Evaluating the Shock Index, Revised Assessment of Bleeding and Transfusion (RABT), Assessment of Blood Consumption (ABC) and novel PTTrauma score to predict critical transfusion threshold (CAT) in penetrating thoracic trauma.

The shock index (SI) has been associated with predicting transfusion needs in trauma patients. However, its utility in penetrating thoracic trauma (PTTrauma) for predicting the Critical Administration Threshold (CAT) has not been well-studied. This study aimed to evaluate the prognostic value of SI in predicting CAT in PTTrauma patients and compare its performance with the Assessment of Blood Consumption (ABC) and Revised Assessment of Bleeding and Transfusion (RABT) scores. We conducted a prognostic type 2, single-center retrospective observational cohort study on patients with PTTrauma and an Injury Severity Score (ISS) > 9. The primary exposure was SI at admission, and the primary outcome was CAT. Logistic regression and decision curve analysis were used to assess the predictive performance of SI and the PTTrauma score, a novel model incorporating clinical variables. Of the 620 participants, 53 (8.5%) had more than one CAT. An SI > 0.9 was associated with CAT (adjusted OR 4.89, 95% CI 1.64-14.60). The PTTrauma score outperformed SI, ABC, and RABT scores in predicting CAT (AUC 0.867, 95% CI 0.826-0.908). SI is a valuable predictor of CAT in PTTrauma patients. The novel PTTrauma score demonstrates superior performance compared to existing scores, highlighting the importance of developing targeted predictive models for specific injury patterns. These findings can guide clinical decision-making and resource allocation in the management of PTTrauma.

Healthcare and economic cost burden of emergency medical services treated non-traumatic shock using a population-based cohort in Victoria, Australia.

OBJECTIVES: We aimed to assess the healthcare costs and impact on the economy at large arising from emergency medical services (EMS) treated non-traumatic shock. DESIGN: We conducted a population-based cohort study, where EMS-treated patients were individually linked to hospital-wide and state-wide administrative datasets. Direct healthcare costs (Australian dollars, AUD) were estimated for each element of care using a casemix funding method. The impact on productivity was assessed using a Markov state-transition model with a 3-year horizon. SETTING: Patients older than 18 years of age with shock not related to trauma who received care by EMS (1 January 2015-30 June 2019) in Victoria, Australia were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome assessed was the total healthcare expenditure. Secondary outcomes included healthcare expenditure stratified by shock aetiology, years of life lived (YLL), productivity-adjusted life-years (PALYs) and productivity losses. RESULTS: A total of 21 334 patients (mean age 65.9 (±19.1) years, and 9641 (45.2%) females were treated by EMS with non-traumatic shock with an average healthcare-related cost of $A11 031 per episode of care and total cost of $A280 million. Annual costs remained stable throughout the study period, but average costs per episode of care increased (Ptrend=0.05). Among patients who survived to hospital, the average cost per episode of care was stratified by aetiology with cardiogenic shock costing $A24 382, $A21 254 for septic shock, $A19 915 for hypovolaemic shock and $A28 057 for obstructive shock. Modelling demonstrated that over a 3-year horizon the cohort lost 24 355 YLLs and 5059 PALYs. Lost human capital due to premature mortality led to productivity-related losses of $A374 million. When extrapolated to the entire Australian population, productivity losses approached $A1.5 billion ($A326 million annually). CONCLUSION: The direct healthcare costs and indirect loss of productivity among patients with non-traumatic shock are high. Targeted public health measures that seek to reduce the incidence of shock and improve systems of care are needed to reduce the financial burden of this syndrome.

Analyst optimism, information disclosure, and stock price collapse risk: Empirical insights from China's A-share market.

