Deep learning evaluation of echocardiograms to identify occult atrial fibrillation.

Atrial fibrillation (AF) often escapes detection, given its frequent paroxysmal and asymptomatic presentation. Deep learning of transthoracic echocardiograms (TTEs), which have structural information, could help identify occult AF. We created a two-stage deep learning algorithm using a video-based convolutional neural network model that (1) distinguished whether TTEs were in sinus rhythm or AF and then (2) predicted which of the TTEs in sinus rhythm were in patients who had experienced AF within 90 days. Our model, trained on 111,319 TTE videos, distinguished TTEs in AF from those in sinus rhythm with high accuracy in a held-out test cohort (AUC 0.96 (0.95-0.96), AUPRC 0.91 (0.90-0.92)). Among TTEs in sinus rhythm, the model predicted the presence of concurrent paroxysmal AF (AUC 0.74 (0.71-0.77), AUPRC 0.19 (0.16-0.23)). Model discrimination remained similar in an external cohort of 10,203 TTEs (AUC of 0.69 (0.67-0.70), AUPRC 0.34 (0.31-0.36)). Performance held across patients who were women (AUC 0.76 (0.72-0.81)), older than 65 years (0.73 (0.69-0.76)), or had a CHA2DS2VASc ≥2 (0.73 (0.79-0.77)). The model performed better than using clinical risk factors (AUC 0.64 (0.62-0.67)), TTE measurements (0.64 (0.62-0.67)), left atrial size (0.63 (0.62-0.64)), or CHA2DS2VASc (0.61 (0.60-0.62)). An ensemble model in a cohort subset combining the TTE model with an electrocardiogram (ECGs) deep learning model performed better than using the ECG model alone (AUC 0.81 vs. 0.79, p = 0.01). Deep learning using TTEs can predict patients with active or occult AF and could be used for opportunistic AF screening that could lead to earlier treatment.

Electrocardiographic deep learning for predicting post-procedural mortality: a model development and validation study.

BACKGROUND: Preoperative risk assessments used in clinical practice are insufficient in their ability to identify risk for postoperative mortality. Deep-learning analysis of electrocardiography can identify hidden risk markers that can help to prognosticate postoperative mortality. We aimed to develop a prognostic model that accurately predicts postoperative mortality in patients undergoing medical procedures and who had received preoperative electrocardiographic diagnostic testing. METHODS: In a derivation cohort of preoperative patients with available electrocardiograms (ECGs) from Cedars-Sinai Medical Center (Los Angeles, CA, USA) between Jan 1, 2015 and Dec 31, 2019, a deep-learning algorithm was developed to leverage waveform signals to discriminate postoperative mortality. We randomly split patients (8:1:1) into subsets for training, internal validation, and final algorithm test analyses. Model performance was assessed using area under the receiver operating characteristic curve (AUC) values in the hold-out test dataset and in two external hospital cohorts and compared with the established Revised Cardiac Risk Index (RCRI) score. The primary outcome was post-procedural mortality across three health-care systems. FINDINGS: 45 969 patients had a complete ECG waveform image available for at least one 12-lead ECG performed within the 30 days before the procedure date (59 975 inpatient procedures and 112 794 ECGs): 36 839 patients in the training dataset, 4549 in the internal validation dataset, and 4581 in the internal test dataset. In the held-out internal test cohort, the algorithm discriminates mortality with an AUC value of 0·83 (95% CI 0·79-0·87), surpassing the discrimination of the RCRI score with an AUC of 0·67 (0·61-0·72). The algorithm similarly discriminated risk for mortality in two independent US health-care systems, with AUCs of 0·79 (0·75-0·83) and 0·75 (0·74-0·76), respectively. Patients determined to be high risk by the deep-learning model had an unadjusted odds ratio (OR) of 8·83 (5·57-13·20) for postoperative mortality compared with an unadjusted OR of 2·08 (0·77-3·50) for postoperative mortality for RCRI scores of more than 2. The deep-learning algorithm performed similarly for patients undergoing cardiac surgery (AUC 0·85 [0·77-0·92]), non-cardiac surgery (AUC 0·83 [0·79-0·88]), and catheterisation or endoscopy suite procedures (AUC 0·76 [0·72-0·81]). INTERPRETATION: A deep-learning algorithm interpreting preoperative ECGs can improve discrimination of postoperative mortality. The deep-learning algorithm worked equally well for risk stratification of cardiac surgeries, non-cardiac surgeries, and catheterisation laboratory procedures, and was validated in three independent health-care systems. This algorithm can provide additional information to clinicians making the decision to perform medical procedures and stratify the risk of future complications. FUNDING: National Heart, Lung, and Blood Institute.

