Predictive value of Systematic Coronary Risk Evaluation 2-Diabetes risk model and arterial stiffness for cardiovascular events in the Asian population with type 2 diabetes mellitus.

AIMS/INTRODUCTION: Individuals with diabetes are at high risk of developing cardiovascular events. The present study investigated the predictive value of the cardio-ankle vascular index (CAVI) when added to the Systematic Coronary Risk Evaluation 2-Diabetes (SCORE2-Diabetes) risk algorithm to predict cardiovascular events in the Asian population. MATERIALS AND METHODS: The SCORE2-Diabetes risk was assessed in 1,502 patients with diabetes, aged 40-69 years. Then, we further stratified each 10-year risk category with a CAVI value of 9.0. The primary outcomes (composite of all causes of death, myocardial infarction, stroke and hospitalization for heart failure) were assessed over 5 years. RESULTS: The mean age of the population was 59.8 ± 6.4 years. The proportion of 10-year risk according to the SCORE2-Diabetes risk of low, moderate, high and very high risk identified at 7.2, 30.0, 27.2 and 35.6%, respectively. The mean CAVI value was 8.4 ± 1.4, and approximately 35.4% of the patients had CAVI ≥9.0. The SCORE2-Diabetes risk algorithm independently predicted the primary outcomes in patients with diabetes (hazard ratio 1.18, 95% confidence interval [CI] 1.13-1.22), whereas CAVI did not (hazard ratio 1.03, 95% CI 0.89-1.18). The C-index for the primary outcomes of the SCORE2-Diabetes risk algorithm alone was 0.72 (95% CI 0.67-0.77). The combination of SCORE2-Diabetes and CAVI, both in the continuous value and risk groups, did not improve discrimination (C-index 0.72, 95% CI 0.67-0.77 and 0.68, 95% CI 0.64-0.74, respectively). CONCLUSIONS: Adding the CAVI to the SCORE2-Diabetes risk algorithm did not improve individual risk stratification in patients with diabetes.

Association of the interatrial block and left atrial fibrosis in the patients without history of atrial fibrillation.

Presence of left atrial (LA) fibrosis reflects underlying atrial cardiomyopathy. Interatrial block (IAB) is associated with LA fibrosis in patients with atrial fibrillation (AF). The association of IAB and LA fibrosis in the patients without history of AF is unknown. We examined association of IAB and LA fibrosis in the patients without AF history. This is a retrospective analysis of 229 patients undergoing cardiac magnetic resonance imaging (CMR). LA fibrosis was reported from spatial extent of late gadolinium enhancement of CMR. IAB was measured from 12-lead electrocardiography using digital caliper. Of 229 patients undergoing CMR, prevalence of IAB was 50.2%. Patients with IAB were older (56.9±13.9 years vs. 45.9±19.2 years, p<0.001) and had higher prevalence of co-morbidities. Left ventricular ejection fraction was lower in IAB group. LA volume index (LAVI) was greater in IAB group (54.6±24.9 ml/m2 vs. 43.0±21.1 ml/m2, p<0.001). Patients with IAB had higher prevalence of LA fibrosis than those without IAB (70.4% vs. 21.2%; p<0.001). After multivariable analysis, only IAB and LAVI were independent factors that predict LA fibrosis. Prevalence of IAB in patients undergoing CMR was high. IAB was highly associated with LA fibrosis and larger LA size in patients without AF history.

Electromagnetic interference from automobile passive keyless entry in cardiovascular implantable electronic devices.