This study selects stock data of listed companies in China's A-share stock market from 2011 to 2020 as research samples. Using a fixed-effects model, it examines the impact of analyst optimism on stock price collapses and the moderating effect of information disclosure quality. Simultaneously, it conducts additional research to explore the potential transmission mechanisms involved. The main findings are as follows: Firstly, a positive correlation exists between analyst optimism and the risk of stock price collapse. Secondly, improving information disclosure quality of listed companies can enhance the positive impact of analyst optimism on the risk of stock price collapses and expedite the market's adjustment of overly optimistic valuations of listed companies. Additionally, analyst optimism can increase the risk of stock price collapses by affecting institutional ownership. These findings provide theoretical support for regulatory authorities to revise and improve the "information disclosure evaluation" system, regulate the analyst industry, guide analyst behavior, and encourage listed companies to enhance internal governance and improve information disclosure practices.

Socioeconomic shocks, social protection and household food security amidst COVID-19 pandemic in Africa's largest economy.

Africa has been known to experience series of problems among which are poverty, food insecurity, lack of access to energy, lack of infrastructure among others. These problems were exacerbated by the COVID-19 pandemic, which has had a severe impact on the socioeconomic status of households in Africa. This paper examines the relationship between socioeconomic shocks, social protection, and household food security during the pandemic in Nigeria, the Africa's largest economy. Using the World Bank's COVID-19 national longitudinal baseline phone survey (2020) for the analysis and applied the multinomial logit regression, the study finds that socioeconomic shocks resulting from the pandemic have led to an increased level of food insecurity. Social protection programmes have played a crucial role in mitigating the impact of these shocks on households. However, the study also highlights the need for more targeted and effective social protection policies to ensure that vulnerable households are adequately protected from the adverse effects of the pandemic. The findings of this study have important implications for policymakers and stakeholders in Africa's largest economy, as they seek to address the challenges posed by the pandemic and promote household food security for the actualisation the United Nations (UN) Sustainable Development Goal (SDG) of food and nutrition security (SDG2). The study, therefore, recommends that efforts be made to preserve food supply chains by mitigating the pandemic's effect on food systems, increasing food production, and looking forward beyond the pandemic by building resilient food systems with the use of social protection interventions.

Serial Assessment of Shock Severity in Cardiac Intensive Care Unit Patients.

BACKGROUND: One-time assessment of the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification robustly predicts mortality in the cardiac intensive care unit (CICU). We sought to determine whether serial SCAI shock classification could improve risk stratification. METHODS AND RESULTS: Unique admissions to a single academic level 1 CICU from 2015 to 2018 were included in this retrospective cohort study. Electronic health record data were used to assign the SCAI shock stage during 4-hour blocks of the first 24 hours of CICU admission. Shock was defined as hypoperfusion (SCAI shock stage C, D, or E). In-hospital death was evaluated using logistic regression. Among 2918 unique CICU patients, 1537 (52.7%) met criteria for shock during ≥1 block, and 266 (9.1%) died in the hospital. The SCAI shock stage on admission was: A, 37.6%; B, 31.5%; C, 25.9%; D, 1.8%; and E, 3.3%. Patients who met SCAI criteria for shock on admission (first 4 hours) and those with worsening SCAI shock stage after admission were at higher risk for in-hospital death. Each higher admission (adjusted odds ratio, 1.36 [95% CI, 1.18-1.56]; area under the receiver operating characteristic curve, 0.70), maximum (adjusted odds ratio, 1.59 [95% CI, 1.37-1.85]; area under the receiver operating characteristic curve, 0.73) and mean (adjusted odds ratio, 2.42 [95% CI, 1.99-2.95]; area under the receiver operating characteristic curve, 0.78) SCAI shock stage was incrementally associated with a higher in-hospital mortality rate. Discrimination was highest for the mean SCAI shock stage (P<0.05). Each additional 4-hour block meeting SCAI criteria for shock predicted a higher mortality rate (adjusted odds ratio, 1.15 [95% CI, 1.07-1.24]). CONCLUSIONS: Dynamic assessment of shock using serial SCAI shock classification assignment can improve mortality risk stratification in CICU patients by quantifying the magnitude and duration of shock.

Systematic Assessment of Shock Severity in Postoperative Cardiac Surgery Patients.