Recurrent Myocarditis Treated with Intravenous Immune Globulin and Steroids.

BACKGROUND Myocarditis is an inflammatory process that can present as acute or chronic with either focal or diffuse involvement of the myocardium. Its incidence is approximately 1.5 million cases per year worldwide. In the United States, viral infection is the most common cause of myocarditis. Most of the reported cases are singular and self-limiting in nature. We present the case of severe recurrent myocarditis in a young adult who was transferred to the Intensive Care Unit. CASE REPORT An 18-year-old man presented with chest pressure and troponin I 33 ng/mL. He had presented to another hospital with similar symptoms 3 months prior and was diagnosed with myocarditis that had resolved with colchicine. As part of his workup during this admission, coronary angiogram was normal and biopsy obtained without evidence of an inflammatory process; however, cardiac magnetic resonance imaging (MRI) was consistent with myocarditis and Coxsackie B titers indicated prior infection, leading to a diagnosis of clinically suspected recurrent viral myocarditis. He was treated with intravenous immunoglobulin (IV Ig) and a steroid taper, with rapid improvement in symptoms over the ensuing weeks without evidence of further recurrence or sequelae. CONCLUSIONS We present a case of recurrent Coxsackie B myocarditis based on presentation and imaging. Myocarditis is an important diagnosis to consider when a young, healthy individual presents with chest pain mimicking acute coronary syndrome, especially during the COVID pandemic. If there is evidence of myocarditis on MRI or endomyocardial biopsy, immunosuppressive therapy should be considered in patients with recurrent and severe presentations.

Premature coronary disease, in-stent restenosis and vascular complications in a young man with Behçet syndrome.

A young man with a history of early-onset coronary disease presented with an ST-elevation myocardial infarction at the age of 38. He subsequently had recurrent in-stent restenosis requiring repeating interventions and ultimately bypass surgery. After 4 years, he presents with systemic symptoms, new skin lesions and a femoral artery pseudoaneurysm. He is diagnosed with Behçet syndrome, a rare systemic vasculitis characterised by the triad of oral aphthous ulcers, genital ulcers and ocular involvement. Behçet is not associated with premature coronary disease but can have a variety of cardiac complications. Additionally, pathergy, an exaggerated inflammatory response to local injury, is characteristic. We hypothesise that in retrospect, subclinical inflammation and a vascular pathergy likely predisposed him to his cardiac and vascular complications. Here, we review risk factors and presentation of premature coronary artery disease and review the literature on the cardiovascular complications of Behçet syndrome.

Associations Between Cardiac Biomarkers and Cardiac Structure and Function in CKD.

