Delta Shock Index and higher incidence of emergency surgery in older adults with blunt trauma.

PURPOSE: Vital signs are important for predicting clinical outcomes in patients with trauma. However, their accuracy can be affected in older adults because hemodynamic changes are less obvious. This study aimed to examine the usefulness of changes in vital signs during transportation in predicting the need for hemostatic treatments in older patients with trauma. METHODS: This retrospective cohort study was conducted using data from the Japan Trauma Data Bank (2004-2019). Patients aged ≥ 65 years who were hemodynamically stable at the scene were included in this study. The incidence of emergency surgery within 12 h after hospital arrival was compared between patients with delta Shock Index (dSI) > 0.1 and those with dSI ≤ 0.1. Predicting ability was examined after adjusting for patient demographics, comorbidities, vital signs at the scene and on hospital arrival, Injury Severity Score, and abbreviated injury scale in each region. RESULTS: Among the 139,242 patients eligible for the study, 3,701 underwent urgent hemostatic surgery within 12 h. Patients with dSI > 0.1 showed a significantly higher incidence of emergency surgery than those with dSI ≤ 0.1 (871/16,549 [5.3%] vs. 2,830/84,250 [3.4%]; odds ratio (OR), 1.60 [1.48-1.73]; adjusted OR, 1.22 [1.08-1.38]; p = 0.001). The relationship between high dSI and a higher incidence of intervention was observed in patients with hypertension and those with decreased consciousness on arrival. CONCLUSION: High dSI > 0.1 was significantly associated with a higher incidence of urgent hemostatic surgery in older patients.

Abnormal obstetric shock index and associated factors among immediate postpartum women following vaginal delivery at a tertiary hospital in southwestern Uganda.

BACKGROUND: Early recognition of haemodynamic instability after birth and prompt interventions are necessary to reduce adverse maternal outcomes due to postpartum haemorrhage. Obstetric shock Index (OSI) has been recommended as a simple, accurate, reliable, and low-cost early diagnostic measure that identifies hemodynamically unstable women. OBJECTIVES: We determined the prevalence of abnormal obstetric shock index and associated factors among women in the immediate postpartum period following vaginal delivery at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda. METHODS: We conducted a cross-sectional study at the labour suite and postnatal ward of MRRH from January 2022 to April 2022. We systematically sampled women who had delivered vaginally, and measured their blood pressures and pulse rates at 1 h postpartum. We excluded mothers with hypertensive disorders of pregnancy. Sociodemographic, medical and obstetric data were obtained through interviewer-administered questionnaires. The prevalence of abnormal OSI was the proportion of participants with an OSI ≥ 0.9 (calculated as the pulse rate divided by the systolic BP). Logistic regression analysis was used to determine associations between abnormal OSI and independent variables. RESULTS: We enrolled 427 women with a mean age of 25.66 ± 5.30 years. Of these, 83 (19.44%), 95% CI (15.79-23.52) had an abnormal obstetric shock index. Being referred [aPR 1.94, 95% CI (1.31-2.88), p = 0.001], having had antepartum haemorrhage [aPR 2.63, 95% CI (1.26-5.73), p = 0.010] and having a visually estimated blood loss > 200 mls [aPR 1.59, 95% CI (1.08-2.33), p = 0.018] were significantly associated with abnormal OSI. CONCLUSION: Approximately one in every five women who delivered vaginally at MRRH during the study period had an abnormal OSI. We recommend that clinicians have a high index of suspicion for haemodynamic instability among women in the immediate postpartum period. Mothers who are referred in from other facilities, those that get antepartum haemorrhage and those with estimated blood loss > 200mls should be prioritized for close monitoring. It should be noted that the study was not powered to study the factors associated with AOSI and therefore the analysis for factors associated should be considered exploratory.

Household hardships and responses to COVID-19 pandemic-related shocks in Eastern Ethiopia.