BACKGROUND: The Society for Cardiovascular Angiography and Interventions (SCAI) shock classification has been shown to provide robust mortality risk stratification in a variety of cardiovascular patients. OBJECTIVES: This study sought to evaluate the SCAI shock classification in postoperative cardiac surgery intensive care unit (CSICU) patients. METHODS: This study retrospectively analyzed 26,792 postoperative CSICU admissions at a heart center between 2012 and 2022. Patients were classified into SCAI shock stages A to E using electronic health record data. Moreover, the impact of late deterioration (LD) as an additional risk modifier was investigated. RESULTS: The proportions of patients in SCAI shock stages A to E were 24.4%, 18.8%, 8.4%, 35.5%, and 12.9%, and crude hospital mortality rates were 0.4%, 0.6%, 3.3%, 4.9%, and 30.2%, respectively. Similarly, the prevalence of postoperative complications and organ dysfunction increased across SCAI shock stages. After multivariable adjustment, each higher SCAI shock stage was associated with increased hospital mortality (adjusted OR: 1.26-16.59) compared with SCAI shock stage A, as was LD (adjusted OR: 8.2). The SCAI shock classification demonstrated a strong diagnostic performance for hospital mortality (area under the receiver operating characteristic: 0.84), which noticeably increased when LD was incorporated into the model (area under the receiver operating characteristic: 0.90). CONCLUSIONS: The SCAI shock classification effectively risk-stratifies postoperative CSICU patients for mortality, postoperative complications, and organ dysfunction. Its application could, therefore, be extended to the field of cardiac surgery as a triage tool in postoperative care and as a selection criterion in research.

Perioperative Point of Care Ultrasound for Hemodynamic Assessment: A Narrative Review.

While transesophageal echocardiography (TEE) has traditionally been used in perioperative care, there is growing evidence supporting point of care ultrasound (POCUS) for the anesthesiologist in guiding patient care. It is a quick way to non-invasively evaluate hemodynamically unstable patients and ascertain their state of shock, determine volume status, and guide resuscitation in cardiac arrest. In addition, through use of POCUS, the anesthesiologist is able to identify signs of chronic heart disease to provide a more tailored and safer approach to perioperative care.

SLICE: An algorithm for incorporating ultrasonography in the assessment of shocked or breathless patients.

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

Household Financial Vulnerability to Income and Medical Expenditure Shocks: Measurement and Determinants.

This paper proposes a novel ex ante indicator to measure the degree of household financial vulnerability by calculating the probability of falling into financial distress under uncertain income and medical expenditure. The advantage of this measure is that it can reflect the capacity of households to deal with income shock and medical expenditure shock and quantify the degree of financial vulnerability for households beforehand. We employ it to measure the financial vulnerability of Chinese urban and rural households separately by using data from the China Health and Retirement Longitudinal Study (CHARLS) 2011, 2013, and 2015. Further, we analyze the potential determinants and their contributions to financial vulnerability changes. We find that rural households experience higher financial vulnerability than urban households. Furthermore, the investigation into the effects of potential determinants suggests that demographic variables (including age, gender, education, marital status, household size, labor force, and area), health-related variables (including health status, disability, and health shock), and medical insurance variables (including urban employee medical insurance and commercial medical insurance) have significant effects on the financial vulnerability of both urban and rural households. Contribution analysis of the determinants of household financial vulnerability shows that variables including disability, health shock, household size, labor force, and education contribute most to the changes in financial vulnerability.

Impact of COVID-19 shocks, precarity and mediating resources on the mental health of residents of share housing in Victoria, Australia: an analysis of data from a two-wave survey.