INTRODUCTION: The automobile passive keyless entry (PKE) system is a potential source of electromagnetic interference (EMI). We aim to determine the incidence and significance of EMI from automobile PKE system in cardiovascular implantable electronic device (CIED) patients. METHODS: This was a single-center cross-sectional study conducted at Maharaj Nakorn Chiang Mai hospital, Thailand. Patients with CIED were instructed to lock and unlock two automobiles using the PKE system. Any EMI or arrhythmias were detected by CIED interrogation and single-lead electrocardiogram event recorder. We also used a spectrum analyzer to identify the automobiles working frequency bandwidth. RESULTS: There was a total of 102 CIED patients. Device types included 48.0% defibrillators, 37.3% permanent pacemakers, and 14.7% cardiac resynchronization therapy device. Both interrogated data from device and event monitor revealed no incidence of EMI during the PKE activation. We failed to identify the working frequency bandwidth of the two studied cars due to very low signal strength, thus blended in with the background noise. CONCLUSIONS: Automobile PKE systems transmitted very low power signals. Therefore, under normal circumstances, CIED patients can use automobile PKE system safely without any EMI regardless of key fob positions in relation to the CIED pulse generator. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (https://clinicaltrials.gov), and the identification number is NCT03016390.

Prognostic Value of Ankle-Brachial Index in Prediction of Cardiovascular Events in an Asian Population with Multiple Atherosclerotic Risk Factors.

We aimed to evaluate the incremental prognostic value after incorporation of the ankle-brachial index (ABI) into the 10-year pool cohort equation (PCE) risk model in patients with multiple risk factors (MRFs). A total of 4332 MRFs patients were divided into 2 groups as ABI ≤.9 or >.9. The primary outcome was hard cardiovascular events (hCVE: including cardiovascular death, myocardial infarction, or ischemic stroke) over a median follow-up of 36 months. The Cox proportional hazards survival model, C-statistic, and net reclassification indices (NRI) were used. The occurrence of the primary outcome in the ABI ≤.9 group (3.7%) was significantly greater than in the ABI > .9 group (1.3%), P < .001. ABI is an independent predictor of hCVE in addition to the variables in the standard risk model (age, gender, and smoking status). ABI modestly improved the C-index when added to the PCE risk model (PCE .70 vs ABI+PCE .74). The addition of ABI to the PCE risk model did not significantly improve the classification of patients (NRI -.029; 95% CI: -.215 to .130). Despite ABI being one of the independent predictors of hCVE, integration of ABI into the PCE model did not improve the efficacy of risk reclassification in patients with MRFs.

Effects of prolonged working hours on heart rate variability in internal medicine physicians.

Prior studies have utilized heart rate variability (HRV) as the assessment tools for psychological and physiological stress during 24-h shift. However, data regarding effects of prolonged working hours > 24 h on HRV are limited. We aimed to compare between pre- and post-call HRV among physicians who worked 24 plus 8 h. The study included 60 physicians in the internal medicine training. All subjects underwent Holter ECG monitoring for HRV assessment. We compared between HRV of an 8-h regular workday (8am to 4 pm) before on-call duty (pre-call HRV) and an 8-h workday after 24-h on-call duty (post-call HRV). The mean age was 26 ± 2.5 years. Mean total sleep time during on-call duty was 238.9 ± 88.3 min. In overall population, the time-domain and frequency-domain HRV parameters were not different between pre- and post-call day. However, the physicians reported their sleep time in the 1st quartile (< 180 min) had significant increase in SDNN, pNN50, high frequency (HF), and decrease in low/high frequency ratio (LF/HF). In contrast, the physicians reported their sleep time in the 4th quartile (> 307.5 min) had significant decrease in pNN50, LF, HF, and increase in heart rate. Multiple linear regression revealed total sleep time as an independent factor associated with pre- and post-call HRV alterations. More sleep during on call (> 5 h) was associated with HRV pattern suggesting both increased sympathetic activity and reduced parasympathetic activity, while less sleep (< 3 h) during on call was associated with post-call parasympathetic rebound HRV pattern.

Effect of particulate matter 2.5 on QT dispersion in patients with chronic respiratory disease.