BACKGROUND: COVID-19 resulted in enormous disruption to life around the world. To quell disease spread, governments implemented lockdowns that likely created hardships for households. To improve knowledge of consequences, we examine how the pandemic period was associated with household hardships and assess factors associated with these hardships. METHODS: We conducted a cross-sectional study using quasi-Poisson regression to examine factors associated with household hardships. Data were collected between August and September of 2021 from a random sample of 880 households living within a Health and Demographic Surveillance System (HDSS) located in the Harari Region and the District of Kersa, both in Eastern Ethiopia. RESULTS: Having a head of household with no education, residing in a rural area, larger household size, lower income and/or wealth, and community responses to COVID-19, including lockdowns and travel restrictions, were independently associated with experiencing household hardships. CONCLUSIONS: Our results identify characteristics of groups at-risk for household hardships during the pandemic; these findings may inform efforts to mitigate the consequences of COVID-19 and future disease outbreaks.

Clinical predictors of circulatory failure and coexisting morbidities in children seen in an emergency room in Southern Nigeria.

Background: Circulatory failure (shock) is a life-threatening emergency referring to a state of poor tissue perfusion and resultant anaerobic respiration at a cellular level. It is a common pathway for several severe pediatric morbidities. Aim: We evaluated the clinical predictors of shock and coexisting morbidities in acutely-ill children. Patients and Methods: This was a descriptive, cross-sectional study. Data were collected using a researcher-administered questionnaire eliciting demography, clinical features, diagnoses/differentials, and comorbidities. After binary analysis, multiple logistic regression identified variables that independently predict circulatory failure in the participants, using odds ratio (OR) and 95% confidence intervals (CI). Results: Five hundred and fifty-four children took part in the study. Their median age was 60 (IQR: 24-132) months, mean weight 16.3 ± 13.6 kg and mean height was 90.8 ± 33.2 cm; 53.7% of them were males while 46.3% were females. The incidence of shock was 14.3% among the participants on arrival at the emergency room. Febrile seizure (14.9%), dehydration (4.7%), pallor (3.1%), and coma (1.8%) were the clinical findings significantly associated with shock (P < 0.05). Leading underlying diagnoses and comorbidities associated with shock were severe malaria (85.4%) and severe sepsis (25.0%) (P ≤ 0.01). Also, seizure (OR = 0.07, 95% CI: 0.04-0.13; P ≤ 0.001) and severe sepsis (OR = 0.31, 95% CI: 0.15-0.65; P = 0.002) were independent predictors of circulatory failure. Conclusion: The presence of acute neurologic morbidities and severe infection predicts circulatory failure in the pediatric emergency setting. Early detection and prompt treatment will forestall shock-related complications in affected children.

Etiology, Pathophysiology and Mortality of Shock in Children in Low (Middle) Income Countries: A Systematic Review.

OBJECTIVES: Shock is a life-threatening condition in children in low- and middle-income countries (LMIC), with several controversies. This systematic review summarizes the etiology, pathophysiology and mortality of shock in children in LMIC. METHODS: We searched for studies reporting on children with shock in LMIC in PubMed, Embase and through snowballing (up to 1 October 2019). Studies conducted in LMIC that reported on shock in children (1 month-18 years) were included. We excluded studies only containing data on neonates, cardiac surgery patients or iatrogenic causes. We presented prevalence data, pooled mortality estimates and conducted subgroup analyses per definition, region and disease. Etiology and pathophysiology data were systematically collected. RESULTS: We identified 959 studies and included 59 studies of which six primarily studied shock. Definitions used for shock were classified into five groups. Prevalence of shock ranged from 1.5% in a pediatric hospital population to 44.3% in critically ill children. Pooled mortality estimates ranged between 3.9-33.3% for the five definition groups. Important etiologies included gastroenteritis, sepsis, malaria and severe anemia, which often coincided. The pathophysiology was poorly studied but suggests that in addition to hypovolemia, dissociative and cardiogenic shock are common in LMIC. CONCLUSIONS: Shock is associated with high mortality in hospitalized children in LMIC. Despite the importance few studies investigated shock and as a consequence limited data on etiology and pathophysiology of shock is available. A uniform bedside definition may help boost future studies unravelling shock etiology and pathophysiology in LMIC.

The Usefulness of Shock Index and Modified Shock Index in Predicting the Outcome of COVID-19 Patients.

