Prone Position Ventilation in Severe ARDS due to COVID-19: Comparison between Prolonged and Intermittent Strategies.

Ventilation in a prone position (PP) for 12 to 16 h per day improves survival in ARDS. However, the optimal duration of the intervention is unknown. We performed a prospective observational study to compare the efficacy and safety of a prolonged PP protocol with conventional prone ventilation in COVID-19-associated ARDS. Prone position was undertaken if P/F < 150 with FiO2 > 0.6 and PEEP > 10 cm H2O. Oxygenation parameters and respiratory mechanics were recorded before the first PP cycle, at the end of the PP cycle and 4 h after supination. We included 63 consecutive intubated patients with a mean age of 63.5 years. Of them, 37 (58.7%) underwent prolonged prone position (PPP group) and 26 (41.3%) standard prone position (SPP group). The median cycle duration for the SPP group was 20 h and for the PPP group 46 h (p < 0.001). No significant differences in oxygenation, respiratory mechanics, number of PP cycles and rate of complications were observed between groups. The 28-day survival was 78.4% in the PPP group versus 65.4% in the SPP group (p = 0.253). Extending the duration of PP was as safe and efficacious as conventional PP, but did not confer any survival benefit in a cohort of patients with severe ARDS due to COVID-19.

Using Machine Learning Techniques to Predict Hospital Admission at the Emergency Department.

Introduction: One of the most important tasks in the Emergency Department (ED) is to promptly identify the patients who will benefit from hospital admission. Machine Learning (ML) techniques show promise as diagnostic aids in healthcare. Aim of the study: Our objective was to find an algorithm using ML techniques to assist clinical decision-making in the emergency setting. Material and methods: We assessed the following features seeking to investigate their performance in predicting hospital admission: serum levels of Urea, Creatinine, Lactate Dehydrogenase, Creatine Kinase, C-Reactive Protein, Complete Blood Count with differential, Activated Partial Thromboplastin Time, DDi-mer, International Normalized Ratio, age, gender, triage disposition to ED unit and ambulance utilization. A total of 3,204 ED visits were analyzed. Results: The proposed algorithms generated models which demonstrated acceptable performance in predicting hospital admission of ED patients. The range of F-measure and ROC Area values of all eight evaluated algorithms were [0.679-0.708] and [0.734-0.774], respectively. The main advantages of this tool include easy access, availability, yes/no result, and low cost. The clinical implications of our approach might facilitate a shift from traditional clinical decision-making to a more sophisticated model. Conclusions: Developing robust prognostic models with the utilization of common biomarkers is a project that might shape the future of emergency medicine. Our findings warrant confirmation with implementation in pragmatic ED trials.

Physiologic effects of stress dose corticosteroids in in-hospital cardiac arrest (CORTICA): A randomized clinical trial.

Aim: Postresuscitation hemodynamics are associated with hospital mortality/functional outcome. We sought to determine whether low-dose steroids started during and continued after cardiopulmonary resuscitation (CPR) affect postresuscitation hemodynamics and other physiological variables in vasopressor-requiring, in-hospital cardiac arrest. Methods: We conducted a two-center, randomized, double-blind trial of patients with adrenaline (epinephrine)-requiring cardiac arrest. Patients were randomized to receive either methylprednisolone 40 mg (steroids group) or normal saline-placebo (control group) during the first CPR cycle post-enrollment. Postresuscitation shock was treated with hydrocortisone 240 mg daily for 7 days maximum and gradual taper (steroids group), or saline-placebo (control group). Primary outcomes were arterial pressure and central-venous oxygen saturation (ScvO2) within 72 hours post-ROSC. Results: Eighty nine of 98 controls and 80 of 86 steroids group patients with ROSC were treated as randomized. Primary outcome data were collected from 100 patients with ROSC (control, n = 54; steroids, n = 46). In intention-to-treat mixed-model analyses, there was no significant effect of group on arterial pressure, marginal mean (95% confidence interval) for mean arterial pressure, steroids vs. control: 74 (68-80) vs. 72 (66-79) mmHg] and ScvO2 [71 (68-75)% vs. 69 (65-73)%], cardiac index [2.8 (2.5-3.1) vs. 2.9 (2.5-3.2) L/min/m2], and serum cytokine concentrations [e.g. interleukin-6, 89.1 (42.8-133.9) vs. 75.7 (52.1-152.3) pg/mL] determined within 72 hours post-ROSC (P = 0.12-0.86). There was no between-group difference in body temperature, echocardiographic variables, prefrontal blood flow index/cerebral autoregulation, organ failure-free days, and hazard for poor in-hospital/functional outcome, and adverse events (P = 0.08->0.99). Conclusions: Our results do not support the use of low-dose corticosteroids in in-hospital cardiac arrest.Trial Registration:ClinicalTrials.gov number: NCT02790788 ( https://www.clinicaltrials.gov ).