OBJECTIVES: COVID-19 lockdown measures have challenged people's mental health, especially among economically vulnerable households. The objective of this study was to investigate the impact of exposure to COVID-19 shocks (defined as job loss, living cost pressures and changing housing conditions throughout the lockdown period) and double precarity (defined as precarity in housing and employment) on mental health outcomes for members of share households as well as the mediating effects of a range of resources. DESIGN: We conducted a two-wave survey of occupants of share housing in June and October 2020 during a prolonged period of population lockdown. Research design involved fixed effects ordered logit regression models to assess the mental health consequences of baseline precarity and COVID-related shocks. SETTING: Victoria, Australia. PARTICIPANTS: We surveyed 293 occupants of share houses (mean age 34 SD 11.5, 56% female). Members of share houses (where individuals are unrelated adults and not in a romantic relationship) are more likely to be young, casually employed, visa-holders and low-income. OUTCOME MEASURES: We measured household composition, housing and employment precarity, access to government support, household crowding, social networks and COVID-19 shocks. We used a self-reported measure of mental health. RESULTS: Those exposed to COVID-19 shocks reported a 2.7 times higher odds of mental health deterioration (OR 2.7, 95% CI 1.53 to 4.85). People exposed to double precarity (precarity in both housing and employment) reported 2.4 times higher odds of mental health deterioration (OR 2.4, 95% CI 0.99 to 5.69). Housing inadequacy and lack of access to sufficient government payments explained 14.7% and 7% of the total effect of double precarity on mental health, respectively. CONCLUSIONS: Results indicate that residents of group households characterised by pre-existing precarity were vulnerable to negative mental health effects during lockdown. Access to sufficient government payments and adequate housing buffered this negative effect.

Assessment of emergency physicians' performance in identifying shockable rhythm in out-of-hospital cardiac arrest: an observational simulation study.

BACKGROUND: Emergency physicians can use a manual or an automated defibrillator to provide defibrillation of patients who had out-of-hospital cardiac arrest (OHCA). Performance of emergency physicians in identifying shockable rhythm with a manual defibrillator has been poorly explored whereas that of automated defibrillators is well known (sensitivity 0.91-1.00, specificity 0.96-0.99). We conducted this study to estimate the sensitivity/specificity and speed of shock/no-shock decision-making by prehospital emergency physicians for shockable or non-shockable rhythm, and their preference for manual versus automated defibrillation. METHODS: We developed a web application that simulates a manual defibrillator (https://simul-shock.firebaseapp.com/). In 2019, all (262) emergency physicians of six French emergency medical services were invited to participate in a study in which 60 ECG rhythms from real OHCA recordings were successively presented to the physicians for determination of whether they would or would not administer a shock. Time to decision was recorded. Answers were compared with a gold standard (concordant answers of three experts). We report sensitivity for shockable rhythms (decision to shock) and specificity for non-shockable rhythms (decision not to shock). Physicians were also asked whether they preferred manual or automated defibrillation. RESULTS: Among 215 respondents, we were able to analyse results for 190 physicians. 57% of emergency physicians preferred manual defibrillation. Median (IQR) sensitivity for a shock delivery for shockable rhythm was 0.91 (0.81-1.00); median specificity for no-shock delivery for non-shockable rhythms was 0.91 (0.80-0.96). More precisely, sensitivities for shock delivery for ventricular tachycardia (VT) and coarse ventricular fibrillation (VF) were both 1.0 (1.0-1.0); sensitivity for fine VF was 0.6 (0.2-1). Specificity for not shocking a pulseless electrical activity (PEA) was 0.83 (0.72-0.86), and for asystole, specificity was 0.93 (0.86-1). Median speed of decision-making (in seconds) were: VT 2.0 (1.6-2.7), coarse VF 2.1 (1.7-2.9), asystole 2.4 (1.8-3.5), PEA 2.8 (2.0-4.2) and fine VF 2.8 (2.1-4.3). CONCLUSIONS: Global sensitivity and specificity were comparable with published automated external defibrillator studies. Shockable rhythms with the best clinical prognoses (VT and coarse VF) were very rapidly recognised with very good sensitivity. The decision-making for fine VF or asystole and PEA was less accurate.

The assessment of blood pressure in pregnant women: pitfalls and novel approaches.