OBJECTIVE: The aim of this study is to investigate the accuracy of shock index (SI) and modified shock index (mSI) in predicting the intensive care unit (ICU) requirement and in-hospital mortality among coronavirus disease (COVID-19) patients who are admitted to the emergency department (ED). Likewise, the effects of patients' conditions such as age, gender, and comorbidity on prognosis will be analyzed. METHODS: The files were retrospectively scanned for all COVID-19 patients over the age of 18 years who were admitted to the ED and hospitalized between January 1, 2021, and March 15, 2021. The area under the receiver operating characteristic curve and the area under the curve (AUC) were used to assess each scoring system discriminatory for predicting in-hospital mortality and ICU admission. RESULTS: There were 464 patients included in this study. The mean age of the patients was 62.4 ± 16.7, of which 245 were men and 219 were women. The most common comorbidity in patients was hypertension (200; 43.1%), followed by chronic obstructive pulmonary disease (174; 37.5%), and coronary artery disease (154; 33.2%). In terms of in-hospital mortality, the AUC of SI, and mSI were 0.719 and 0.739, respectively. In terms of an ICU requirement, the AUC of SI, and mSI were 0.704 and 0.729, respectively. CONCLUSION: In this study, it was concluded that SI and mSI are useful in predicting in-hospital mortality and ICU requirement in COVID-19 patients. In addition, another important result of the study is that advanced age, male gender, and hypertension may be associated with a poor prognosis.

A multicentre outcome analysis to define global benchmarks for donation after circulatory death liver transplantation.

BACKGROUND & AIMS: The concept of benchmarking is established in the field of transplant surgery; however, benchmark values for donation after circulatory death (DCD) liver transplantation are not available. Thus, we aimed to identify the best possible outcomes in DCD liver transplantation and to propose outcome reference values. METHODS: Based on 2,219 controlled DCD liver transplantations, collected from 17 centres in North America and Europe, we identified 1,012 low-risk, primary, adult liver transplantations with a laboratory MELD score of ≤20 points, receiving a DCD liver with a total donor warm ischemia time of ≤30 minutes and asystolic donor warm ischemia time of ≤15 minutes. Clinically relevant outcomes were selected and complications were reported according to the Clavien-Dindo-Grading and the comprehensive complication index (CCI). Corresponding benchmark cut-offs were based on median values of each centre, where the 75th-percentile was considered. RESULTS: Benchmark cases represented between 19.7% and 75% of DCD transplantations in participating centres. The 1-year retransplant and mortality rates were 4.5% and 8.4% in the benchmark group, respectively. Within the first year of follow-up, 51.1% of recipients developed at least 1 major complication (≥Clavien-Dindo-Grade III). Benchmark cut-offs were ≤3 days and ≤16 days for ICU and hospital stay, ≤66% for severe recipient complications (≥Grade III), ≤16.8% for ischemic cholangiopathy, and ≤38.9 CCI points 1 year after transplant. Comparisons with higher risk groups showed more complications and impaired graft survival outside the benchmark cut-offs. Organ perfusion techniques reduced the complications to values below benchmark cut-offs, despite higher graft risk. CONCLUSIONS: Despite excellent 1-year survival, morbidity in benchmark cases remains high. Benchmark cut-offs targeting morbidity parameters offer a valid tool to assess the protective value of new preservation technologies in higher risk groups and to provide a valid comparator cohort for future clinical trials. LAY SUMMARY: The best possible outcomes after liver transplantation of grafts donated after circulatory death (DCD) were defined using the concept of benchmarking. These were based on 2,219 liver transplantations following controlled DCD donation in 17 centres worldwide. Donor and recipient combinations with higher risk had significantly worse outcomes. However, the use of novel organ perfusion technology helped high-risk patients achieve similar outcomes as the benchmark cohort.

Hemodynamic Profiles of Shock in Patients With COVID-19.