Micronutrient dietary intakes and their food sources in adults: the Hellenic National Nutrition and Health Survey (HNNHS).

BACKGROUND: The present study aimed to assess micronutrient intake among Greek adults and to identify the main food sources that contribute to it. METHODS: Food consumption data from 2389 participants in the Hellenic National Nutrition and Health Survey (HNNHS), collected with 24-h recalls, was used to calculate micronutrient intakes. Usual nutrient intake was estimated according to the National Cancer Institute method. Nutrient adequacy was estimated using the estimated average requirement (EAR) cut-point method, when available, or adequate intake otherwise. The probability approach was used to determine iron intake adequacy in females of reproductive age. Food group contribution for each nutrient assessed was derived to identify their main food sources. RESULTS: Almost all individuals had vitamin D intake below EAR, whereas vitamins A, E, K and C, as well as potassium intake, were also insufficient in a considerable percentage of the population (>70% in most age groups). Calcium intake was substantially below the EAR for females aged >50 years and males >70 years; the same for magnesium in males >70 years. Furthermore, 50% of females, including those of reproductive age, had intake of folate below EAR. More than 50% of the population (to 79%) exceeded the upper tolerable limit for sodium (2300 mg day-1 ). Food contribution analysis revealed that most vitamins were derived from low-quality foods (i.e. fast-food). CONCLUSIONS: A significant proportion of adults residing in Greece have low nutrient intake and poor food selections. These results provide guidance to public health policy makers for developing strategies to improve the dietary quality in Greece.

Usefulness of F2-isoprostanes in early prognostication after cardiac arrest: a topical review of the literature and meta-analysis of preclinical data.

Prognostication after cardiac arrest (CA) represents a challenging issue, and several biomarkers have been proposed in the attempt to predict outcome. Among these, F2-isoprostanes stand out as potential biomarkers for early prognostication, providing information on the magnitude of global oxidative injury after return of spontaneous circulation (ROSC). We performed a topical review searching PubMed and Scopus databases to identify studies evaluating the modifications of F2-isoprostanes in the early period after CA, and a meta-analysis of studies providing curves of F2-isoprostanes plasma levels seeking to describe the biomarker's kinetics after CA. Evidence suggests that plasma levels of F2-isoprostanes increase in the early post-resuscitation period and seem well correlated with the burden of ischaemia-reperfusion injury. Our meta-analysis shows a possible increase as early as 5 minutes after ROSC, which persists at 2 hours and is attenuated at 4 hours. Clinical studies are warranted to evaluate the utility of this biomarker for prognostication purposes in CA survivors.

Publisher Correction: Exposure to Stress-Dose Steroids and Lethal Septic Shock After In-Hospital Cardiac Arrest: Individual Patient Data Reanalysis of Two Prior Randomized Clinical Trials that Evaluated the Vasopressin-Steroids-Epinephrine Combination Versus Epinephrine Alone.

The original version of this article unfortunately contained a mistake. In Table 2, the frequency of Septic Shock reported just below the frequency of "At least 1 Episode of VAP" actually corresponds to the First (and not the Second) Episode of VAP during the postresuscitation period.