PM2.5 air pollutants increased risk of ventricular arrhythmias. The prolonged corrected QT interval (QTc) and QT dispersion (QTd) is common in patients with chronic airway disease and is associated with heightened risk of ventricular tachyarrhythmia. We sought to examine the effect of PM2.5 exposure on QTc and QTd in patients with chronic airway disease. We enrolled 73 patients with chronic airway disease into the study. The 12-lead ECGs were recorded during high-exposure and low-exposure periods of PM2.5. QTc and QTd were compared between 2 periods. Mean age was 70 ± 10 years. Mean FEV1/FVC was 63 ± 14%. There was no difference in QTc between PM2.5 high-exposure and low-exposure periods. However, QTd was significantly increased during PM2.5 high-exposure compared to low-exposure periods in male patients (43.5 ± 15.0 vs. 38.2 ± 12.1 ms, P = 0.044) but no difference was found in females. We found that patients who worked mostly indoor had less QTd than those working outdoor during PM2.5 low-exposure period. In addition, those who wore face mask tended to have less QTd during low-exposure period than those who did not. High PM2.5 exposure increased QTd in male patients with chronic airway disease. Working indoors and wearing face mask were associated with less QTd.

Bradycardia and Heart Rate Fluctuation Are Associated with a Prolonged Intensive Care Unit Stay in Patients with Severe COVID-19.

Background and Objective: Bradycardia has been observed among patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is suspected to be associated with poorer outcomes. Heart rate (HR) fluctuation has been found to be correlated with a greater mortality rate in critically ill patients. The association of bradycardia and HR fluctuation with the outcome of severe coronavirus disease 2019 (COVID-19) patients has not been clarified. Therefore, we aimed to examine whether bradycardia and HR fluctuation correlated with poor outcomes in patients with severe COVID-19. Materials and Methods: We conducted a secondary analysis from a prospective data collection of patients admitted to the intensive care unit, between April and June 2021, at Chiang Mai University Hospital. Results: The results showed that 62 of 86 patients (72.1%) had bradycardia, defined by HR < 60 beats per minute (bpm). The number of patients with high HR fluctuation, defined as the difference in HR during admission ≥ 40 bpm, was greater among the bradycardia group than in the non-bradycardia group (70.9% vs. 14.7%, p = 0.015, respectively). The patients with bradycardia had greater levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). In addition, a greater proportion of patients with bradycardia received interleukin-6 inhibitors and hemoperfusion as a rescue therapy than those with non-bradycardia. After adjusting for age, gender, body mass index, CRP, and mechanical ventilator; bradycardia and the high HR fluctuation were significantly associated with a longer length of stay in the intensive care unit (ICU-LOS), with adjusted risk ratios of 2.67, 95% CI; 1.02, 6.94, p = 0.045 and 2.88, 95% CI; 1.22, 6.78, p = 0.016, respectively. Conclusion: We found that bradycardia and a high heart rate fluctuation were associated with a poorer ICU outcome in terms of longer ICU-LOS among the patients with severe COVID-19.

Adult-Onset Still's Disease-like Syndrome following COVID-19 Vaccination: A Case Report and Review of the Literature.

Adult-onset Still's disease (AOSD)-like syndrome has rarely been reported as a complication of COVID-19 vaccination. This study reports a 31-year-old female patient who presented with fever, myalgia, arthralgia, pleuropericarditis, leukocytosis, and transaminitis following ChAdOx1 vaccination, and met Yamaguchi's criteria. A PubMed literature search, performed up until March 2022, identified 10 such cases. A total of 11 cases, including the one in this report, developed AOSD-like syndrome after administration of the viral vector (ChAdOx1) vaccine (six patients) and mRNA vaccine (five patients: BNT162b2 in four and mRNA-1273 in one). There were four male and seven female patients, with their median (Q1, Q3) age and the onset of symptoms after vaccination being 36 years (29, 45) and 10 days (6, 13), respectively. Fever (100%), arthralgia/arthritis (90.9%), skin rashes (81.8%), and sore throat (81.8%) were the main clinical findings. Pericarditis (45.5%), myocarditis/cardiac dysfunction (36.4%), pleuritis (54.6%), and pulmonary infiltrations (36.4%) were also common. One patient developed macrophage activation syndrome. One patient responded well to non-steroidal anti-inflammatory drugs, and the other six showed a good response to high-dose corticosteroids alone. Of the remaining four patients, who showed partial responses to high dose corticosteroids, showed good responses to biological agents. AOSD-like syndrome following COVID-19 vaccination shared many similar clinical features and treatment outcomes to those of idiopathic AOSD (but with a higher prevalence of cardiopulmonary involvement in the former). Physicians should be aware of this extremely rare complication to achieve early diagnosis and provide proper management.

