Aspects of intensive care after cardiac arrest

Background: Cardiovascular disease, and in particular cardiac arrest with the subsequent associated brain injury, is the most common cause of death in many countries. Annually, around 6000 people suffer from Out-of-Hospital Cardiac Arrest (OHCA) in Sweden and only around 10% survive to hospital discharge. Apart from early cardiopulmonary resuscitation (CPR) and defibrillation, it has been difficult to find interventions that can increase survival in OHCA, in particular in the post-resuscitation phase. Methods and results: Study I. A national observational retrospective study, evaluating the adherence to Targeted Temperature Management (TTM) guidelines in Sweden after the publication of the TTM trial, and if the change in targeted temperature level (from 33 oC to 36 oC) influences 6-month survival. In total, 2899 OHCA patients were included, and of those, 1038 were treated by means of TTM. The proportion of patients with initial shockable rhythm receiving any TTM, i.e., following international guidelines, decreased after publication of the TTM trial (from 70.5% to 54.5%). There was no difference in 6-month survival between the TTM33 (47.2%) and the TTM36 (47.3%) groups (adjusted odds OR 1.12, 95% CI 0.80–1.56). Study II. A sub-analysis of the PRINCESS trial, in which 677 OHCA patients were randomized to trans-nasal intra-arrest cooling initiated by the emergency medical services (EMS) or cooling started after hospital arrival. In this sub-analysis, the association between early initiation of intra-arrest cooling and neurological outcome was evaluated. Early cooling (intervention group, n=150) was defined as cooling initiated ≤ 20 minutes from collapse, and these patients were propensity score-matched with comparable controls (n=150). The primary outcome was survival with good neurological outcome (defined as Cerebral Performance Category [CPC] 1–2) at 90 days. The proportion of cases with CPC 1–2 at 90 days was 23.3% in the intervention group vs. 16% in the control group (OR 1.92, 95% CI 0.95–3.85). In patients with shockable rhythm the corresponding figures were 50.9% (intervention) vs. 29.8% (control) (OR 3.25, 95% CI 1.06–9.97). Study III. A nationwide observational retrospective study, evaluating the association between different levels of hyperoxemia at Intensive Care Unit (ICU) arrival after cardiac arrest, and 30-day survival. Partial oxygen pressure (PaO2) was recorded in a standardized way at ICU admission (± one hour). Hyperoxemia was defined as mild (13.4–20 kPa), moderate (20.1–30 kPa), severe (30.1–40 kPa) or extreme (>40 kPa). Normoxaemia was defined as PaO2 8–13.3 kPa and hypoxemia as PaO2 <8 kPa. In total, 9735 patients were included. Of these, 44.6% were hyperoxemic, 44.8% were normoxaemic and 10.5% were hypoxemic. Compared with the normoxemia group, the adjusted risk ratios (RRs) for 30-day survival in the hyperoxemia groups were: mild 0.91 (95% CI 0.85–0.91), moderate 0.88 (95% CI 0.82–0.95), severe 0.79 (95% CI 0.7– 0.89), and extreme 0.68 (95% CI 0.58–0.79). Study IV. A post-hoc analysis of the TTM2 trial, in which 1900 resuscitated OHCA patients were randomized to either hypothermia (TTM of 33 oC) or normothermia (<37.8 oC) groups for 28 hours. This sub-analysis was carried out to evaluate if there is any association between the cooling method used, i.e., intravascular (IC) vs. surface cooling (SFC), in the TTM 33oC group, and neurological outcome. The primary outcome was survival with good neurological outcome (defined as modified Rankin scale [mRS] result of 0–3) at six months. In total, 876 patients were included in this study, in which 30% were treated by means of IC and 70% by SFC. At six months, after propensity score matching, 53.0% of the patients in the IC group and 42.3% of the patients in the SFC group were alive, with mRS scores of 0–3 (OR 1.5, 95% CI 1.05–2.15). The IC group demonstrated better cooling speed and precision compared with the SFC group. Conclusions: After publication of the TTM trial, fewer OHCA patients in Sweden received any TTM and this change of practice did not affect six-month survival among patients who underwent TTM. In the PRINCESS trial, intra-arrest cooling started within 20 minutes of arrest, compared with cooling started after hospital admission, was not associated with a significantly better neurological outcome. In the subgroup with shockable rhythms, early cooling was associated with better neurological outcome. Among resuscitated OHCA patients, hyperoxaemia at ICU admission, compared with normoxemia, was associated with lower 30-day survival. The association was stronger in connection with higher PaO2 levels. In OHCA patients in the TTM2 trial treated by means of TTM 33 oC, intravascular cooling, compared with surface cooling, was associated with better cooling performance and better neurological outcomes after six months