Accurate assessment of blood pressure is fundamental to the provision of safe obstetrical care. It is simple, cost effective, and life-saving. Treatments for preeclampsia, including antihypertensive drugs, magnesium sulfate, and delivery, are available in many settings. However, the instigation of appropriate treatment relies on prompt and accurate recognition of hypertension. There are a number of different techniques for blood pressure assessment, including the auscultatory method, automated oscillometric devices, home blood pressure monitoring, ambulatory monitoring, and invasive monitoring. The auscultatory method with a mercury sphygmomanometer and the use of Korotkoff sounds was previously recommended as the gold standard technique. Mercury sphygmomanometers have been withdrawn owing to safety concerns and replaced with aneroid devices, but these are particularly prone to calibration errors and regular calibration is imperative to ensure accuracy. Automated oscillometric devices are straightforward to use, but the physiological changes in healthy pregnancy and pathologic changes in preeclampsia may affect the accuracy of a device and monitors must be validated. Validation protocols classify pregnant women as a "special population," and protocols must include 15 women in each category of normotensive pregnancy, hypertensive pregnancy, and preeclampsia. In addition to a scarcity of devices validated for pregnancy and preeclampsia, other pitfalls that cause inaccuracy include the lack of training and poor technique. Blood pressure assessment can be affected by maternal position, inappropriate cuff size, conversation, caffeine, smoking, and irregular heart rate. For home blood pressure monitoring, appropriate instruction should be given on how to use the device. The classification of hypertension and hypertensive disorders of pregnancy has recently been revised. These are classified as preeclampsia, transient gestational hypertension, gestational hypertension, white-coat hypertension, masked hypertension, chronic hypertension, and chronic hypertension with superimposed preeclampsia. Blood pressure varies across gestation and by ethnicity, but gestation-specific thresholds have not been adopted. Hypertension is defined as a sustained systolic blood pressure of ≥140 mm Hg or a sustained diastolic blood pressure of ≥90 mm Hg. In some guidelines, the threshold of diagnosis depends on the setting in which blood pressure measurement is taken, with a threshold of 140/90 mm Hg in a healthcare setting, 135/85 mm Hg at home, or a 24-hour average blood pressure on ambulatory monitoring of >126/76 mm Hg. Some differences exist among organizations with respect to the criteria for the diagnosis of preeclampsia and the correct threshold for intervention and target blood pressure once treatment has been instigated. Home blood pressure monitoring is currently a focus for research. Novel technologies, including early warning devices (such as the CRADLE Vital Signs Alert device) and telemedicine, may provide strategies that prompt earlier recognition of abnormal blood pressure and therefore improve management. The purpose of this review is to provide an update on methods to assess blood pressure in pregnancy and appropriate technique to optimize accuracy. The importance of accurate blood pressure assessment is emphasized with a discussion of preeclampsia prediction and treatment of severe hypertension. Classification of hypertensive disorders and thresholds for treatment will be discussed, including novel developments in the field.

Shock Index in the early assessment of febrile children at the emergency department: a prospective multicentre study.

OBJECTIVE: (1) To derive reference values for the Shock Index (heart rate/systolic blood pressure) based on a large emergency department (ED) population of febrile children and (2) to determine the diagnostic value of the Shock Index for serious illness in febrile children. DESIGN/SETTING: Observational study in 11 European EDs (2017-2018). PATIENTS: Febrile children with measured blood pressure. MAIN OUTCOME MEASURES: Serious bacterial infection (SBI), invasive bacterial infection (IBI), immediate life-saving interventions (ILSIs) and intensive care unit (ICU) admission. The association between high Shock Index (>95th centile) and each outcome was determined by logistic regression adjusted for age, sex, referral, comorbidity and temperature. Additionally, we calculated sensitivity, specificity and negative/positive likelihood ratios (LRs). RESULTS: Of 5622 children, 461 (8.2%) had SBI, 46 (0.8%) had IBI, 203 (3.6%) were treated with ILSI and 69 (1.2%) were ICU admitted. High Shock Index was associated with SBI (adjusted OR (aOR) 1.6 (95% CI 1.3 to 1.9)), ILSI (aOR 2.5 (95% CI 2.0 to 2.9)), ICU admission (aOR 2.2 (95% CI 1.4 to 2.9)) but not with IBI (aOR: 1.5 (95% CI 0.6 to 2.4)). For the different outcomes, sensitivity for high Shock Index ranged from 0.10 to 0.15, specificity ranged from 0.95 to 0.95, negative LRs ranged from 0.90 to 0.95 and positive LRs ranged from 1.8 to 2.8. CONCLUSIONS: High Shock Index is associated with serious illness in febrile children. However, its rule-out value is insufficient which suggests that the Shock Index is not valuable as a screening tool for all febrile children at the ED.