INTRODUCTION: Subclinical changes to cardiac structure and function detected with echocardiography precede the development of clinical heart failure (HF) in persons with chronic kidney disease (CKD). Circulating cardiac biomarkers may reflect these pathophysiological changes. This study investigated associations between established biomarkers (N-terminal pro-B-type natriuretic peptide [NT-proBNP] and high-sensitivity troponin T [hsTnT]) and novel biomarkers (growth differentiation factor 15 [GDF-15], galectin-3 [Gal-3], and soluble ST-2 [sST-2]), using echocardiographic measurements in persons with CKD. METHODS: In cross-sectional analyses among 2101 participants with mild to moderate CKD in the Chronic Renal Insufficiency Cohort (CRIC), biomarker levels measured at baseline were evaluated with echocardiographic measurements 1 year later. These included left ventricular mass index (LVMI), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), and left atrial diameter (LAD). Multivariable linear regression analyses tested associations of each biomarker with echocardiographic measurements, adjusting for covariates. RESULTS: GDF-15 was significantly associated with higher LVMI (1.0 g/m2.7; 95% CI, 0.4-1.7), LVESV (0.4 ml/m2.7; 95% CI, 0.0-0.7), and LVEDV (0.6 ml/m2.7; 95% CI, 0.1-1.1), but not with LVEF or LAD. These findings were not significant when adjusting for NT-proBNP and hsTnT. Gal-3 and sST-2 had no significant associations. Higher levels of NT-proBNP and hsTnT were associated with all echocardiographic measurements. CONCLUSION: In patients with CKD, the novel biomarker GDF-15, a marker of inflammation and tissue injury, and clinical biomarkers NT-proBNP and hsTnT, were associated with echocardiographic measurements of subclinical cardiovascular disease. Collectively, these biomarkers may highlight biological pathways that contribute to the development of clinical HF.

Moral injury in Veterans with nonepileptic seizures.

OBJECTIVE: Over 40% of combat Veterans report exposure to at least one type of morally injurious experience (MIE). While moral injury (MI) is described among Veterans with posttraumatic stress disorder (PTSD), MI has not been studied in Veterans with psychogenic nonepileptic seizures (PNES). We sought to identify MI in a clinical sample of Veterans with PNES and describe differences between those with MI and those without. METHODS: We conducted a retrospective cross-sectional study of 82 male and female Veterans with video-electroencephalography (EEG)-confirmed PNES consecutively seen in a Veterans Administration neuropsychiatry clinic. Identification of MI (witnessed or experienced events that conflict with one's moral compass) was made based by an independent observer using a survey of MIEs. Comorbidities, trauma history, and symptom scales were compared among those with and without MI. RESULTS: Twelve of 82 Veterans with PNES had MI. Those with MI reported higher guilt, depression symptoms and were of younger average age. There were no significant differences for categorical PTSD diagnosis, abuse history, or other demographic variables between those with and without MI. SUMMARY: In this sample of Veterans with PNES, MI was present in 14.6%. Those with MI had more guilt and depressive symptoms than those without. An increased understanding of this condition may aid in the development of diagnostic screenings and therapy options for those with PNES.

Sources of moral injury among war veterans: A qualitative evaluation.

OBJECTIVE: Service members deployed to war are at risk for moral injury, but the potential sources of moral injury are poorly understood. The aim of this qualitative study was to explore the types of events that veterans perceive as morally injurious and to use those events to develop a categorization scheme for combat-related morally injurious events. METHOD: Six focus groups with US war veterans were conducted. RESULTS: Analysis based on Grounded Theory yielded two categories (and eight subcategories) of events that putatively cause moral injury. The two categories were defined by the focal attribution of responsibility for the event: Personal Responsibility (veteran's reported distress is related to his own behavior) versus Responsibility of Others (veteran's distress is related to actions taken by others). Examples of each type of morally injurious event are provided. CONCLUSIONS: Implications for the further development of the moral injury construct and treatment are discussed.

Revision rates and time to revision following endoscopic sinus surgery: A large database analysis.

OBJECTIVES/HYPOTHESIS: Endoscopic sinus surgery (ESS) is performed for patients with chronic rhinosinusitis (CRS) that have failed maximal medical therapy. This study seeks to determine the prevalence of revision surgery and factors predicting the need for revision after ESS using a large statewide surgery database. STUDY DESIGN: Large retrospective cohort study using the State Ambulatory Surgery Database for the state of California between 2005 and 2011. METHODS: We identified over 61,000 patients with CRS who underwent ESS, determined by Current Procedural Terminology code. We identified which patients underwent a repeat surgery, and performed multivariable modeling to determine which factors (nasal polyps, age, gender, insurance, hospital setting, ethnicity) predicted the need for revision. Adjusted odds ratios (AOR) and 95% confidence intervals are presented. RESULTS: Of 61,339 patients who underwent ESS, 4,078 (6.65%) returned for revision ESS during the time period investigated. In a multivariable logistic regression model, positive predictors of revision were a diagnosis of nasal polyps (AOR: 1.20, 95% CI: 1.11-1.29, P < .001) and female gender (AOR: 1.20, 95% CI: 1.11-1.29, P < .001); public insurance was marginally predictive of increased reoperation (AOR: 1.10, 95% CI: 1.00-1.21, P = .048). Patients of Hispanic ethnicity were less likely to have revision surgery (AOR: 0.86, 95% CI: 0.77-0.97, P = .011). Age, income, and hospital setting were not significant predictors. CONCLUSIONS: A minority of patients with CRS who undergo ESS will have a revision surgery. This likelihood is increased in female patients and those with nasal polyps, and decreased in patients of Hispanic ethnicity, even when controlling for income, insurance, and hospital setting. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:31-36, 2018.