Patients with serious COVID infections develop shock frequently. To characterize the hemodynamic profile of this cohort, 156 patients with COVID pneumonia and shock requiring vasopressors had interpretable echocardiography with measurement of ejection fraction (EF) by Simpson's rule and stroke volume (SV) by Doppler. RV systolic pressure (RVSP) was estimated from the tricuspid regurgitation peak velocity. Patients were divided into groups with low or preserved EF (EFL or EFP, cutoff ≤45%), and low or normal cardiac index (CIL or CIN, cutoff ≤2.2 L/min/m2). Mean age was 67 ± 12.0, EF 59.5 ± 12.9, and CI 2.40 ± 0.86. A minority of patients had depressed EF (EFLCIL, n = 15, EFLCIN, n = 8); of those with preserved EF, less than half had low CI (EFPCIL, n = 55, EFPCIN, n = 73). Overall hospital mortality was 73%. Mortality was highest in the EFLCIL group (87%), but the difference between groups was not significant (p = 0.68 by ANOVA). High PEEP correlated with low CI in the EFPCIL group (r = 0.44, p = 0.04). In conclusion, this study reports the prevalence of shock characterized by EF and CI in patients with COVID-19. COVID-induced shock had a cardiogenic profile (EFLCIL) in 9.6% of patients, reflecting the impact of COVID-19 on myocardial function. Low CI despite preservation of EF and the correlation with PEEP suggests underfilling of the LV in this subset; these patients might benefit from additional volume. Hemodynamic assessment of COVID patients with shock with definition of subgroups may allow therapy to be tailored to the underlying causes of the hemodynamic abnormalities.

Development of a field artificial intelligence triage tool: Confidence in the prediction of shock, transfusion, and definitive surgical therapy in patients with truncal gunshot wounds.

BACKGROUND: In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury. METHODS: Using an American College of Surgeons Trauma Quality Improvement Program-derived database of truncal and junctional gunshot wound (GSW) patients (aged 16-60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0-1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables. RESULTS: A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery. CONCLUSION: Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings. LEVEL OF EVIDENCE: Prognostic, Level III.

Applying the RE-AIM framework in a process evaluation of the introduction of the Non-Pneumatic Anti-Shock Garment in a rural district of Zimbabwe.

The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that can halt and reverse hypovolemic shock secondary to obstetric hemorrhage. The World Health Organization recommended the NASG for use as a temporizing measure in 2012, but uptake of the recommendation has been slow, partially because operational experience is limited. The study is a process evaluation of the introduction of NASG in a public sector health facility network in rural Zimbabwe utilizing an adapted RE-AIM, categorizing observations into the domains of: reach, effectiveness, adoption, implementation and maintenance. The location of the study was Hurungwe district, where staff members of 34 health facilities at primary (31), secondary (2) and tertiary (1) levels of care participated. We found that all facilities became skilled in using the NASG, and that the NASG was used in 10 of 11 instances of severe hemorrhage. In the cases of hypovolemic shock where the NASG was used, there were no maternal deaths and no extreme adverse outcomes related to obstetric hemorrhage in the study period. Among the 10 NASG uses, the garment was used correctly in each case. Fidelity to processes was high, especially in regard to training and cascading skills, but revisions of the NASG rotation and replacement operating procedures were required to keep clean garments stocked. Clinical documentation was also a key challenge. NASG introduction dovetailed very well with pre-existing systems for obstetric emergency response, and improved clinical outcomes. Scale-up of the NASG in the Zimbabwean public health system can be undertaken with careful attention to mentorship, drills, documentation and logistics.

Impact of the ICD-9-CM to ICD-10-CM transition on the incidence of severe maternal morbidity among delivery hospitalizations in the United States.

BACKGROUND: Surveillance of maternal mortality and severe maternal morbidity is important to identify temporal trends, evaluate the impact of clinical practice changes or interventions, and monitor quality of care. A common source for severe maternal morbidity surveillance is hospital discharge data. On October 1, 2015, all hospitals in the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for diagnoses and procedures. OBJECTIVE: This study aimed to evaluate the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding systems on the incidence of severe maternal morbidity in the United States in hospital discharge data. STUDY DESIGN: Using data from the National Inpatient Sample, obstetrical deliveries between January 1, 2012, and December 31, 2017, were identified using a validated case definition. Severe maternal morbidity was defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (January 1, 2012, to September 30, 2015) and the International Classification of Diseases, Tenth Revision, Clinical Modification (October 1, 2015, to December 31, 2017) codes provided by the Centers for Disease Control and Prevention. An interrupted time series and segmented regression analysis was used to assess the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding on the incidence of severe maternal morbidity per 1000 obstetrical deliveries. RESULTS: From 22,751,941 deliveries, the incidence of severe maternal morbidity in the International Classification of Diseases, Ninth Revision, Clinical Modification coding era was 19.04 per 1000 obstetrical deliveries and decreased to 17.39 per 1000 obstetrical deliveries in the International Classification of Diseases, Tenth Revision, Clinical Modification coding era (P<.001). The transition to International Classification of Diseases, Tenth Revision, Clinical Modification coding led to an immediate decrease in the incidence of severe maternal morbidity (-2.26 cases of 1000 obstetrical deliveries) (P<.001). When blood products transfusion was removed from the case definition, the magnitude of the decrease in the incidence of SMM was much smaller (-0.60 cases/1000 obstetric deliveries), but still significant (P<.001). CONCLUSION: After the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for health diagnoses and procedures in the United States, there was an abrupt statistically significant and clinically meaningful decrease in the incidence of severe maternal morbidity in hospital discharge data. Changes in the underlying health of the obstetrical population are unlikely to explain the sudden change in severe maternal morbidity. Although much work has been done to validate the International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe maternal morbidity, it is critical that validation studies be undertaken to validate the International Classification of Diseases, Tenth Revision, Clinical Modification codes for severe maternal morbidity to permit ongoing surveillance, quality improvement, and research activities that rely on hospital discharge data.