Time to intra-arrest therapeutic hypothermia in out-of-hospital cardiac arrest patients and its association with neurologic outcome: a propensity matched sub-analysis of the PRINCESS trial

© 2020, The Author(s). Purpose: To study the association between early initiation of intra-arrest therapeutic hypothermia and neurologic outcome in out-of-hospital cardiac arrest. Methods: A prespecified sub-analysis of the PRINCESS trial (NCT01400373) that randomized 677 bystander-witnessed cardiac arrests to transnasal evaporative intra-arrest cooling initiated by emergency medical services or cooling started after hospital arrival. Early cooling (intervention) was defined as intra-arrest cooling initiated \u3c 20 min from collapse (i.e., ≤ median time to cooling in PRINCESS). Propensity score matching established comparable control patients. Primary outcome was favorable neurologic outcome, Cerebral Performance Category (CPC) 1–2 at 90 days. Complete recovery (CPC 1) was among secondary outcomes. Results: In total, 300 patients were analyzed and the proportion with CPC 1–2 at 90 days was 35/150 (23.3%) in the intervention group versus 24/150 (16%) in the control group, odds ratio (OR) 1.92, 95% confidence interval (CI) 0.95–3.85, p =.07. In patients with shockable rhythm, CPC 1–2 was 29/57 (50.9%) versus 17/57 (29.8%), OR 3.25, 95%, CI 1.06–9.97, p =.04. The proportion with CPC 1 at 90 days was 31/150 (20.7%) in the intervention group and 17/150 (11.3%) in controls, OR 2.27, 95% CI 1.12–4.62, p =.02. In patients with shockable rhythms, the proportion with CPC 1 was 27/57 (47.4%) versus 12/57 (21.1%), OR 5.33, 95% CI 1.55–18.3, p =.008. Conclusions: In the whole study population, intra-arrest cooling initiated \u3c 20 min from collapse compared to cooling initiated at hospital was not associated with improved favorable neurologic outcome. In the subgroup with shockable rhythms, early cooling was associated with improved favorable outcome and complete recovery

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Thermal and dynamic performance of kenaf/washingtonia fibre-based hybrid composites

The application of hybrid natural fibres incorporated with bio phenolic composites is significant due to their sustainability and low-cost rates. In this paper, two natural fibres composites were prepared using a hand lay-up technique. The thermal stability, dynamic-mechanical, and thermo-mechanical characterisations of kenaf fibre (KF)/Washingtonia Leaf Stalk Fibres (AW)/epoxy biocomposite were investigated in this paper. Thermomechanical analysis (TMA) and dynamic mechanical analysis (DMA), respectively, were used to examine the thermal stability and the coefficient of thermal expansion (CTE) and the dynamic mechanical properties of composites, respectively. The Thermogravimetric (TG) analyses showed that the addition of KF and AW enhanced the thermal stability of the epoxy composites. 7AW/3KENAF showed the most significant improvement in thermal stability (Tonset; 284.52 °C and Tmax; 368.25. Furthermore, the hybrid biocomposite exhibited the highest storage modulus (2668.9 MPa) among all other pure and hybrid biocomposites. On the other hand, the TMA findings illustrated that the 50% AW sample exhibited the highest value of CTE (242 μm/m °C) at the maximum temperature (175 °C) among all samples. Briefly, it is obvious that the combination of WA with KENAF enhanced the potential in improving thermal, dimensional and dynamic mechanical characterisations of epoxy composites and can be utilised in building applications that dictate elevated dimensional stability. It was proven that the hybrid biocomposites prepared in this work supported by hybrid natural fibres as strengthened bio fillers might benefit the performance of epoxy composites, which could broaden the application range of industrial and engineering applications and provide novel ways for its effective uses

Effect of Resilience on Health-Related Quality of Life during the COVID-19 Pandemic: A Cross-Sectional Study

The unprecedented outbreak of coronavirus disease 2019 (COVID-19) has caused a huge global health and economic crisis. The aim of the study was to examine the extent to which the resilience of a person is associated with the quality of life (QoL) of adults amongst Saudi Arabia. A cross-sectional study was conducted among a sample of adults in Saudi Arabia. A total of 385 adults voluntarily participated in and completed the survey. The quality of life was measured using the “World Health Organization QoL”. The “Connor-Davidson Resilience Scale” instrument was also used to assess resilience during the COVID-19 pandemic. Amongst the 385 participants, 179 (46%) showed a good QoL, and 205 (54%) reported a relatively poor QoL. The resilience was found to be significantly associated with QoL. The study further revealed that gender-based differences were dominant in the QoL; the men respondents reported a significantly higher QoL in all the domains in comparison to the women respondents. The gender, income, and psychological health and interaction effect of resilience and age explained 40% of the variance in the total score of QoL. In reference to the predictors of the physical health domain of QoL, resilience, gender, and psychological health were significantly associated with the physical health domain of the QoL (R2 = 0.26, p = 0.001). It was also noted that gender was not associated with the social relationships and environmental domains of QoL (p &gt; 0.05). Findings showed a statistically significant association between the score of QoL and resilience, age, gender, income, and psychological health. These findings highlight the significant contribution of gender-based differences, psychological health, and resilience on the domains of QoL

