardiogram changes in AMI. Materials and Methods: This clinical trial was conducted on 80 subjects with AMI. They were divided into an intervention (received reflexology for 3 consecutive days) and a control (received the routine care) group. The Multidimensional Fatigue Inventory, the Pittsburgh Sleep Quality Index, a pain numeric analog scale, a daily physiological indices form, and daily electrocardiogram were used to collect data. The collected data were analyzed in SPSS software. The study was conducted based on CONSORT criteria. Results: After controlling the covariates, a significant difference was found between the intervention and control groups with regard to the mean scores of fatigue (F5,80 = 16.33; p < 0.001), sleep quality (F5,80 = 16.56; p < 0.001), and chest pain intensity (F5,80 = 6.86; p = 0.010); means of systolic blood pressure (F5,80 = 22.20; p < 0.001), heart rate (F5,80 = 5.86; p = 0.010), respiration (F5,80 = 9.37; p = 0.003), and temperature (F5,80= -4.23; p < 0.001); and incidence of ST-segment (χ21,80 = 5.00; p = 0.020) and T-wave changes (χ21,80 = 6.05, p = 0.010) on the fourth day of the intervention. Conclusions: Given the effectiveness of foot reflexology in different aspects of AMI patients, the implementation of this intervention is recommended for these patients in coronary care units. [ABSTRACT FROM AUTHOR]

There has been an evolution in the disease severity and complexity of patients presenting to the cardiac intensive care unit (CICU). There are limited data evaluating the role of palliative care in contemporary CICU practice. PubMed Central, CINAHL, EMBASE, Medline, Cochrane Library, Scopus, and Web of Science databases were evaluated for studies on palliative care in adults (≥18 years) admitted with acute cardiovascular conditions – acute myocardial infarction, cardiogenic shock, cardiac arrest, advanced heart failure, post-cardiac surgery, spontaneous coronary artery dissection, Takotsubo cardiomyopathy, and pulmonary embolism – admitted to the CICU, coronary care unit or cardiovascular intensive care unit from 1/1/2000 to 8/8/2022. The primary outcome of interest was the utilization of palliative care services. Secondary outcomes of included studies were also addressed. Meta-analysis was not performed due to heterogeneity. Of 5711 citations, 30 studies were included. All studies were published in the last seven years and 90 % originated in the United States. Twenty-seven studies (90 %) were retrospective analyses, with a majority from the National Inpatient Sample database. Heart failure was the most frequent diagnosis (47 %), and in-hospital mortality was reported in 67 % of studies. There was heterogeneity in the timing, frequency, and background of the care team that determined palliative care consultation. In two randomized trials, there appeared to be improvement in quality of life without an impact on mortality. Despite the growing recognition of the role of palliative care, there are limited data on palliative care consultation in the CICU. • Palliative care has been studied infrequently in the cardiac intensive care unit (CICU). • The CICU population has undergone a significant shift in disease severity and complexity. • Multiple barriers to palliative care utilization exist in contemporary literature. [ABSTRACT FROM AUTHOR]

Optimal blood pressure (BP) for patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) remains unclear. This study aims to identify the optimal BP by investigating the association between average office BP and future clinical events in patients undergoing PCI. Consecutive patients undergoing PCI from 2012 to 2016 were included. They were divided into five groups according to the average follow-up BP after discharge. The co-primary outcomes were net adverse clinical events (NACE) and major adverse cardiac and cerebrovascular events (MACCE) up to 5 years. NACE was defined as a composite of MACCE (all-cause death, non-fatal myocardial infarction (MI), non-fatal stroke, or any revascularization) or major bleeding. A total of 2845 patients were included, and among them, 787 (27.7%) experienced the NACE during the follow-up period. Patients in the highest SBP group (adjusted hazard ratio [HR] 1.495, confidence interval [CI] 1.189–1.880) and lowest SBP group (adjusted HR 1.625, CI 1.214–2.176) had a significantly higher risk of 5-year NACE. Similar associations were observed between SBP and the risk of MACCE, and similar results based on DBP categories were also observed. There was a J-curve relationship between SBP and DBP with respect to 5-year NACE and MACCE. The nadir point of risk for NACE and MACCE was found at 121.4/74.8 and 120.4/73.7 mmHg. In patients underwent PCI, there is a significant correlation between office BP level and clinical events, indicates the importance of efforts for optimal BP control to reduce ischemic and bleeding events. Trial registration: HanYang University Medical Center (HYUMC) Registry, NCT05935397. [ABSTRACT FROM AUTHOR]