Índices de shock prehospitalario y hospitalario como predictores de transfusión masiva en la atención inicial del paciente politraumático / Prehospital and hospital shock indices as predictors of massive blood transfusion during the initial treatment of polytrauma patients

OBJETIVOS: Establecer la posible relación entre el Índice de Shock (IS) con los requerimientos de transfusión masiva, estancia hospitalaria y en unidad de críticos, y mortalidad. MÉTODO: Estudio observacional de los pacientes mayores de 18 años con traumatismos de alta energía del registro TraumCat atendidos en el Hospital Universitario de Bellvitge entre 2012 y 2016. Se recogió el IS prehospitalario (PH), a la llegada al hospital (H) y en la unidad de reanimación (IS-C), y la cantidad de transfusión las primeras 24 horas. RESULTADOS: Se recogieron 184 pacientes y 75 (41%) recibieron transfusión sanguínea. Las medianas de los IS para todos los pacientes del estudio fueron: IS-PH 0,77 (Q1-Q3; 0,61-1,01), IS-H 0,78 (Q1-Q3; 0,64-1), IS-C 0,92 (Q1-Q3;0,76-1,13). Fallecieron 46 pacientes (25%). El IS-PH y el IS-H fueron los que diferenciaron de manera significativa la cantidad de transfusión. El valor 0,9 mostró una especificidad/sensibilidad del 73%/66% para el IS-PH y del 74%/80%para el IS-H. El área bajo la curva ROC para el IS-PH y el IS-H fue del 68% (IC 95% 61-75) y del 72% (IC 95% 65-79) respectivamente. No hubo relación significativa de los IS con la mortalidad y la estancia hospitalaria. CONCLUSIÓN: El IS es una herramienta útil y accesible para identificar pacientes politraumatizados con requerimientos transfusionales de manera temprana y optimizar el tratamiento. Para evaluar estancias hospitalarias o mortalidad, podrían ser más útiles otros índices

OBJECTIVES: To explore a possible association between the shock index and a need for massive blood transfusion, duration of hospital stay in the critical care unit, and mortality. METHODS: Observational study of data for all patients over the age of 18 years with multiple high-energy injuries included in the TraumCat Registry who were treated in Hospital Universitario de Bellvitge between 2012 and 2016.We calculated shock index values before hospital emergency department arrival, on arrival at the hospital, and on admission to the critical care unit for resuscitation. The amount of blood transfused in the first 24 hours was also obtained from the registry. RESULTS: Of 184 polytrauma patients, 75 (41%) received blood transfusions. Median (interquartile range) shock indices were as follows: prehospital, 0.77 (0.61-1.01); on hospital arrival, 0.78 (0.64-1); and on critical care admission, 0.92 (0.76-1.13). Forty-six patients (25%) died. A prehospital shock index of 0.9 was significant, differentiating the amount of blood transfused. The specificity and sensitivity of the cut off were 73% and 66%,respectively, at the prehospital recording and 74% and 80% on hospital arrival. The areas under the receiver operating characteristic curve and 95% CIs were as follows for prehospital and on-arrival shock indices: 68% (61%-75%) and 72% (65%-79%). Mortality and hospital stay were not significantly associated with shock indices. CONCLUSIONS: The shock index is a useful, easy-to-obtain predictor to identify polytrauma patients who need early blood transfusion for optimal treatment. Hospital stay and mortality might be better predicted by other indicators

Clinical risk factors for the development of late-onset circulatory collapse in premature infants.