Procedural outcome of lead explant and countertraction-assisted femoral lead extraction in Thai patients with cardiac implantable electronic device infection.

BACKGROUND: Cardiac implantable electronic device (CIED) implantation rate has been increasing worldwide. Despite proper surgical technique and preincisional intravenous antibiotics, the incidence of infected CIED remains high and leads to serious complications. When encountered with CIED infection, complete CIED system removal is indicated. Several lead extraction approaches have shown a high success rate. However, the facilities are limited in Thailand. In our current practice, we perform lead extraction using the Dotter basket snare femoral approach as our primary method. There are no prior data on this countertraction-assisted transfemoral technique. Therefore, we aim to study the procedural outcome of countertraction-assisted transfemoral lead removal technique of CIED infection in Thai patients. METHODS: Patients diagnosed with CIED infection and with a history of device infection were retrospectively included. Simple manual removal was performed. In case of failure, we proceeded with the modified countertraction-assisted transfemoral technique. RESULTS: There were 35 patients in the study. The success rate was 94.3%. Most of the leads, 62.8%, were removed by simple manual traction. In the 37.1% who required further femoral approach lead extractions, procedural failure was observed in 5.7% and procedure-related adverse events in 5.6%. CIED infection-related death accounted for 5.7% and nosocomial infection-related death, 2.8%. CONCLUSION: The success rate of CIED infection lead explant and countertraction-assisted transfemoral lead extraction technique was high with small complications and can be performed without advanced facilities. However, the procedure required a main center with a cardiovascular thoracic surgery support team.

Prevalence of Staphylococcus aureus nasal carriage and surgical site infection rate among patients undergoing elective cardiac surgery.

BACKGROUND: Nasal carriers of Staphylococcus aureus are at increased risk of postoperative surgical site infection. Nasal decolonization with mupirocin is recommended in patients undergoing cardiac surgery to reduce surgical site infection. These data are still lacking in Thailand. Therefore, the aim of this study was to determine the prevalence of S. aureus nasal carriage in Thai patients undergoing elective cardiac surgery. The association of surgical site infection and S. aureus nasal carriage was also examined. METHODS: This was a prospective cohort study of 352 patients who planned to undergo elective cardiac surgery. Nasal swab culture was performed in all patients preoperatively. RESULTS: Of 352 patients, 46 (13.1%) had a positive nasal swab culture for methicillin-sensitive S. aureus (MSSA) and one patient (0.3%) harbored a methicillin-resistant S. aureus (MRSA) strain. The incidence of superficial and deep surgical site infection was 1.3% and 0.3%, respectively. After multivariate analysis, S. aureus nasal carriage was independently associated with superficial surgical site infection (odds ratio 13.04, 95% confidence interval 1.28-133.27; P=0.03). CONCLUSIONS: The prevalence of MSSA and MRSA nasal carriage in Thai patients undergoing elective cardiac surgery was low. The incidence of surgical site infection was also very low in the population studied. Nevertheless, it was found that S. aureus nasal carriage increased the risk of superficial surgical site infection.

Sinus arrest: A rare observation during radiofrequency ablation along the coronary sinus roof.