Time to intra-arrest therapeutic hypothermia in out-of-hospital cardiac arrest patients and its association with neurologic outcome: a propensity matched sub-analysis of the PRINCESS trial

Purpose: To study the association between early initiation of intra-arrest therapeutic hypothermia and neurologic outcome in out-of-hospital cardiac arrest. Methods: A prespecified sub-analysis of the PRINCESS trial (NCT01400373) that randomized 677 bystander-witnessed cardiac arrests to transnasal evaporative intra-arrest cooling initiated by emergency medical services or cooling started after hospital arrival. Early cooling (intervention) was defined as intra-arrest cooling initiated < 20 min from collapse (i.e. ≤ median time to cooling in PRINCESS). Propensity score matching established comparable control patients. Primary outcome was favorable neurologic outcome, Cerebral Performance Category (CPC) 1–2 at 90 days. Complete recovery (CPC 1) was among secondary outcomes. Results: In total, 300 patients were analyzed and the proportion with CPC 1–2 at 90 days was 35/150 (23.3%) in the intervention group versus 24/150 (16%) in the control group, odds ratio (OR) 1.92, 95% confidence interval (CI) 0.95–3.85, p =.07. In patients with shockable rhythm, CPC 1–2 was 29/57 (50.9%) versus 17/57 (29.8%), OR 3.25, 95%, CI 1.06–9.97, p =.04. The proportion with CPC 1 at 90 days was 31/150 (20.7%) in the intervention group and 17/150 (11.3%) in controls, OR 2.27, 95% CI 1.12–4.62, p =.02. In patients with shockable rhythms, the proportion with CPC 1 was 27/57 (47.4%) versus 12/57 (21.1%), OR 5.33, 95% CI 1.55–18.3, p =.008. Conclusions: In the whole study population, intra-arrest cooling initiated < 20 min from collapse compared to cooling initiated at hospital was not associated with improved favorable neurologic outcome. In the subgroup with shockable rhythms, early cooling was associated with improved favorable outcome and complete recovery.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Successful management of late stage of acute compartment syndrome after 72 h snake bite in 8-year-old female. A case report

One of the most serious complications of snakebite is compartment syndrome (CS), Signs of CS include paresthesia in the distal part and pain that is out of proportion to the severity of the injury, Management involves improving the general condition, and fasciotomy has been found to be effective. An 8-year-old girl was referred to the internal emergency department in our hospital 72 h after a snake bite. She was unconscious, in poor general condition, and had a high fever. Edema was present throughout the right lower limb, extending to the abdomen, with signs of cellular necrosis (blackening with bubbles) on the right foot. The diagnosis of CS was made, and the patient underwent fasciotomy after improving the general condition. Although snake bites are rare, surgeons should be concerned about life-threatening and limb-threatening complications. CS can be effectively treated with fasciotomy. Additionally, it is important to emphasize the significance of daily dressing and regular follow-up for achieving the best results

Kaempferol increases levels of coenzyme Q in kidney cells and serves as a biosynthetic ring precursor.

Coenzyme Q (Q) is a lipid-soluble antioxidant essential in cellular physiology. Patients with Q deficiencies, with few exceptions, seldom respond to treatment. Current therapies rely on dietary supplementation with Q10, but due to its highly lipophilic nature, Q10 is difficult to absorb by tissues and cells. Plant polyphenols, present in the human diet, are redox active and modulate numerous cellular pathways. In the present study, we tested whether treatment with polyphenols affected the content or biosynthesis of Q. Mouse kidney proximal tubule epithelial (Tkpts) cells and human embryonic kidney cells 293 (HEK 293) were treated with several types of polyphenols, and kaempferol produced the largest increase in Q levels. Experiments with stable isotope 13C-labeled kaempferol demonstrated a previously unrecognized role of kaempferol as an aromatic ring precursor in Q biosynthesis. Investigations of the structure-function relationship of related flavonols showed the importance of two hydroxyl groups, located at C3 of the C ring and C4' of the B ring, both present in kaempferol, as important determinants of kaempferol as a Q biosynthetic precursor. Concurrently, through a mechanism not related to the enhancement of Q biosynthesis, kaempferol also augmented mitochondrial localization of Sirt3. The role of kaempferol as a precursor that increases Q levels, combined with its ability to upregulate Sirt3, identify kaempferol as a potential candidate in the design of interventions aimed on increasing endogenous Q biosynthesis, particularly in kidney