Therapeutic intravascular normothermia reduces the burden of metabolic crisis.

BACKGROUND: We aim to investigate whether therapeutic-induced normothermia (TIN) ≤ 37.5 °C, by means of intravascular cooling devices is more efficacious than standard medical therapy (MED) in alleviating metabolic crisis (MC) acutely following traumatic brain injury (TBI). METHODS: We retrospectively analyzed data from 62 patients with severe TBI, GCS ≤ 8. We divided the cohort into two groups. (1) Patients who had temperature controlled via standard medical therapies (n = 52), (2) TIN group (n = 10). For each group, we analyzed the percent time spent in normothermia, and in MC. Furthermore, we focused the investigation on pre-TIN versus post-TIN comparing temp, intracranial pressure (ICP), sedation, and MC before and after intravascular cooling. RESULTS: TIN patients had a better temperature control than MED group (60.72 ± 19.53 vs 69.75 ± 24.98 %, p < 0.001) and spent shorter time in MC (22.60 ± 20.45 vs 32.17 ± 27.25 %, p < 0.001). Temperature control was associated with reduced incidence of MC in TIN (OR 0.51, CI 0.38-0.67, p < 0.001, p < 0.001) but not in MED (OR 0.97, CI 0.87-1.1, p = 0.63). Within TIN group analysis, following TIN both temperature and incidence of MC improved from 37.62 ± 0.34 versus 36.69 ± 0.90 °C (p < 0.005) and 41.95 ± 27.74 % before to 8.35 ± 9.78 % (p = 0.005) after, respectively. ICP was well controlled both before and after intravascular cooling (13.07 vs 15.83 mmHg, p = 0.20). CONCLUSION: Therapeutic normothermia, using intravascular cooling, results in a reduction in the burden of MC. This differential effect occurs despite equivalent control of ICP in both TIN and MED treatments. These results demonstrate proof of concept of normothermia, when applied in a controlled manner, being neuroprotective.

Spiritual distress of military veterans at the end of life.

OBJECTIVE: Although combat experiences can have a profound impact on individuals' spirituality, there is a dearth of research in this area. Our recent study indicates that one unique spiritual need of veterans who are at the end of life is to resolve distress caused by combat-related events that conflict with their personal beliefs. This study sought to gain an understanding of chaplains' perspectives on this type of spiritual need, as well as the spiritual care that chaplains provide to help veterans ease this distress. METHOD: We individually interviewed five chaplains who have provided spiritual care to veterans at the end of life in a Veterans Administration hospital. The interviews were recorded, transcribed, and analyzed based on "grounded theory." RESULTS: Chaplains reported that they frequently encounter veterans at the end of life who are still suffering from thoughts or images of events that occurred during their military career. Although some veterans are hesitant to discuss their experiences, chaplains reported that they have had some success with helping the veterans to open up. Additionally, chaplains reported using both religious (e.g., confessing sins) and nonreligious approaches (e.g., recording military experience) to help veterans to heal. SIGNIFICANCE OF RESULTS: Our pilot study provides some insight into the spiritual distress that many military veterans may be experiencing, as well as methods that a chaplain can employ to help these veterans. Further studies are needed to confirm our findings and to examine the value of integrating the chaplain service into mental health care for veterans.

The differential impact of terrorism on two Israeli communities.