Catheter-based radiofrequency (RF) ablation targeting segments of the cardiac conduction system and/or selected regions of myocardium is an accepted treatment for many cardiac arrhythmias. On the other hand, while purposeful extension of RF ablation to include nearby cardiac neural elements, particularly epicardial ganglionated plexi (GP), remains a subject of ongoing study, inadvertent stimulation of such structures may occur during an otherwise conventional RF ablation procedure. Thus, asystolic pauses have been observed during RF ablation of left ventricular free-wall accessory pathways, slow AV node pathways, and the left superior pulmonary vein. In this report, sinus arrest occurred within 3.3 s of RF application (40 W at 50°C) along the coronary sinus roof for treatment of an atypical "slow-slow" atrioventricular nodal reentrant tachycardia. Energy delivery was immediately terminated, but asystole persisted for 4.7 s followed by sinus bradycardia. The procedure was temporarily halted, but later was successfully resumed. Given the latency from terminating RF to return of sinus node function, the sinus arrest was likely a centrally mediated reflex vagal response. Consequently, while parasympathetic ganglia near the CS os are believed to principally innervate the AV node, not the sinus node, our observation highlights the neural cross-communications that likely exist in this region of the heart.

Effects of metformin on atrial and ventricular arrhythmias: evidence from cell to patient.

Metformin has been shown to have various cardiovascular benefits beyond its antihyperglycemic effects, including a reduction in stroke, heart failure, myocardial infarction, cardiovascular death, and all-cause mortality. However, the roles of metformin in cardiac arrhythmias are still unclear. It has been shown that metformin was associated with decreased incidence of atrial fibrillation in diabetic patients with and without myocardial infarction. This could be due to the effects of metformin on preventing the structural and electrical remodeling of left atrium via attenuating intracellular reactive oxygen species, activating 5' adenosine monophosphate-activated protein kinase, improving calcium homeostasis, attenuating inflammation, increasing connexin-43 gap junction expression, and restoring small conductance calcium-activated potassium channels current. For ventricular arrhythmias, in vivo reports demonstrated that activation of 5' adenosine monophosphate-activated protein kinase and phosphorylated connexin-43 by metformin played a key role in ischemic ventricular arrhythmias reduction. However, metformin failed to show anti-ventricular arrhythmia benefits in clinical trials. In this review, in vitro and in vivo reports regarding the effects of metformin on both atrial arrhythmias and ventricular arrhythmias are comprehensively summarized and presented. Consistent and controversial findings from clinical trials are also summarized and discussed. Due to limited numbers of reports, further studies are needed to elucidate the mechanisms and effects of metformin on cardiac arrhythmias. Furthermore, randomized controlled trials are needed to clarify effects of metformin on cardiac arrhythmias in human.

QTc dispersion as a novel marker in identifying patients requiring an epicardial approach for ablation of scar mediated ventricular tachycardia.

INTRODUCTION: Epicardial exit sites of ventricular tachycardia (VT) are frequently encountered during VT ablation requiring an epicardial ablation approach for successful elimination of VT. We sought to assess the utility of repolarization markers in identifying individuals requiring an epicardial ablation approach in addition to an endocardial approach. METHODS: 32 patients who underwent successful ablation for scar mediated VT were included in the study. Fourteen patients who required a combined endocardial and epicardial VT ablation were defined as epicardial VT group (Epi) whereas 18 patients who were successfully ablated from the endocardium alone constituted the endocardial VT group (Endo). Repolarization markers during sinus rhythm were compared between the two groups. RESULTS: A higher QTc max and QTc dispersion were seen in the Epi group compared to Endo group (479 ± 34 vs 449 ± 20, p = 0.008 and 63 ± 13 vs 38 ± 8, p = 0.001, respectively). Ts-p and Ts-p/Tp-e were higher in the Epi group (166 ± 23 vs 143 ± 23, p = 0.008 and 1.55 ± 0.26 vs 1.3 ± 0.21, p < 0.005). On multivariate regression, QTc dispersion was an independent predictor of the need for an epicardial approach to ablation. A QTc dispersion more than 51.5 msec identified individuals requiring a combined epicardial and endocardial approach to ablation with a sensitivity of 92.9% and a specificity of 100%. CONCLUSIONS: Patients requiring an epicardial ablation have a higher QTc dispersion. A value greater than 51.5 msec reliably differentiates between the two groups with high sensitivity and specificity.