BACKGROUND: Very low birth weight (VLBW) infants may be at risk for late-onset circulatory collapse (LCC) where otherwise stable infants develop hypotension resistant to vasoactive agents. The risk factors for LCC development are poorly defined, and it has been theorized that it may be in part due to withdrawal from exogenous prenatal steroids. The goal of this study was to define the clinical characteristics of LCC and investigate its association with antenatal steroid administration. METHODS: This is a retrospective cohort study of infants born ≤1500 g. LCC was retrospectively diagnosed in infants requiring glucocorticoids for circulatory instability at >1 week of life. Demographic and clinical characteristics were compared between groups using Mann-Whitney test. RESULTS: Three hundred and ten infants were included; 19 (6.1%) developed LCC. Infants with LCC were born at a median 4.6 weeks' lower gestation, 509 g lower birth weight than those without LCC. There was no difference in antenatal steroid delivery between the groups. CONCLUSIONS: LCC occurs in a distinct subset of VLBW infants, suggesting the need for monitoring in this high-risk population. Antenatal steroids did not significantly increase the risk of LCC development in this study. IMPACT: Late-onset circulatory collapse (LCC) is a life-threatening clinical entity occurring in around 6% in VLBW infants and is likely underdiagnosed in the United States. Targeting specific demographic characteristics such as birth weight (<1000 g) and gestational age at birth (<26 weeks) may allow for early identification of high-risk infants, allowing close monitoring and prompt treatment of LCC. No significant association was found between antenatal steroid administration and LCC development, suggesting that the theoretical risks of antenatal steroids on the fetal HPA axis does not outweigh the benefits of antenatal steroids in fetal lung maturity. To date, no studies characterizing LCC have originated outside of Asia. Therefore, providing a description of LCC in a U.S.-based cohort will provide insight into both its prevalence and presentation to inform clinicians about this potentially devastating disorder and foster early diagnosis and treatment. This study validates LCC characteristics and prevalence previously outlined by Asian studies in a single-center U.S.-based cohort while also identifying potential risk factors for LCC development. This manuscript will provide education for U.S. physicians about the risk factors and clinical presentation of LCC to facilitate early diagnosis and treatment, potentially decreasing neonatal mortality. With prompt recognition and treatment of LCC, infants may have decreased exposure to vasoactive medications that have significant systemic effects.

Serum citrullinated histone H3 concentrations differentiate patients with septic verses non-septic shock and correlate with disease severity.

PURPOSE: Microbial infection stimulates neutrophil/macrophage/monocyte extracellular trap formation, which leads to the release of citrullinated histone H3 (CitH3) catalyzed by peptidylarginine deiminase (PAD) 2 and 4. Understanding these molecular mechanisms in the pathogenesis of septic shock will be an important next step for developing novel diagnostic and treatment modalities. We sought to determine the expression of CitH3 in patients with septic shock, and to correlate CitH3 levels with PAD2/PAD4 and clinically relevant outcomes. METHODS: Levels of CitH3 were measured in serum samples of 160 critically ill patients with septic and non-septic shock, and healthy volunteers. Analyses of clinical and laboratory characteristics of patients were conducted. RESULTS: Levels of circulating CitH3 at enrollment were significantly increased in septic shock patients (n = 102) compared to patients hospitalized with non-infectious shock (NIC) (n = 32, p < 0.0001). The area under the curve (95% CI) for distinguishing septic shock from NIC using CitH3 was 0.76 (0.65-0.86). CitH3 was positively correlated with PAD2 and PAD4 concentrations and Sequential Organ Failure Assessment Scores [total score (r = 0.36, p < 0.0001)]. The serum levels of CitH3 at 24 h (p < 0.01) and 48 h (p < 0.05) were significantly higher in the septic patients that did not survive. CONCLUSION: CitH3 is increased in patients with septic shock. Its serum concentrations correlate with disease severity and prognosis, which may yield vital insights into the pathophysiology of sepsis.