Socio-demographic characteristics and pre-hospital care of children with circulatory failure in a children's emergency room in southern Nigeria.

INTRODUCTION: circulatory failure is a major childhood emergency. Several disease-related and patient-related factors can predispose children to shock. Early detection of such factors will improve its prevention, management and outcome. This study aimed to evaluate the incidence, socio-demographic characteristics and pre-hospital care of children presenting with circulatory failure (shock) in children´s emergency room (CHER). METHODS: this study adopted cross-sectional design in CHER of the University of Benin Teaching Hospital, Nigeria, from October 2018 to March 2019. Data were collected using a semi-structured questionnaire eliciting demography, socio-economic status, pre-hospital care and presence of shock. In a sub-analysis, multiple logistic regression identified variables that are independently associated with circulatory failure in the participants, using adjusted odds ratio (OR) and 95% confidence intervals (CI). RESULTS: a total of 554 acutely-ill children participated in the study. Their median age was 60 (IQR: 24-132) months. Shock was present in 79 (14.3%) of the children on arrival at CHER. Children referred from private clinics were more likely to arrive CHER in shock compared to those coming directly from home (OR = 2.67, 95%CI: 1.07-6.69; p = 0.036) while children from lower socio-economic class families presented more frequently with shock than those from higher class (OR = 14.39, 95% CI: 2.61-79.44; p = 0.002). Also, children that received oral rehydration solution as pre-hospital care seemed more likely to present with shock in CHER (OR = 6.63, 95% CI: 2.15-20.46; p =0.001). CONCLUSION: quality of pre-hospital care and parental socio-economic status influence the presence of shock in children seen at the emergency unit. Focused health education and prevention of finance-related delays in emergency care are needed.

Assessment of Tissue Perfusion Using the Peripheral Perfusion Index and Lactate Clearance in Shock in Pediatric Patients.

BACKGROUND: Pediatric shock has a high mortality rate because many of the early clinical signs are subtle and have poor sensitivity and specificity. Pediatric shock was categorized either: compensated with normal blood pressure, poor skin perfusion (CRT >2 s, mottled, cool peripheries, peripheral cyanosis), weak peripheral pulse, age specific tachycardia, tachypnoea, and oliguria or decompensated with hypotension (SBP < 70 + (2× age in years) mm Hg and decreased mental status. The perfusion index is a non-invasive method for assessing peripheral perfusion and may be a useful marker for identifying shock early in pediatric patients. OBJECTIVE: This prospective cohort study (November 2019 to August 2020) evaluated whether the perfusion index, lactate, and/or lactate clearance could predict mortality among pediatric shock patients. METHODS: Fifty children (68% male) with shock underwent assessments at presentation to the emergency room to evaluate their heart rate, blood pressure, capillary refill time, central venous pressure, perfusion index, cardiac index, systemic vascular resistance, central venous oxygen saturation, and lactate clearance. RESULTS: The perfusion index range was 0.03 to 2.2 and ≤0.18 as the cut-off for mortality prediction providing 74% sensitivity and 78% specificity. The serum lactate concentration range was 0 to 16 mmol/L and >5.7 mmol/L as the cut-off for mortality prediction provided 70% sensitivity and 96% specificity at presentation to the emergency room. The lactate clearance range was 3% to 75% and >10% as the cut-off for survival prediction after resuscitation and at 6 h later. CONCLUSION: Perfusion index (PI), lactate, and lactate clearance provided comparable sensitivity and specificity for predicting outcomes among pediatric patients with shock Therefore, we suggest that the PI is an inexpensive, rapid, and non-invasive tool that can be used to predict illness severity and mortality in busy pediatric intensive care units and emergency departments. This tool may guide better patient triage and an earlier diagnosis of shock in this setting.

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era.

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

Early Sequential Microcirculation Assessment In Shocked Patients as a Predictor of Outcome: A Prospective Observational Cohort Study.