Exposure to Stress-Dose Steroids and Lethal Septic Shock After In-Hospital Cardiac Arrest: Individual Patient Data Reanalysis of Two Prior Randomized Clinical Trials that Evaluated the Vasopressin-Steroids-Epinephrine Combination Versus Epinephrine Alone.

PURPOSE: Low-dose steroids may reduce the mortality of severely ill patients with septic shock. We sought to determine whether exposure to stress-dose steroids during and/or after cardiopulmonary resuscitation is associated with reduced risk of death due to postresuscitation septic shock. METHODS: We analyzed pooled, individual patient data from two prior, randomized clinical trials (RCTs). RCTs evaluated vasopressin, steroids, and epinephrine (VSE) during resuscitation and stress-dose steroids after resuscitation in vasopressor-requiring, in-hospital cardiac arrest. In the second RCT, 15 control group patients received open-label, stress-dose steroids. Patients with postresuscitation shock were assigned to a Steroids (n = 118) or No Steroids (n = 73) group according to an "as-treated" principle. We used cumulative incidence competing risks Cox regression to determine cause-specific hazard ratios (CSHRs) for pre-specified predictors of lethal septic shock (primary outcome). In sensitivity analyses, data were analyzed according to the intention-to-treat (ITT) principle (VSE group, n = 103; control group, n = 88). RESULTS: Lethal septic shock was less likely in Steroids versus No Steroids group, CSHR, 0.40, 95% confidence interval (CI), 0.20-0.82; p = 0.012. ITT analysis yielded similar results: VSE versus Control, CSHR, 0.44, 95% CI, 0.23-0.87; p = 0.019. Adjustment for significant, between-group baseline differences in composite cardiac arrest causes such as "hypotension and/or myocardial ischemia" did not appreciably affect the aforementioned CSHRs. CONCLUSIONS: In this reanalysis, exposure to stress-dose steroids (primarily in the context of a combined VSE intervention) was associated with lower risk of postresuscitation lethal septic shock.

Drugs in cardiac arrest: the rise and fall of antiarrhythmics.

Since the publication of 2000 guidelines for resuscitation, amiodarone is considered the antiarrhythmic drug of choice for refractory ventricular fibrillation/pulseless ventricular tachycardia. However, to date there is no proven benefit in terms of neurologically intact survival to hospital discharge. A comprehensive search of the recent literature on amiodarone, nifekalant and lidocaine in cardiac arrest was performed. Amiodarone and nifekalant are superior to lidocaine with regards to the return of spontaneous circulation and survival to hospital admission. Nifekalant shows a trend towards quicker termination of ventricular fibrillation compared to amiodarone. There is great uncertainty about the efficacy of antiarrhythmics in cardiac arrest. Failure to show improvements regarding meaningful survival questions their current use and suggests the need for re-evaluating their place in cardiopulmonary resuscitation.

Induction of anaesthesia with remifentanil after bolus midazolam administration in Landrace/Large White swine.

OBJECTIVE: To investigate an alternative combination for anaesthesia induction in swine. STUDY DESIGN: Randomized, 'blinded' experimental study. ANIMALS: Forty-five Landrace/Large White swine weighing 20.0±1.5 kg. METHODS: Pulse oximetry, heart rate (HR) and blood pressure were measured after premedication with ketamine, midazolam and atropine as well as after intubation following induction with a fixed dose of 0.2 mg kg-1 midazolam combined with 1, 2, 3, 4 or 5 µg kg-1 remifentanil (groups R1, R2, R3, R4 and R5, respectively). Intubation was evaluated using a numerical scoring system assessing jaw relaxation, resistance to the laryngoscope, vocal cord position, vocal cord movement and response to intubation. The time required to intubate and necessity for an additional midazolam dose were recorded. Baseline and post-intubation variables were compared with paired t tests, whereas for differences between the remifentanil groups the Spearman's rank correlation coefficient was estimated. Multivariate regression analysis was performed to disentangle the effect of remifentanil dose and the additional midazolam. RESULTS: Higher dose of remifentanil was associated with better vocal cord position (p<0.001), better response to intubation (p<0.001), shorter time required for intubation (p=0.030) and less frequent necessity for additional administration of midazolam (p=0.004). In total, 39.5% of the animals required additional midazolam. In groups R1, R4 and R5, there were decreases in HRs (p=0.009, p=0.008 and p=0.032, respectively) between baseline and post-intubation phase; in groups R3 and R4, there were decreases in systolic blood pressure (p=0.040 and p=0.019, respectively). In the multivariate analysis, remifentanil dose was not associated with the observed changes in haemodynamic variables. One animal developed apnoea and four electrocardiographic anomalies; all resolved without pharmaceutical interventions. CONCLUSIONS AND CLINICAL RELEVANCE: A combination of 0.2 mg kg-1 midazolam with 4 or 5 µg kg-1 remifentanil may provide an alternative method of anaesthesia induction for swine.