The authors evaluated 2 cohorts of individuals from different Israeli communities (Sderot and Otef Aza) that are repeatedly subjected to potentially lethal missile attacks. Although both communities border the Gaza Strip and face similar levels of threat, the authors hypothesized that the Sderot cohort would endorse higher rates of stress-related symptoms because it has fewer mitigating economic and psychosocial resources. The authors further hypothesized that there would be a significant relationship between exposure to terror and psychopathology regardless of community context. To test these predictions, the authors compared the levels of exposure to terror, posttraumatic stress disorder (PTSD), and depression in representative samples of adults from the 2 communities (n = 298 and n = 152, respectively). Residents of Sderot had a much higher rate of probable PTSD (35.2% vs. 6.6%), and community context was the most important predictor of PTSD and depression. The study also revealed a significant relationship between exposure and psychopathology, but for Sderot residents only. The conclusion is that researchers, mental health workers, and policy makers should pay attention to the influence of community characteristics, such as the availability of resources, the general sense of support, and the level of solidarity, on the mental health response to exposure to terror.

Electroencephalographic inverse localization of brain activity in acute traumatic brain injury as a guide to surgery, monitoring and treatment.

OBJECTIVE: To inverse-localize epileptiform cortical electrical activity recorded from severe traumatic brain injury (TBI) patients using electroencephalography (EEG). METHODS: Three acute TBI cases were imaged using computed tomography (CT) and multimodal magnetic resonance imaging (MRI). Semi-automatic segmentation was performed to partition the complete TBI head into 25 distinct tissue types, including 6 tissue types accounting for pathology. Segmentations were employed to generate a finite element method model of the head, and EEG activity generators were modeled as dipolar currents distributed over the cortical surface. RESULTS: We demonstrate anatomically faithful localization of EEG generators responsible for epileptiform discharges in severe TBI. By accounting for injury-related tissue conductivity changes, our work offers the most realistic implementation currently available for the inverse estimation of cortical activity in TBI. CONCLUSION: Whereas standard localization techniques are available for electrical activity mapping in uninjured brains, they are rarely applied to acute TBI. Modern models of TBI-induced pathology can inform the localization of epileptogenic foci, improve surgical efficacy, contribute to the improvement of critical care monitoring and provide guidance for patient-tailored treatment. With approaches such as this, neurosurgeons and neurologists can study brain activity in acute TBI and obtain insights regarding injury effects upon brain metabolism and clinical outcome.

Development and validation of the coping with terror scale.

Terrorism creates lingering anxiety about future attacks. In prior terror research, the conceptualization and measurement of coping behaviors were constrained by the use of existing coping scales that index reactions to daily hassles and demands. The authors created and validated the Coping with Terror Scale to fill the measurement gap. The authors emphasized content validity, leveraging the knowledge of terror experts and groups of Israelis. A multistep approach involved construct definition and item generation, trimming and refining the measure, exploring the factor structure underlying item responses, and garnering evidence for reliability and validity. The final scale comprised six factors that were generally consistent with the authors' original construct specifications. Scores on items linked to these factors demonstrate good reliability and validity. Future studies using the Coping with Terror Scale with other populations facing terrorist threats are needed to test its ability to predict resilience, functional impairment, and psychological distress.

Trajectories of response to treatment for posttraumatic stress disorder.

Research on the predictors of response to cognitive-behavioral treatments for PTSD has often produced inconsistent or ambiguous results. We argue this is in part due to the use of statistical techniques that explore relationships among the entire sample of participants rather than homogeneous subgroups. Using 2 large randomized controlled trials of Cognitive Processing Therapy (CPT), CPT components, and Prolonged Exposure, we employed growth mixture modeling to identify distinct trajectories of treatment response and to determine the predictors of those trajectories. We determined that the participants' trajectories could be best represented by 2 latent classes, which we subsequently labeled responders (87% of the sample) and nonresponders (13% of the sample). Notably, there was not a separate class for partial responders. Assignment to the nonresponder class was associated with receiving the written accounts (WA) component of CPT, a pretreatment diagnosis of major depression (MDD), and more pretreatment hyperarousal symptoms. Thus, it appears that some individuals do not benefit from merely writing about their trauma and processing it with the therapist; they may also need to engage in cognitive restructuring to successfully ameliorate their symptoms. Additionally, those who meet criteria for MDD or have high levels of hyperarousal at the onset of treatment might require additional treatment or support.