Rationale: Cardiac monitoring has often been identified as an area of overutilization and remains a limited resource in many hospitals. With the aim of reducing telemetry overuse, we added clinical decision support to our health system's telemetry order with guidance on appropriate indications for monitoring. The new order requires selection of an appropriate clinical indication. Aims and Objectives: In this study, we aimed to understand provider engagement with this tool by assessing concordance between selected indications within the order and the clinical presence of those conditions as documented within the patient chart. Methods: We randomly selected 100 telemetry orders from July to October 2022 across four different hospitals at NYU Langone Health. Two independent, blinded reviewers used a structured protocol to identify documentation of actual indications for telemetry in each selected chart. We calculated the rate of concordance between indications selected in the order and indications that were determined to be clinically present on chart review. Results: There were 30,839 telemetry orders placed during the study timeframe. Overall concordance between the selection within the order and the actual indication was 48% (95% confidence interval [CI], 38.21%−57.79%). We observed especially low concordance rates for vague indications, such as 'Other', and for 'Confirmed Stroke', which was the only indication allowing for indefinite telemetry. Conclusion: The overall low concordance suggests a disconnect between the support tool and clinical practice. Providers are more likely to select an indication that reduces downstream work regardless of a patient's true clinical indication. [ABSTRACT FROM AUTHOR]

Introduction: Varying rates of access site infections with temporary percutaneous cardiac devices have been reported in the literature. The purpose of this study is to determine the impact of a change in institutional practice in utilizing antimicrobial prophylaxis to prevent access site infections in patients with these devices. Methods: This observational, pre-post implementation analysis evaluated the benefit of prophylactic antimicrobial therapy in adult patients with temporary percutaneous cardiac devices admitted to cardiac intensive care units. Patients in the pre-cohort received prophylactic antibiotics for the duration of device insertion. Patients in the post-cohort received a single dose of intravenous antibiotics for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella® 5.5 device placement, and no antimicrobial prophylaxis for all other devices placed. The primary endpoint was the incidence of definitive access site infection. Secondary endpoints included the incidence of Clostridium difficile infection and initiation of broad-spectrum antibiotics. Results: Fifty patients in the pre-cohort and 45 patients in the post-cohort were evaluated. Devices included intra-aortic balloon pumps, VA-ECMO, Impella® CP and Impella® 5.5. The median duration of device insertion was four days. No significant difference in the primary outcome was seen between the two groups. A significant reduction in prophylactic antimicrobial utilization and total days of antimicrobial exposure was observed in the post-implementation cohort. Conclusion: Based on the results of our study, the implemented guideline reduces the utilization of antimicrobial prophylaxis in patients with temporary percutaneous cardiac devices and does not result in an increased rate of infections. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to investigate the impact of an education program on diabetes self-management among individuals with type 2 diabetes (T2D) who had experienced an acute myocardial infarction (AMI). Methods: This randomized controlled trial was conducted at a training and research hospital in Turkey, which also functions as a cardiology specialty center. The hospital features two coronary intensive care units and three cardiology departments. Data collection took place between January 15 and June 15, 2023. In total, 102 patients with T2D who had undergone AMI were selected and randomly assigned to either the intervention and control groups. The intervention group received individualized diabetes education through two sessions, each lasting approximately 15 minutes. Diabetes self-management levels were assessed at baseline and again one month after the educational intervention. This study followed the consolidated standards of reporting trials reporting guidelines. Results: At the 1-month follow-up, the intervention group demonstrated significantly higher diabetes self-management scores compared with the control group (p<0.001). Intra-group analysis further indicated a substantial improvement in the intervention group's post-education self-management scores compared with their pre-education scores (p<0.001). Conclusion: The educational program significantly improved diabetes self-management among patients with T2D following AMI. Nurse-led educational intervention is an effective approach that can be seamlessly integrated into routine patient care for this population. [ABSTRACT FROM AUTHOR]