Body mass index and outcome of out-of-hospital cardiac arrest patients not treated by targeted temperature management.

BACKGROUND: Obesity has been demonstrated to increase the risk of out-of-hospital cardiac arrest (OHCA) and may influence the quality and effectiveness of cardiopulmonary resuscitation. Our aim was to investigate the association between body mass index (BMI) and the outcome of OHCA victims not treated by targeted temperature management. METHODS: This was a prospective observational study of OHCA patients. The patients were categorized according to BMI into two groups: the normal BMI group (nBMI) and the elevated BMI group (eBMI). The primary endpoint was return of spontaneous circulation (ROSC), while secondary outcomes were survival to intensive care unit (ICU) admission and survival to ICU discharge. RESULTS: Of the initial 99 patients who were transported to the Emergency Department, 84 (85%) were included in the study. Mean BMI was 29.8kg/m2. Thirteen (15.5%) patients achieved ROSC and were admitted to the ICU, with the mean duration of ICU length of stay being 6.7±4.9days. Survival to ICU admission and ICU discharge were higher in the eBMI group (17.6% vs. 6.25%, p=0.010 and 10.3% vs. 6.25%, p=0.021, respectively). Survival to ICU discharge was higher in ventricular fibrillation patients compared to patients with non-shockable rhythms, irrespectively of their BMI (p=0.002). All patients that survived to ICU discharge did so with a cerebral performance category score of 2. CONCLUSIONS: Survival to ICU admission and ICU discharge were higher in the eBMI group.

Correlation of Impedance Threshold Device use during cardiopulmonary resuscitation with post-cardiac arrest Acute Kidney Injury.

PURPOSE: To assess whether use of Impedance Threshold Device (ITD) during cardiopulmonary resuscitation (CPR) reduces the degree of post-cardiac arrest Acute Kidney Injury (AKI), as a result of improved hemodynamics, in a porcine model of ventricular fibrillation (VF) cardiac arrest. METHODS: After 8 min of untreated cardiac arrest, the animals were resuscitated either with active compression-decompression (ACD) CPR plus a sham ITD (control group, n=8) or with ACD-CPR plus an active ITD (ITD group, n=8). Adrenaline was administered every 4 min and electrical defibrillation was attempted every 2 min until return of spontaneous circulation (ROSC) or asystole. After ROSC the animals were monitored for 6 h under general anesthesia and then returned to their cages for a 48 h observation, before euthanasia. Two novel biomarkers, Neutrophil Gelatinase-Associated Lipocalin (NGAL) in plasma and Interleukin-18 (IL-18) in urine, were measured at 2 h, 4 h, 6 h, 24 h and 48 h post-ROSC, in order to assess the degree of AKI. RESULTS: ROSC was observed in 7 (87.5%) animals treated with the sham valve and 8 (100%) animals treated with the active valve (P=NS). However, more than twice as many animals survived at 48 h in the ITD group (n=8, 100%) compared to the control group (n=3, 37.5%). Urine IL-18 and plasma NGAL levels were augmented post-ROSC in both groups, but they were significantly higher in the control group compared with the ITD group, at all measured time points. CONCLUSION: Use of ITD during ACD-CPR improved hemodynamic parameters, increased 48 h survival and decreased the degree of post-cardiac arrest AKI in the resuscitated animals.