A scheme for categorizing traumatic military events.

A common assumption among clinicians and researchers is that war trauma primarily involves fear-based reactions to life-threatening situations. However, the authors believe that there are multiple types of trauma in the military context, each with unique perievent and postevent response patterns. To test this hypothesis, they reviewed structured clinical interviews of 122 active duty service members and assigned the reported index (principal, most currently distressing) events to one or more of the following categories: Life Threat to Self, Life Threat to Others, Aftermath of Violence, Traumatic Loss, Moral Injury by Self, and Moral Injury by Others. They found high interrater reliability for the coding scheme and support for the construct validity of the categorizations. In addition, they discovered that certain categories were related to psychiatric symptoms (e.g., reexperiencing of the traumatic event, guilt, anger) and negative thoughts about the world. Their study provides tentative support for use of these event categories.

End-of-life spiritual care at a VA medical center: chaplains' perspectives.

OBJECTIVE: Spiritual care is an essential component of quality palliative care. Recognizing the importance, the Department of Veterans Affairs (VA) mandates the inclusion of chaplains in a palliative care consult team (PCCT). The purpose of this study is to explain the process and content of spiritual care provided in a VA Medical Center from chaplains' perspectives. METHOD: Five Christian chaplains who provide care to patients at end of life were interviewed. Each interview was recorded and transcribed. Analysis based on the grounded theory was used to identify themes from each interview question. RESULTS: The PCCT in this study appeared to have a strong referral and communication system in which every palliative care patient was seen by a chaplain and the care plan was discussed with an interdisciplinary team. Chaplains reported providing a range of services, which addressed religious, spiritual, emotional, family, and illness concerns. Chaplains were aware of the unique spiritual needs of veterans, including working through guilt for killing in war and requiring forgiveness. Chaplains' ideas for improvement of spiritual care services included increasing time to provide care, providing bereavement care and support to families, and adding chaplains with different religious backgrounds. Chaplains reported how their own spirituality influenced the care they provided. SIGNIFICANCE OF RESULTS: Spiritual care in the VA can include a range of services and should consider the unique needs of the veteran population. Future studies can build upon our findings from chaplains to learn about the perspectives of patients, family, and other healthcare providers of spiritual care. This information would allow identification of strengths of current spiritual care practices and areas for care improvement, and ultimately could improve the well-being of patients at the end of life.

Pregabalin effects on neural response to emotional faces.

Pregabalin has shown promise in the treatment of anxiety disorders. Previous functional magnetic resonance imaging (fMRI) studies indicate agents used to treat anxiety, e.g., SSRIs and benzodiazepines, attenuate amygdala, insula, and medial prefrontal cortex (mPFC) activation during emotional processing. Our prior study has shown that during anticipation of an emotional stimulus, pregabalin attenuates amygdala and insula activation but increases medial PFC activation. In this study, we examined whether, similar to SSRIs and benzodiazepines, pregabalin attenuates amygdala, insula, and medial PFC during emotional face processing. Sixteen healthy volunteers underwent a double-blind within-subjects fMRI study investigating effects of placebo, 50 mg, and 200 mg pregabalin on neural activation during an emotional face-matching task. Linear mixed model analysis revealed that pregabalin dose-dependently attenuated left amygdala activation during fearful face-matching and left anterior insula activation during angry face-matching. The 50 mg dose exhibited more robust effects than the 200 mg dose in the right anterior insula and ventral ACC. Thus, pregabalin shares some similarity to SSRIs and benzodiazepines in attenuating anger and fear-related insula and amygdala activation during emotional face processing. However, there is evidence that a subclinical 50 mg dose of pregabalin produced more robust and widespread effects on neural responses in this paradigm than the more clinically relevant 200 mg dose. Taken together, pregabalin has a slightly different effect on brain activation as it relates to anticipation and emotional face processing, which may account for its unique characteristic as an agent for the treatment of anxiety disorders.