OBJECTIVES: A dysfunctional microcirculation is universal in shock and is often dissociated from global hemodynamic parameters. Persistent microcirculatory derangements reflect ongoing tissue hypoperfusion and organ injury. The initial microcirculatory dysfunction and subsequent resolution could potentially guide therapy and predict outcomes. We evaluated the microcirculation early in a heterogenous shocked population. Microcirculatory resolution was correlated with measures of tissue perfusion and global hemodynamics. The relationship between the microcirculation over 24 h and outcome were evaluated. DESIGN: We prospectively recruited patients with all forms of shock, based on global hemodynamics and evidence of organ hypoperfusion. SETTING: A 30-bed adult intensive care unit (ICU). PATIENTS: Eighty-two shocked patients. MEASUREMENTS AND MAIN RESULTS: Following the diagnosis of shock, patients underwent a sublingual microcirculation examination using Sidestream Dark Field Imaging. The median age of patients was 66 years old (interquartile range [IQR] 54-71), with an Acute Physiology and Chronic Health Evaluation II of 27 (IQR 20-32). Microcirculatory parameters included Percentage Perfused Vessels (PPV), De Backer Score, and a heterogeneity index in patients with septic shock, according to the second consensus guidelines Additional parameters collected: temperature, heart rate and arterial pressure, cumulative fluid balance, and vasopressor use. Arterial blood samples were taken at the time of microcirculatory assessments, providing HCO3, lactate concentrations, PaO2, and PaCO2 measurements. A statistically significant improvement in PPV and the heterogeneity index was demonstrated. This improvement was mirrored by biomarkers of perfusion; however, the global hemodynamic parameter changes were not significantly different over the 24-h period. The early microcirculatory improvement was not predictive of an improvement in acute kidney injury, length of stay, ICU, or hospital mortality. CONCLUSIONS: Early sequential evaluation of the microcirculation in shocked patients, demonstrated statistically significant improvement in the PPV and microvascular heterogeneity with standard care. These improvements were mirrored by biomarkers of organ perfusion; however, the changes in global hemodynamics were not as pronounced in this early phase. Early improvement in the microcirculation did not predict clinical outcome.

Birth hospital and racial and ethnic differences in severe maternal morbidity in the state of California.

BACKGROUND: Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited. OBJECTIVE: We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity. STUDY DESIGN: This cohort study used data on all births at ≥20 weeks gestation in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women. RESULTS: Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19-1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20-1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11-1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21-1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups. CONCLUSION: In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

Echocardiographic assessment of hemodynamic changes in preterm neonates with shock: a prospective pragmatic cohort study.

Shock is a state of circulatory dysfunction and its diagnosis is complex in neonates. Hemodynamic assessment using echocardiography has potential to guide better management regimes in neonates with shock. Objective of this study is to analyze changes in the echocardiographic parameters in preterm neonates with shock at presentation and after resolution. In this prospective pragmatic Cohort study, eligible neonates with shock were monitored for changes in echocardiographic parameters at onset of shock and after resolution of shock. Paired data analysis was done for observed changes in the parameters. Based on initial clinical parameters and echocardiographic parameters, infants were assigned into different types of shock. Data of 37 infants were analyzed for baseline clinical and echocardiographic parameters, and data of 31 infants were analyzed for the changes in the observed parameters after shock resolution. Statistically significant changes were observed in inferior vena cava collapsibility index (ICI), left ventricular end diastolic volume (LVEDV), isovolemic ventricular relaxation time (IVRT), left and right ventricular stroke volume, and ejection fraction (EF). There was no agreement between clinical and echocardiographic definitions of shock.Conclusion: We noticed shock has overlapping pathophysiologic features. Our study highlights the importance of baseline documentation of echocardiographic parameters of all infants who are at risk of shock and repeat echocardiography at onset of shock to observe the changes in ICI, LVEDV, IVRT, stroke volume, and EF. This would guide pathophysiological management of shock in neonates. What is Known: • In neonates pathophysiology of shock is overlapping. • Echocardiography can help in better understanding and management of shock. What is New: • Study gives median changes in major echocardiographic parameters in neonatal shock. • These changes can guide for selection of volume and inotropes in management.