Kawasaki Disease and Kawasaki Disease Shock Syndrome Hospitalization Rates in the United States, 2006-2018.

BACKGROUND: Kawasaki disease (KD) is a febrile illness of unknown etiology. Patients with Kawasaki disease shock syndrome (KDSS) may present with clinical signs of poor perfusion and systolic hypotension in addition to typical KD features. The United States Centers for Disease Control and Prevention analyzes and interprets large hospitalization databases as a mechanism for conducting national KD surveillance. METHODS: The Kids' Inpatient Database (KID), the National (Nationwide) Inpatient Sample (NIS), and the IBM MarketScan Commercial (MSC) and MarketScan Medicaid (MSM) databases were analyzed to determine KD-associated hospitalization rates and trends from 2006 to the most recent year of available data. KD and potential KDSS hospitalizations were defined using International Classification of Disease-Clinical Modification codes. RESULTS: For the most recent year, the KD-associated hospitalization rates for children <5 years of age were 19.8 (95% CI: 17.2-22.3, KID: 2016), 19.6 (95% CI: 16.8-22.4, NIS: 2017), 19.3 (MSC: 2018), and 18.4 (MSM: 2018) per 100,000. There was no indication of an increase in KD rates over the time period. Rates of potential KDSS among children <18 years of age, ranging from 0.0 to 0.7 per 100,000, increased; coding indicated potential KDSS for approximately 2.8%-5.3% of KD hospitalizations. CONCLUSIONS: Analyses of these large, national databases produced consistent KD-associated hospitalization rates, with no increase over time detected; however, the percentage of KD hospitalizations with potential KDSS increased. Given reports of increasing incidence elsewhere and the recent identification of a novel virus-associated syndrome with possible Kawasaki-like features, continued national surveillance is important to detect changes in disease epidemiology.

Shock in the cardiac intensive care unit: Changes in epidemiology and prognosis over time.

There are few studies documenting the changing epidemiology and outcomes of shock in cardiac intensive care unit (CICU) patients. We sought to describe the changes in shock epidemiology and outcomes over time in a CICU population. METHODS: We included 1859 unique patients admitted to the Mayo Clinic Rochester CICU from 2007 through 2018 with an admission diagnosis of shock. Temporal trends, including mortality, were assessed across 3-year periods. RESULTS: Shock comprised 15.1% of CICU admissions during the study period, increasing from 8.8% of CICU admissions in 2007 to 21.6% in 2018 (P < .01 for trend). Mean age was 68 ±â€¯14 years (38% females). Shock was cardiogenic in 65%, septic in 10% and mixed cardiogenic-septic in 15%. Concomitant diagnoses in patients with cardiogenic shock (CS) included acute coronary syndrome (ACS) in 17%, heart failure (HF) in 35% and both in 40%. There was no significant change in the prevalence of individual shock subtypes over time (P > .1). Among patients with CS, the prevalence of ACS decreased and the prevalence of HF increased over time (P < .01). Hospital mortality was highest among patients with mixed shock (39%; P = .05). Among patients with CS, hospital mortality was lower among those with HF compared to those without HF (31% vs. 40%, P < .01). Hospital mortality decreased over time among patients with shock (P < .01) and CS (P = .02). CONCLUSIONS: The prevalence of shock in the CICU has increased over time, with a substantial prevalence of mixed CS. The etiology of CS has changed over the last decade with HF overtaking ACS as the most common cause of CS in the CICU.

Acute Cardiovascular Manifestations in 286 Children With Multisystem Inflammatory Syndrome Associated With COVID-19 Infection in Europe.