Characteristics and periodicity of sustained ventricular tachyarrhythmia events in a population of military veterans with implantable cardioverter defibrillator.

PURPOSE: Circadian patterns of ventricular tachyarrhythmias (VTAs) in ICD patients from SCD-HeFT and MADIT-CRT have yielded differing results. The aim was to investigate VTA patterns in a large population of military veterans with ICD. METHODS: This retrospective study analyzed biorhythm periodicity of sustained VTAs (≤ 300 ms). Findings were derived from the Veterans Affairs (VA) National Cardiac Device Surveillance database encompassing January 1, 2005, to December 31, 2017. RESULTS: The patient population comprised 1559 consecutive patients with 17,039 VTAs. There were 763 patients with clinical information with the mean age of 67.8 ± 9 years old and 99% male. An hourly non-uniform VTA distribution with a bimodal pattern and a predominant afternoon peak was seen (χ2 = 5057, P < 0.0001). VTAs treated successfully by anti-tachycardia pacing (ATP) showed a bimodal pattern with even distributions. VTAs treated by ICD shocks showed a bimodal pattern with a predominant afternoon peak. The duration of VTA peaks was increased from 13.5 to 17 h with increasing daylight time from 9.9 to 14.5 h. The weekly VTA distribution showed a significant septadian pattern with lowest frequency on weekend and highest on weekdays (χ2 = 4840, P < 0.0001). No annual periodicity and monthly periodicity were seen. CONCLUSIONS: Sustained VTA events exhibited a circadian rhythm in a large population of military veterans with ICD/CRT-D; specifically, a bimodal pattern with a predominant afternoon peak was observed. Further, the majority of VTA episodes treated by ICD shock occurred in the afternoon, and the duration of VTA peak lengthened with increased duration of daylight time.

A single center experience on the clinical utility evaluation of an insertable cardiac monitor.

BACKGROUND: The evaluation of insertable cardiac monitor (ICM) has been largely on the device performance and safety with only limited studies on the clinical utility. The aim of this study was to evaluate the clinical utility of ICM in patients with a variety of clinical presentations. METHODS: A single-center retrospective study on the clinical utility, as measured by both expected and unexpected clinical useful ICM findings and the initiation of therapeutic interventions, was conducted. RESULTS: Ninety-five consecutive patients (median age 68 years) received ICM Reveal LINQ™ for clinical indications of unexplained syncope (53), cryptogenic stroke (19), unexplained infrequent palpitations (14) and AF management (9). During a median follow-up of 414 days, the causes for unexplained syncope were arrhythmia-related (11.3%), arrhythmia-unrelated (32%) and undetermined (56.6%). Atrial fibrillation in patients with cryptogenic stroke was detected in 31.6% (6/19). The clinical utility occurrence was 48.4% with the expected and incidental (unexpected) clinical utility of 41% and 7.4% patients respectively. Of these, therapeutic interventions based on ICM diagnoses were initiated in 18.9% (18/95) of patients. CONCLUSIONS: ICM (Reveal LINQ™) offers substantial expected and unexpected clinical utility in patients with a variety of clinical presentations. The causes of nearly one third of patients receiving ICM for unexplained syncope were unrelated to cardiac arrhythmia. Nearly one fifth of patients with newly diagnosed arrhythmia from ICM received therapeutic interventions.

Risk factors and prevention of dabigatran-related gastrointestinal bleeding in patients with atrial fibrillation.