Amiodarone and cardiac arrest: Systematic review and meta-analysis.

INTRODUCTION: The 2015 Guidelines for Resuscitation recommend amiodarone as the antiarrhythmic drug of choice in the treatment of resistant ventricular fibrillation or pulseless ventricular tachycardia. We reviewed the effects of amiodarone on survival and neurological outcome after cardiac arrest. METHODS: We systematically searched MEDLINE and Cochrane Library from 1940 to March 2016 without language restrictions. Randomized control trials (RCTs) and observational studies were selected. RESULTS: Our search initially identified 1663 studies, 1458 from MEDLINE and 205 from Cochrane Library. Of them, 4 randomized controlled studies and 6 observational studies met the inclusion criteria and were selected for further review. Three randomized studies were included in the meta-analysis. Amiodarone significantly improves survival to hospital admission (OR=1.402, 95% CI: 1.068-1.840, Z=2.43, P=0.015), but neither survival to hospital discharge (RR=0.850, 95% CI: 0.631-1.144, Z=1.07, P=0.284) nor neurological outcome compared to placebo or nifekalant (OR=1.114, 95% CI: 0.923-1.345, Z=1.12, P=0.475). CONCLUSIONS: Amiodarone significantly improves survival to hospital admission. However there is no benefit of amiodarone in survival to discharge or neurological outcomes compared to placebo or other antiarrhythmics.

Theoretical knowledge and skill retention 4 months after a European Paediatric Life Support course.

OBJECTIVE: The European Paediatric Life Support (EPLS) provider course aims at training doctors and nurses in the efficient and prompt management of cardiopulmonary arrest in children. EPLS is a 2-day European Resuscitation Council course, involving the teaching of theoretical knowledge and practical skills. The aim of the study was to evaluate the retention of theoretical knowledge and certain skills of EPLS providers 4 months after the course. MATERIALS AND METHODS: In total, 80 doctors and nurses who attended three EPLS provider courses, from May 2012 to December 2012, were asked to participate in the study and only 50 responded positively. Demographic data (age, sex, occupation) of the participants were collected. The European Resuscitation Council-approved EPLS written test was used to assess theoretical knowledge right after the course and after 4 months. The retention of certain skills (airway opening, bag-mask ventilation, chest compressions) was also examined. RESULTS: The theoretical knowledge decreased significantly (P<0.001) 4 months after the course. Age, sex and occupational status (medical or nursing profession) had no effect in theoretical knowledge retention. Interestingly, certain skills such as the application of airway opening manoeuvres and effective bag-mask ventilation were retained 4 months after the course, whereas chest compression skill retention significantly declined (P=0.012). CONCLUSION: According to our findings, theoretical knowledge of the EPLS course uniformly declines, irrespective of the provider characteristics, whereas retention of certain skills is evident 4 months after the course.

Nifekalant Versus Amiodarone in the Treatment of Cardiac Arrest: an Experimental Study in a Swine Model of Prolonged Ventricular Fibrillation.

PURPOSE: The purpose of the experiment was to compare the effects of nifekalant and amiodarone on the return of spontaneous circulation (ROSC), survival, as well as on the hemodynamic parameters in a swine model of prolonged ventricular fibrillation (VF). METHODS: After 8 min of untreated VF, bolus doses of epinephrine (adrenaline) and either nifekalant, or amiodarone, or saline (n = 10 per group), were administered after randomization. Cardiopulmonary resuscitation (CPR) was commenced immediately after drug administration and defibrillation was attempted 2 min later. CPR was resumed for another 2 min after each defibrillation attempt and the same dose of adrenaline was given every 4th minute during CPR. RESULTS: Forty-eight hour survival was significantly higher with nifekalant compared to amiodarone (p < 0.001) and saline (p = 0.02), (9/10 vs. 0/10 vs. 3/10, respectively). Systolic aortic pressure, diastolic aortic pressure and coronary perfusion pressure were significantly higher with nifekalant during CPR and immediate post-resuscitation period (p < 0.05). The animals in the amiodarone group had a slower heart rate at the 1st and 45th min post-ROSC (p < 0.001 and p = 0.006, respectively). The number of electric shocks required for terminating VF, time to ROSC and adrenaline dose were significantly higher with amiodarone compared to nifekalant (p < 0.001). CONCLUSIONS: Nifekalant showed a more favorable hemodynamic profile and improved survival compared to amiodarone and saline in this swine model.