Early cerebral metabolic crisis after TBI influences outcome despite adequate hemodynamic resuscitation.

BACKGROUND: Optimal resuscitation after traumatic brain injury (TBI) remains uncertain. We hypothesize that cerebral metabolic crisis is frequent despite adequate resuscitation of the TBI patient and that metabolic crisis negatively influences outcome. METHODS: We assessed the effectiveness of a standardized trauma resuscitation protocol in 89 patients with moderate to severe TBI, and determined the frequency of adequate resuscitation. Prospective hourly values of heart rate, blood pressure, pulse oximetry, intracranial pressure (ICP), respiratory rate, jugular venous oximetry, and brain extracellular values of glucose, lactate, pyruvate, glycerol, and glutamate were obtained. The incidence during the initial 72 h after injury of low brain glucose <0.8 mmol/L, elevated lactate/pyruvate ratio (LPR) >25, and metabolic crisis, defined as the simultaneous occurrence of both low glucose and high LPR, were determined for the group. RESULTS: 5 patients were inadequately resuscitated and eight patients had intractable ICP. In patients with successful resuscitation and controlled ICP (n = 76), within 72 h of trauma, 76% had low glucose, 93% had elevated LPR, and 74% were in metabolic crisis. The duration of metabolic crisis was longer in those patients with unfavorable (GOSe ≤ 6) versus favorable (GOSe ≥ 7) outcome at 6 months (P = 0.011). In four multivariate models the burden of metabolic crisis was a powerful independent predictor of poor outcome. CONCLUSIONS: Metabolic crisis occurs frequently after TBI despite adequate resuscitation and controlled ICP, and is a strong independent predictor of poor outcome at 6 months.

Spiritual needs and spiritual care for veterans at end of life and their families.

Spiritual care is an important domain of palliative care programs across the country and in the Veterans Affairs (VA) Healthcare System specifically. This qualitative study assessed the spiritual needs, spiritual care received, and satisfaction with spiritual care of both Veterans at the end of life and their families. Seventeen Veterans and 9 family members participated. They expressed a wide range of spiritual needs, including a wish of Veterans to have a better understanding of traumatic events that occurred during their combat experience. Some Veterans reported military experience enhanced their spirituality. Generally, respondents reported satisfaction with VA spiritual care, but indicated that Veterans may benefit from greater access to VA chaplains and explicit discussion of the impact of their military experience on their spirituality.

Muscle microdialysis to confirm sublethal ischemia in the induction of remote ischemic preconditioning.

Exposure of one tissue to ischemia-reperfusion confers a systemic protective effect, referred to as remote ischemic preconditioning (RIPC). Confirmation that the desired effect of ischemia is occurring in tissues used to induce RIPC requires an objective demonstration before this technique can be used consistently in the clinical practice. Enrolled patients underwent three to four RIPC sessions on non-consecutive days. Sessions consisted of 4 cycles of 5 min of leg cuff inflation to 30 mmHg above the systolic blood pressure followed by reperfusion. Absence of leg pulse was confirmed by Doppler evaluation. To evaluate limb transient ischemia, patients were monitored with muscle microdialysis. Glucose, lactate, lactate/pyruvate ratio, and glycerol levels were measured. Fourteen microdialysis sessions were performed in seven patients undergoing RIPC (42.8 % male; mean age, 51.8; Fisher grade 4 in all seven patients, Hunt and Hess grade 5 in five patients, four in one patient and one in one patient). An average follow-up of 29 days demonstrated no complications associated with the procedure. Muscle microdialysis during RIPC sessions showed a significant increase in lactate/pyruvate ratio (21.2 to 26.8, p = 0.001) and lactate (3.0 to 3.9 mmol/L, p = 0.002), indicating muscle ischemia. There was no significant variation in glycerol (234 to 204 µg/L, p = 0.43), indicating no permanent cell damage. The RIPC protocol used in this study is safe, well tolerated, and induces transient metabolic changes consistent with sublethal ischemia. Muscle microdialysis can be used safely as a confirmatory tool in the induction of RIPC.