INTRODUCTION: Dabigatran, as compared with warfarin, was associated with lower rates of stroke and systemic embolism with similar rates of major hemorrhage. But it has a significantly higher risk of gastrointestinal bleeding (GIB). There are limited data on how to prevent GIB from dabigatran and what are the risk factors. METHODS: We performed a retrospective cohort study of patients with atrial fibrillation who have ever taken dabigatran for thromboprophylaxis from October 2010 to February 2013. RESULTS: A total of 247 patients were identified. There were 10 (4%) patients who developed GIB (6 (6.5%) in PPI/H2RA users vs 4 (2.6%) in non-PPI/H2RA users; P = .184). History of GIB within 1 year prior to dabigatran initiation and HAS-BLED score ≥3 are independent risk factors for GIB, with odds ratio of 25.14 (95% CI, 2.85-221.47; P < .01) and 5.85 (95% CI, 1.31-26.15; P = .021), respectively. CONCLUSION: In this real-world cohort, PPI/H2RA use was not associated with reduced GIB events. HAS-BLED score ≥3 and prior history of GIB within 1 year are independent risk factors for GIB among dabigatran users.

Trends in Subcutaneous Cardiac Monitoring Technology.

Ambulatory cardiac monitoring is a rapidly expanding field and one that is likely to progress beyond electrocardiographic (ECG) and blood pressure recordings. To date, the primary cardiac monitoring focus has been ambulatory ECG (AECG) monitoring. In this setting, AECG monitoring has become a diagnostic tool used daily by physicians of many specialties. In this regard, both wearable and subcutaneous ECG monitoring technologies are now widely available, with the appropriate choice for a given patient being best determined by the frequency with which the patient's symptom recurrences are expected. In other words, the less frequent the symptomatic events, then the longer the monitoring duration requirement should be. However, multiple factors other than the technology used impact success. For example, wearable AECG systems are only capable of monitoring patients for a period of a few days to several weeks due to limited battery longevity, patient intolerance to cutaneous ECG electrodes, the cumbersome nature of the device, or a combination of these factors. Current-generation insertable cardiac monitors (ICMs), on the other hand, offer three years of monitoring and infrequent skin irritation. Additionally, automatic remote download, a valuable feature in many cases, is only offered by certain wearable technologies, but is an option in all currently available ICMs. This report focuses on the current status of subcutaneous ICMs and their indications and limitations. The goal is to highlight the variety of utility of current ICM technologies and to provide insight into potential future subcutaneous ICM applications.

Factors Associated With Reintubation in Patients With Chronic Obstructive Pulmonary Disease.

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (COPD) increase morbidity, mortality, and health care costs in COPD patients. Patients who require mechanical ventilation and fail extubation often have longer hospital stays and/or increased mortality. Determining predictors to identify patients who might require reintubation could help respiratory care teams manage these patients better. METHODS: We retrospectively reviewed data of COPD patients over a 3-year period. Inclusion criteria were patients with acute exacerbations of COPD, age more than 45 years, and patients on mechanical ventilation. Exclusion criteria were ventilated via tracheostomy, unplanned extubation, and reintubation for reasons other than respiratory failure. RESULTS: This study included 88 patients; 61 patients were successfully extubated, 11 patients were extubated and required reintubation, and 16 patients were not extubated during their intensive care unit stay. There were no differences in demographic or clinical characteristics between the patients with successful extubation and failed extubation. Patients with successful extubation were more likely to have a "good cough" assessment and to not receive any sedatives or analgesics in the 24 hours prior to extubation than patients who failed extubation (P < .05). Multiple variable logistic regression demonstrated that reintubation was significantly associated with sedatives/analgesics given prior to extubation (odds ratio = 8.6; 95% confidence interval, 1.23-60.8). Intensive care unit and hospital lengths of stay, tracheostomy events, and mortality rates were higher in the reintubation group (P < .001). CONCLUSION: Sedative and analgesic drug use prior to extubation was associated with more frequent reintubation in patients with acute exacerbations of COPD. This study suggests that the judicious withdrawal of sedatives prior to extubation may reduce reintubations.