Comparative analysis of two venipuncture learning methods on nursing students.

INTRODUCTION: Venus cannulation is one of the main nursing actions. For the safety of patients and nurses, this skill is important to be performed in a proper and responsible way. Thus, the need for adequate education on this skill is essential. STUDY OBJECTIVE: Comparison between the 4-stage (demonstration, deconstruction, comprehension, performance) learning method and the simplified 2-stage method (deconstruction, performance) on venous cannulation. METHODS: The study took place from November 2011 to March 2012. In total, 117 students of the Nursing Department of Technological Educational Institute of Athens were randomized into two education groups of the 2- (Group A) and 4- (Group B) stage method respectively. Students of both groups were assessed during training and 45days later for skill retention. For the assessment of all students, a check list with the steps required to venous cannulation was used. The time to complete the process was also assessed. RESULTS: Group A included 54 students and Group B 50 students. During initial training, the average time to complete the process without any errors was lower for Group A compared to Group B (1.77±0.12min vs. 2.33±0.13min, p=0.006). Regarding the appropriate steps for venous cannulation, Group A made fewer errors compared to Group B (0.95±0.95 vs. 1.38±1.10, p=0.021). In addition, Group A omitted more steps than Group B (0.29±0.06 vs. 0.11±0.05, p=0.042). During skill retention assessment, no significant difference was observed in the number of incorrect steps or in the number of omitted steps between groups. CONCLUSION: According to our findings, the 4-stage method, is associated with less omitted steps, while the 2-stage method, is associated with less time required to complete the procedure and less errors during performance, at initial stages. However, skill retention does not seem to be associated with the type of the educational methodology.

Pneumonia presenting with lower right abdominal pain and migratory polyarthritis.

The clinical presentation of community acquired pneumonia (CAP) in adults includes mainly symptoms from the respiratory system, whereas CAP is considered as a main cause of abdominal pain in pediatric patients. We present the case of a patient, who was admitted to our hospital due to abdominal pain that deteriorated progressively and radiated to the lumbar region. The clinical examination revealed decreased breath sounds at the right lung base after 72 h, while the chest X-ray showed pneumonia of the right lung base. The blood culture isolated Streptococcus pneumoniae, and the patient received penicillin according to the results of the antibiogram. In addition, the patient developed symptoms of migratory arthritis, which resolved after 48 h. CAP should be included in the differential diagnosis of abdominal pain in adult patients. Furthermore, the hematogenous spread of S. pneumoniae may be associated with the development of migratory arthritis.

Enhanced external counterpulsation: mechanisms of action and clinical applications.

Symptomatic coronary artery disease (CAD) and heart failure (HF), either of ischaemic or nonischaemic aetiology, are common medical problems. Despite optimal medical treatment and improved revascularisation techniques, a significant number of patients are not successfully managed.Among the non-pharmacological, alternative, non-invasive treatments suggested for these patients, enhanced external counterpulsation (EECP) is considered the most effective one. EECP, administered in an outpatient setting, consists of three pneumatic cuffs applied to each of the patient's legs that are sequentially inflated and deflated synchronised with the cardiac cycle. Numerous clinical trials have shown that EECP is safe and effective in patients with ischaemic heart disease, with or without left ventricular dysfunction, improving their quality of life. EECP appears to be beneficial as an adjunctive therapy in patients with HF of any aetiology. Cardiac syndrome X has been shown to be effectively treated with EECP. Research in EECP expanded in its potential use for entities other than heart disease. More trials are necessary, including sham-controlled trials, to further establish EECP among medical society.