BACKGROUND: The aim of the study was to document cardiovascular clinical findings, cardiac imaging, and laboratory markers in children presenting with the novel multisystem inflammatory syndrome associated with coronavirus disease 2019 (COVID-19) infection. METHODS: This real-time internet-based survey has been endorsed by the Association for European Paediatric and Congenital Cardiologists Working Groups for Cardiac Imaging and Cardiovascular Intensive Care. Children 0 to 18 years of age admitted to a hospital between February 1 and June 6, 2020, with a diagnosis of an inflammatory syndrome and acute cardiovascular complications were included. RESULTS: A total of 286 children from 55 centers in 17 European countries were included. The median age was 8.4 years (interquartile range, 3.8-12.4 years) and 67% were boys. The most common cardiovascular complications were shock, cardiac arrhythmias, pericardial effusion, and coronary artery dilatation. Reduced left ventricular ejection fraction was present in over half of the patients, and a vast majority of children had raised cardiac troponin when checked. The biochemical markers of inflammation were raised in most patients on admission: elevated C-reactive protein, serum ferritin, procalcitonin, N-terminal pro B-type natriuretic peptide, interleukin-6 level, and D-dimers. There was a statistically significant correlation between degree of elevation in cardiac and biochemical parameters and the need for intensive care support (P<0.05). Polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 was positive in 33.6%, whereas immunoglobulin M and immunoglobulin G antibodies were positive in 15.7% cases and immunoglobulin G in 43.6% cases, respectively, when checked. One child in the study cohort died. CONCLUSIONS: Cardiac involvement is common in children with multisystem inflammatory syndrome associated with the Covid-19 pandemic. The majority of children have significantly raised levels of N-terminal pro B-type natriuretic peptide, ferritin, D-dimers, and cardiac troponin in addition to high C-reactive protein and procalcitonin levels. In comparison with adults with COVID-19, mortality in children with multisystem inflammatory syndrome associated with COVID-19 is uncommon despite multisystem involvement, very elevated inflammatory markers, and the need for intensive care support.

[Surgical treatment of infective endocarditis: Surgical indications, complications, intrahospital and long-term mortality]. / Endocardites infectieuses opérées : indications chirurgicales, complications, mortalité intrahospitalière et à long terme.

BACKGROUND: In addition to medical treatment, half of the patients with infective endocarditis (IE) receive surgical treatment. Despite clear recommendations on the indications and the operating delays, the decision remains difficult and must take into consideration several factors. METHODS: A retrospective study was performed at Foch Hospital. All patients operated for IE between 2005 and 2018 were included. Patient characteristics, indications and operating delays, as well as intrahospital mortality, were noted. Patient follow-up was provided by phone calls. RESULTS: Fifty-two patients were operated on for IE between 2005 and 2018. The most frequent surgical indications were the presence of a massive symptomatic regurgitation, an uncontrolled infection and large vegetations with embolism. The average operative delay was 13.2 days with 56.5% of patients operated within the first 10 days. The most common postoperative complications were acute kidney injury (AKI) in 57.7% of cases, with 9.6% of dialysis, shock in 50% of cases, rhythm disorders in 40.4% of cases, infectious complications in 19.2% of cases, conductive disorders in 25% of cases, of which 17.3% require a definitive pacemaker implementation. The intrahospital mortality was 7.7% and the average length of hospital stay was 35 days. Survival at one year and 5 years was 95% and 85%, respectively. CONCLUSION: The indications and the operating delays were conformed to international recommendations. Intrahospital and long-term mortality rate was low.

The severity of fall injuries in Saudi Arabia: a cross-sectional study.

INTRODUCTION: fall injuries constitute a major public health concern worldwide, contributing to over 646,000 deaths every year. The aim of this study was to determine the nature and severity of fall injuries at a tertiary hospital in the Kingdom of Saudi Arabia (KSA). METHODS: we conducted a cross-sectional study at the King Khalid Hospital and Prince Sultan Centre for Health Care in Al Kharj. We recruited the patients and followed them through the triage, admission and discharge processes. We analyzed the participant´s clinical notes on the electronic health record (EHR) to obtain information relevant to the study, including the nature, cause, mechanism of injury, demographic characteristics and prognostic factors captured through the injury severity score (ISS), the Glasgow coma scale (GCS) and the presence or absence of shock. RESULTS: of 264 patients, most of the patients were children under the age of ten (25.7%), followed by young adults between the ages of twenty-one and thirty (18.2%). The ISS was associated with severe head, chest, skull, brain, scalp, rib, abdominal, pelvic and lower limb injuries. The GCS was associated with severe the head, chest, skull, brain and rib injuries (p<0.005). The degree of shock was also significantly associated with pelvic, head, chest, skull, brain, scalp, abdominal and upper limb injuries (p<0.05). Conclusion: fall injuries in our setting are severe. Training of staff should prioritize head, chest, skull, brain, abdominal and rib injury management. As a reference hospital, minor injuries are more likely to be managed at lower levels of care.